Proceedings of the Subcommittee on Veterans Affairs
Issue 6 - Evidence - June 13, 2012
OTTAWA, Wednesday, June 13, 2012
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 12:12 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 Donald Neil Plett (Deputy Chair) in the chair.
[English]
The Deputy Chair: Honourable senators, I declare the meeting in session. My name is Senator Don Plett. I am a senator from the province of Manitoba and the deputy chair of this committee. I will be sitting in, today, for Senator Dallaire, who is the chair. I want to welcome you all to the meeting of the Subcommittee on Veterans Affairs. The committee is presently continuing its study on the transition to civilian life of veterans. Today, we are hearing from representatives of Veterans Affairs Canada, VAC. They will inform the committee about the National Centre for Operational Stress Injuries and their clinics and the services that they offer to veterans.
We will be hearing, today, from Raymond Lalonde, Director General, National Centre for Operational Stress Injuries, and David Ross, National Clinical Coordinator, Operational Stress Injuries National Network.
Thank you for accepting our invitation, gentlemen. Welcome. I know that you have a presentation to make. After the presentation, we will have a question and answer session. I think we are starting with Mr. Lalonde, so the floor is yours, sir. Again, welcome to this committee.
[Translation]
Raymond Lalonde, Director General, National Centre for Operational Stress Injuries, Veterans Affairs: Honourable senators, I would like to express my appreciation to be here today to testify on the services offered to veterans and to their families in the operational stress injuries clinics.
I am very pleased to have the opportunity to share with you the great work done by the clinics in the network.
[English]
The VAC OSI network is composed of eight independently operated mental health clinics, established by VAC through a series of memorandums of understanding with provincial health organizations, as well as two clinics established under VAC management. Nine of the ten OSI clinics established across Canada are outpatient clinics and one is a national, residential treatment facility.
[Translation]
The VAC clinic network is part of a larger one referred to as the joint network of clinics, which includes the seven operational trauma and stress support centres operated by the DND which offer similar services.
In partnership, VAC and DND have in place 17 facilities providing specialized interdisciplinary mental health services for psychological trauma related to operational stress injuries for CF members, veterans and their families across the country. This partnership also extends to the RCMP members and retired personnel suffering from an operational stress injury.
Since the opening of the first clinic in 2001 up to March 31, 2012, the VAC network of clinics received 5,374 referrals for assessment and treatment. It is a key component of the VAC continuum of services for those who suffer from the consequences of operational stress injuries.
Today, I will be pleased to answer your questions so that you can learn more about how the clinics operate and their contribution to the well-being of veterans.
[English]
The Deputy Chair: Thank you, sir. Mr. Ross, do you have anything to add? No? Thank you very much.
In some of the briefing notes that we have, it says that loved ones can be involved in the treatment, and eligible family members can also receive services. Who would be eligible family members?
Mr. Lalonde: It is any family member of a veteran for whom care would be instrumental to the treatment of the veteran. There is an entitlement process here; if we need to take care of the family member to benefit the veteran's treatment, these people would be entitled as per the Veterans Affairs policies. In the network of clinics, 11 per cent of our clients are family members. This is an increase of 83 per cent from the previous year because we put a lot of effort into looking at how family-friendly the clinics could be. We looked at all of the opportunities to promote the fact that we were providing services to family members. Every time a veteran comes for an assessment, the family member is invited to participate in the assessment process. We promote a lot. We have looked at screening tools and the best treatment approaches for families. We also look at the competencies of staff in OSI clinics to support family members. Of course, we specialize in trauma. We cannot, in our network of OSI clinics, provide treatment for all of the facets of the family needs. Sometimes it is conducting the assessments and working with the family members to find a service in a community that is more appropriate. For example, young teenager issues may be best addressed in a clinic that is focused on dealing with teenagers, so it is a mix.
The Deputy Chair: Thank you. Before we started the meeting we were chatting and I have found, in the time that I have served on this committee and on the Standing Senate Committee on National Security and Defence, that communication is so often a problem in whatever we do. Of course, good stories generally do not make the rounds as well as negative stories. We hear more about the negativity of any program, whether it is here or whether it is any other program.
What are you doing at VAC to communicate the good programs you offer and the successes you have over the odd failure or the odd weakness that there may be?
Mr. Lalonde: Of course, at VAC there is a lot of emphasis on providing information to veterans through seminars and different venues. For the OSI clinics, because that is my area of specialty, one of the mandates of the OSI clinics is outreach. I will let Dr. Ross speak more about what we are looking at when we are talking about outreach of the OSI clinics.
David Ross, National Clinical Coordinator, Operational Stress Injuries National Network, Veterans Affairs: In terms of outreach, as a clinical network we are primarily interested in doing what we were tasked to do, which is not to duplicate services but to complement them and make sure that we collaborate with our partners to deliver services close to home. That primarily involves a couple of different interventions. One is going out and making sure the people know where we are, and continuing to do that because it is like a media pulse. You do a PR thing, people become aware of you and then you drop off the screen. You need to do that periodically.
The other thing that is really most valuable is just-in-time training. That involves making sure that when one of our veterans has a specific need that involves their partners, we have already identified who those potential partners are and that they are already briefed. We make sure we provide them the support they need to work with us on a continuing basis. That might mean short training, but sometimes it just means a phone call. We need to make sure there is that human contact and that is sustained.
We have concentrated primarily on that. We have used other strategies as well, but find we get the best return on investment in terms of improved client outcomes when we focus there.
Mr. Lalonde: I would say our biggest focus is dealing with the health professionals in the communities. They are the ones who see our veterans first and the family members of veterans first, including the GPs and the health services. That is the liaison where the clinics are building and providing support but also providing knowledge on best practices and working in collaboration. I believe that is very effective.
[Translation]
Senator Nolin: Welcome to both of you, and thank you for accepting our invitation. We have spent a few meetings studying the whole issue of operational stress injuries. However, perhaps no one has ever stopped to define this type of injury.
First, I would like to try to determine what "an operational stress injury " is, since we have often passed over this stage of the analysis. Could you explain to us, and to Canadians who are listening, what this consists of? What causes this type of injury? What are the symptoms?
You referred to the RCMP, among others. How might a member of the RCMP experience that type of injury? It seems a little more obvious with members of the military, but I am wondering how to link RCMP members to that type of injury.
Mr. Lalonde: I will give the floor to Dr. Ross, a clinician. He is in a better position than I am to give you those details.
[English]
Mr. Ross: I will try to address the spirit of that definition because it was created for a reason, and that is to specifically try to de-stigmatize the consequences of participating in military or police operations. Operational stress injury refers to any kind of mental health problem that has arisen as a result of participation in active services.
In my profession it is referred to as a category of inclusion. In fact, it is quite inclusive. There is a whole range of potential presenting problems that people can develop as a result. The signature condition is post-traumatic stress disorder, which I believe you are already familiar with.
Senator Nolin: Yes, we are, but I want to give you the possibility to explain the magnitude of the situation.
Mr. Ross: Do you mean in terms of the impact it can have?
Senator Nolin: Really, I am asking about the medical side.
Mr. Ross: Okay.
Senator Nolin: Then we will look into the clinics, and the array of centres and clinics.
Mr. Ross: In terms of post-traumatic stress disorder, people experience three classes of symptoms. One is hyper- arousal, where the person constantly feels on edge, is jittery, and their autonomic nervous system is cranked to the maximum. It is as if they are in a life-or-death situation constantly.
They also experience intrusions. These are intrusive experiences; they may be memories or cognitions; they can happen in their dreams, but they can happen at any time. They may or may not be triggered by perceptions that remind them of the original circumstances, but they trigger a personal experience that is indistinguishable from actually being there. All of a sudden, you are in a shopping mall and then you are back in Rwanda. That is a multi-sensory experience. This is not an "as if " experience. You will smell the smells. You will hear the sounds. You will live it as if you are physically present, and this is tremendously unsettling.
The last thing you tend to see is avoidance. This is a silent but terribly important problem because it tends to slowly cut you off from everything that matters. We wake up in the morning because we want to have a life. We want to experience pleasure, we want to talk to our friends, we want to experience intimacy, and we want to be able to go to work. Due to the nature of PTSD, it slowly tends to encourage you to pull back and pull back to the point where you are no longer working or socializing.
Someone who I am working with right now rarely leaves his kitchen and the reason for that is his kitchen is completely surrounded by windows. This is the only place where this individual feels safe. He sleeps in the kitchen and has been doing so for quite a long time. He is not working. He bought a new motorcycle last year. He cannot ride it. That is just to give you a feel of how crippling it is.
Senator Nolin: Thank you; that answers my question.
I mentioned the RCMP. I think I can understand with the military personnel. What about police personnel? What kind of event can trigger such a situation for them?
Mr. Ross: This is actually something we are getting to understand better more in recent years. I do not want to oversimplify it, but there are two paths that can take you down that road. One is the situation I have just described, where you can have a discrete event or a series of discrete events that are horrific. They are beyond the normal range of human experience. Police officers experience this regularly.
My sister is a police officer and she has had all kinds of experiences where they need to pick up body parts or they are first on the scenes of accidents and so on. However, there is another way that this can happen and it is analogous to slowly getting your gas tank filled up. It is like you have all these traumatic experiences day after week, after month, after year, and for many reasons you do not feel you can talk about it.
[Translation]
It brews and brews, and then it tends to go bad.
[English]
It just goes bad on you.
It is fair to say that for many people in the line of duty there is only so much you can take. You just reach a point where you have had too much. Unfortunately, that tends to be a slower onset that is harder to discern; but they end up having the same presentation many times: the intrusions, the hyper arousal, the impairment of intimacy, the loss of engagement and the pulling back.
Senator Nolin: Can it surface a long time after the event?
Mr. Ross: We have seen some striking examples of it appearing long after the event. The U.S. VA has recognized that, so they are much less persistent than they used to be about requiring a clear temporal relationship between the initial traumatic events and the presentation of the trauma. We have learned through our experience that there is no necessary relationship there.
[Translation]
Senator Nolin: Mr. Lalonde, I have one question that concerns Quebec and the Sainte-Anne-de-Bellevue centre. The department finally reached an agreement with the provincial authorities for the transfer. Can you explain how, despite the transfer, the Sainte-Anne-de-Bellevue centre will continue to operate the service, if the service is provided at the centre?
Mr. Lalonde: There are two factors that need to be taken into account at the Ste. Anne hospital: there are two clinics, one for outpatients and one for inpatients. According to the announcement, these two clinics will be part of the transfer to the province in the same way as the eight other clinics, and will be managed by the provinces through an agreement with the federal government, with Veterans Affairs Canada. Employees of the national OSI centre will remain with the department. The clinics are already under the responsibility of the hospital, nursing services, professional services and everything having to do with the role of expertise, with network management and with mine, which involves establishing the administration of agreements. All of that will remain federal and will not be affected by the transfer to the province.
Senator Nolin: This may become fairly complicated for everyone because there are centres that are under your responsibility at the department, others that are the entrusted to the provinces, others that pertain to a partnership between you and the defence department. Not everyone has access to a computer to view the web pages for your department and for DND. Is there a simple way of telling people about the services being offered and where?
Mr. Lalonde: There is a simple way. For the 10 departmental clinics, I am responsible for funding and for managing agreements. When the Ste. Anne hospital is transferred to the province, the 10 clinics will all become provincial. There will be no difference in the status of the clinics that Veterans Affairs Canada funds.
As for the DND clinics, they basically serve active service personnel. Veterans have some access at a few places, such as in Halifax and in Ottawa, on occasions. But the 10 clinics are basically accessible to veterans. The clinics are on our website. All the contact information for each of the provincial clinics is there with the contacts, and referrals are made by the department's case managers. So it is fairly easy.
Senator Nolin: It may seem that way to you, but it is not so obvious for the average person.
[English]
The Deputy Chair: Could you explain the in-patient clinic? Is it typically a hospital?
Mr. Lalonde: Mr. Chair, the in-patient clinic is a 10-bed clinic. It is not a hospital, per se. We call it a "residential treatment clinic. " It is within Ste. Anne's Hospital and will be transferred to the province. The focus of the in-patient clinic is twofold: first is to stabilize clients for whom medication needs to be adjusted, for example with supervision 24- 7 for a period of time, and to diminish the symptoms of PTSD; second is an eight-week program that builds on the abilities of the veterans participating in the program to learn more about PTSD and OSIs. There are a lot of group activities and work on things such as chronic pain management and anger management. It is an intensive program for eight weeks, on average, with the two parts: stabilization, and psycho-education and rehabilitation. The average is about 10 to 11 weeks in residence at the hospital.
The Deputy Chair: Thank you for that explanation
Senator Day: I was following the explanation of Mr. Lalonde on the various names and clinics. Many names seem to be coming at us in terms of networks. Eight plus two are Veterans Affairs and add seven with National Defence to make a total of 17 networks. Mr. Lalonde, I believe that you have a coordinating role between serving personnel who would be treated at DND clinics when they retire or leave the Armed Forces for whatever reason. Is the transition seamless to a different clinic that they would have to follow? How does that work?
Mr. Lalonde: The transition from CF member to civilian life takes two or three years before it occurs. In most of our clinics, we see CF members before they are released. Actually, 17 per cent of our clients are still serving in the Canadian Forces so that there is an easier transition.
The Canadian Forces does not have an Operational Trauma Stress Support Centre in Manitoba. Therefore, our clinic in Winnipeg sees probably half of their clients who are still serving members. We collaborate with the CF in this way. In many clinics, once someone is on the release path, often within the last six months but maybe longer, the person has already been transferred to the Veterans Affairs clinic. That makes the transition easier.
Senator Day: I am glad to hear that. Mr. Ross, I would like to go down another line of questioning to expand on the symptoms, and this may not be a symptom. I do not know what you would call the result of someone suffering from this injury. What are some of the outcomes if this person does not get this under control? What are you seeing?
Mr. Ross: Thank you for that excellent question. It makes a difference whether we see them sooner or later. The earlier we see them, the better the treatment outcome is and vice versa. The more there is a delay, the more you tend to see a progression of the avoidance. You tend to see a conservation of the intrusions and the hyper vigilance, which can worsen because a person can become very isolated. We do not do well in isolation because we are social beings. The more we get cut off socially, the more we tend to ruminate; and that can only serve to aggravate these kinds of problems.
The person becomes more and more symptomatic and distressed. Everyone is embedded in the support network, and they can take only so much. As that burden increases, you start to see breaks in the network. Family members, no matter how much they love the veteran, have their limits as well and can become quite burdened and symptomatic themselves.
Again, this is not specific to PTSD. You see this with any chronic mental health condition. It is not something that tends to go away; it is something that can get worse if we do not intervene. You end up with more isolation and distress and less vocational functioning, obviously, because they will not be working under these kinds of conditions. Unfortunately, they may tend to take extreme measures to isolate themselves. They may go further and further away from urban centres, which can compromise our ability to reach them because we only have so many clinics and resources.
Have I answered your question?
Senator Day: Yes, and I have a follow-up. We heard a while back from the veterans ombudsman about a lot of retired personnel on the streets, and this could be some of the isolation that you are talking about. The facilities are there for them, but they are staying away from them for whatever reason.
Mr. Ross: You can think of that as an extreme end point, but that is very visible and memorable. I also want to draw attention to the people who are in the grey zone. They are not working anymore, but could be. They are not socializing anymore, but they want to be. It is like the death of 1,000 cuts in a way. Again, you find people all the way along that continuum and will tend to see more closer to the norm, and less as you go toward the extremes. If you are seeing homeless people, look for many more people who have very legitimate needs who are a little less in that visible limelight.
Senator Day: Is there any place on that timeline where we start to see more suicides, addiction to drugs and those sad outcomes?
Mr. Ross: You will see a progression from substance abuse to substance dependency the longer the condition goes untreated. Specifically speaking to post-traumatic stress disorder, it is one condition in mental health where it has been empirically demonstrated repeatedly to be functionally related; it is very important to understand that those two tend to feed on each other.
It is important for us to ensure that we have our eyes on the prize and not think in terms of silos. Some of these conditions are functionally interdependent, and if you pick that up and make the right move early, you save yourself a tonne of grief. Much research has been done looking at the life trajectories of these conditions. If you intervene early you can cut 10 years off the condition with all of the benefits to the veteran, but also to their families.
Senator Day: If you can show that that is clinically connected like that, then more substance abuse would happen if someone is —
Mr. Ross: It predisposes you to it.
Senator Day: You are looking at one thing and the other is probably there.
Mr. Ross: Say I am isolated, having flashbacks, constantly feeling like my fingers are in an electric socket, scanning the environment, checking locks and doors, constantly feeling I am in danger, and I know if I have a couple shots of alcohol that it radically suppresses those symptoms, what do we think will happen?
Again, I do not want to give the wrong impression, because that is actually a poison gift. Ultimately the alcohol worsens the presentation and makes it more chronic and treatment resistant. I am not presenting it as a solution, but if that is all you have, and when life is like this . . .
[Translation]
Senator Nolin: I need to bring up the police forces that are confronted with individuals whose attitude might, obviously, not be "normal ". It takes a police officer who knows about these symptoms to be able to take the individual and bring him or her to you or take him or her to one of the centres.
Can we presume that this is not always the case and that the police have to interact with the people using your services? How does that work?
Mr. Lalonde: We could not give a good estimate of the work done in training police forces.
Senator Nolin: That was one of my sub-questions. Do you interact in that respect?
Mr. Lalonde: We do not currently provide training to police forces. And this is not specific to veterans. They have to deal regularly with people who have very different mental health problems. It may be post-traumatic stress syndrome or a personality disorder. They must have training, but we do not interact with the police forces to train them.
Senator Nolin: The Senate produced a very lengthy report on mental health a few years ago. And this entire issue of interaction between health care staff and law enforcement personnel is critical. We obviously have not reached this level of improvement. Perhaps we should think about it and discuss it in our findings.
[English]
The Deputy Chair: How much of a stigma issue is still out there, with people being afraid to come in? They have pride; it is not something they want to talk about. They are taking those shots of alcohol rather than coming in, or they are just simply keeping it to themselves, taking it out on their families, so on and so forth.
Mr. Lalonde: A lot of work has been done within the Canadian Forces and has trickled down to veterans around the stigma. The leader of the Canadian Forces, the CDS, made a real stand for the responsibility of everyone in the Canadian Forces to care for the mental health of his peers.
It is hard for us, in the veterans' population, to assess the level of stigma, but we still see it even though we think it has lessened. In some cases we see veterans who do not want to come forward. We provide services, for example via telehealth, for veterans who live in remote communities. Some do not want to get the services in their communities; they would rather travel to another community so that no one knows they are seeing someone for a mental health condition. It does exist. That is why our services need to provide different types of access. We have our clinics, remote sites where we go, and telehealth. Some clinics have started posting some testimonials. For example, the Royal Ottawa Hospital has worked with National Defence to post some videos to help family members understand the impact of an OSI on the family. All of these things are helping.
Mr. Ross: I would like to underscore that when we ask these questions about stigma, there are really two groups we need to think about. There are the newer, younger veterans, and I wholeheartedly agree with Mr. Lalonde. We also continue to get veterans who come in and need help, who went through the service long before that wave started and whose legacy was still the older vision of "suck it up and deal with it. "
I just do not want to obscure the fact or make it look like it is just one homogenous group because it is not. There are two separate kinds of presentations, and with the older veterans my concern is that the issue of stigma is still very much alive. It is still very hard to deal with, because it has been hammered in for 15 years, to "deal with it. "
I do not want to suggest for one second this is any kind of character issue; this is how this they were trained and it served them well. However, they did not have the debrief, and so they tend to go on with the same trajectories.
The Deputy Chair: Thank you very much for that answer.
When we are finished with our study, we are planning on writing a report. What recommendations would you have for us to put into that report? If you could suggest one, two or three recommendations, what would they be?
Mr. Lalonde: I would not want to put myself in your position and take your words from it. However, I think we need to continue to ensure communication, awareness and working with health professionals. It is something that we are doing with clinics and it is something we need to probably do more of.
As Dr. Ross was saying, many veterans do not go out for care. However, if they hear the story of a peer who has lived the same events, who was in the same unit — been there, done that — suffered, went to the clinic, got better, they will come; they will be more inclined to come to get services with that exposure. The communication is very important.
One of the things that we are also doing with the network of OSI clinics is promoting evidence-based practice. Much research is being done on how best to treat clients with mental health conditions and clients with operational stress injuries, and we are working a lot in our network to promote that to ensure our clinicians are well trained.
We are trying to share that information with the health providers in the communities, because even though research demonstrates that some treatment approaches are better in terms of outcomes, they are not always being used. One of the actions we have taken lately was to work with Ryerson University, which applied for a grant from the CIHR, the Canadian Institutes of Health Research. They got funding of a large amount of money, so we have trained 140 clinicians. About 40 are from our networks, some from DND and the others were private clinicians, psychologists mostly, in the communities. We trained them on one of the evidence-based practices.
We are doing research on the best way to do some clinical supervision after the training not only to ensure the training is understood but that it is applied in the treatment. It is also an avenue, helping build the knowledge and the capacity of health professionals in the community.
Communications and the type of approaches — I think it would be very good for us to continue to do that.
[Translation]
Senator Nolin: We are going to write a report. We are thinking of making recommendations on the quality of the cooperation between you, your service, the rest of Veterans Affairs and the Department of National Defence. Unless you say to us, "Do not touch anything, everything is fine, we do not need to adjust anything, the violins are in tune and the music is beautiful. " We doubt that is the case.
What areas should have improved cooperation between you, your service, the rest of your department and the Department of National Defence? That rounds out the deputy chair's question a bit.
Mr. Lalonde: Certainly, the joint network of clinics was started 10 years ago. We started with a clinic at the Ste. Anne hospital and, in 2007, we obtained funding to increase from five clinics to 10. The number of referrals we receive from the offices of the department's case managers. . .
Senator Nolin: When you say "department ". . .
Mr. Lalonde: I mean Veterans Affairs and the pension officers who assess disability claims. This increased gradually. I think the communication is getting better and better. Let me give you an example. Last year, we served 36 per cent more clients, veterans and family members in our clinics that the year before, and the year before, that number was 28 per cent. So it has started to grow.
Of course we want to improve our access in different parts of the country. With the size of a country like Canada, we can understand that, with 10 or 9 outpatient clinics, we cannot be everywhere. How, through various ways, can we be closer to veterans? There are people who will travel to this place or that to provide services. Some clinics have people located in certain remote places. They work in collaboration with the main team, but closer to veterans.
Senator Nolin: So there are more resources?
Mr. Lalonde: We adjust the number of resources based on need, given that it is one statutory benefit that veterans are entitled to. We have adjusted the level of resources along the way to deal with the growing demand, and we will continue to do so in the future.
Senator Nolin: With National Defence?
Mr. Lalonde: There are two components with National Defence. There is the interface with people who are on release, and also the whole aspect of skills development. Defence staff has taken part in a lot of training that was held at Ryerson University. We are working closely with defence at the new military and veteran health research institute, in Kingston.
This is working well for the clinics. We have similar interdisciplinary approaches, and we both intend to have evidence-based practices. Basically, this involves continuing training, updating knowledge and looking at research projects that will enable us both to understand the issues better.
[English]
Senator Nolin: Dr. Ross, what should we do to do it better?
Mr. Ross: I would have to say that the shortest road to better outcomes is getting evidence-based practice from the bench to the bedside. That has been the big challenge, and not just in our network but in all networks. It is funny because, when we think about that, we tend to think about disseminating different treatment techniques. We have been doing that; we focused on some evidence-based practices. However, the other thing that has been missed in Canada, but not so much in the United States, is an emphasis on monitoring and managing our outcomes.
Senator Nolin: Evaluating the results?
Mr. Ross: Not only that, but using the systems that we have now that can do a very rapid assessment and can provide instant feedback to the clinician and the client before the session starts, to let them know whether they are on trajectory or not. Those systems allow you to have the best outcome with the people who are the most vulnerable.
We just spent three years developing and getting ready to implement just that kind of a system nationally. It is the first time that it is being used in Canada at that level. However, it is important to train your staff to monitor and manage the outcomes. It is also quite collaborative. The assessment is very quick; you get a printout immediately and ask the client if it makes sense. When you do that, you find that the rate of dropout, premature termination and deterioration of the most vulnerable people takes a nosedive. That kind of strategy is where you can really get some big gains. I think that is the question. It is not just whether we can have an effect. It is, rather, how will we get the biggest return on our investment? Our resources are limited and always will be.
Senator Nolin: What do you need to achieve that — more resources?
Mr. Ross: We have the resources for that, fortunately. That is what we have been doing over the last few years.
This will be good to go fairly soon. It will allow us to answer clearly as to what our outcomes are and how our people are responding. It also addresses issues of perception and communication, because then it is not, "Well, we think we are doing okay. " Rather, it is, "Well, actually, I can tell you how long it is taking, " and we can see what we are not doing so well, we can learn from our experiences, and we can really get with the program.
Senator Day: I have been thinking about operational stress injury as most likely occurring from one major event that has occurred. However, have you found that it develops over time from a number of instances?
Mr. Ross: The question we had earlier about police officers, that tends to be the presentation that you see. Again, I do not want to oversimplify it, because they can see some pretty horrific things and it can be a one-shot deal. However, we know from the research that it is the cumulative exposure to those events that increases the probability of someone developing these kinds of conditions.
The truth is that you have a foot in both worlds there, the longer you are exposed to these things. I have heard so many times it was just one too many — one car accident too many, one assault too many. Sometimes it is a one-shot deal and sometimes it is not.
Senator Day: Presumably it could get started during someone's time in the Armed Forces, but then some things happen in civilian life afterwards that would bring this on?
Mr. Ross: Sure.
Senator Day: That is interesting.
The leadership, in terms of clinical research in Canada, is still within DND and Veterans Affairs, or are you finding some civilian-side leadership coming forward now?
Mr. Lalonde: The Canadian Institute for Military and Veteran Health Research has 20 affiliated universities. It is collaboration between universities, key researchers, the Department of National Defence and Veterans Affairs Canada. They held their second forum last November and there will be a third this year in Kingston.
Senator Day: Would you say Canada is a leader in this research?
Mr. Lalonde: It is hard to compare ourselves to our friends south of the border, where they have 30 million veterans and huge budgets. We are well positioned in terms of working in partnership with key leaders, internationally, around veterans issues.
We have the Senior International Forum, for example. We are in contact with the Australians, looking at outcome measurements and training. It is a very collaborative environment. All the countries are open to sharing their learning and tools to collaborate on research. It is not as if we are alone and trying to be the best; we are collaborating with those who sometimes have more capacity and experience than we have.
Senator Day: That is both the civilian side and the military side?
Mr. Lalonde: Yes.
The Deputy Chair: Dr. Ross, have you anything to add to that?
Mr. Ross: Yes. One of the lessons of the last 30 years in mental health is that we hang together or we hang separately. The reality is that we have international partners who are dealing with similar problems. They, too, have limited budgets, but they have some really bright people.
I went to Australia last year and spent three months with the Australian Centre for Posttraumatic Mental Health. I consulted with the Australian Department of Veterans Affairs, specifically to see how we could be collaborating. I go to the ISTSS, International Society for Traumatic Stress Studies, international conference every year. We are forming international groups so that we can share our resources and focus our efforts so we do not duplicate them and so we can be as harmonized as possible in order to get the best outcomes in the shortest time. It really is a matter of collaboration.
Senator Day: The record will show the name of the international collaboration. Is there any other advice you can give to us that would help us raise this issue from the exchange of information internationally?
Mr. Ross: This may sound trite, but thinking globally and acting locally. When I visited the Americans and Australians, I was struck by the amount of overlap and also the amount of goodwill, the generosity of these people, and their real willingness to work with us and to pool their resources. I would humbly suggest that that is something you might want to emphasize, as a shorter way home, if you will.
[Translation]
Senator Day: Would you like to add anything, Mr. Lalonde?
Mr. Lalonde: I think that Dr. Ross' comments are timely. We have an opportunity to work together; we need to take advantage of that and work with our colleagues on specific projects to put in place collaborative research and information exchange projects.
[English]
Senator Nolin: Dr. Ross, I hesitate to ask this question because I do not want to look stupid. However, with regard to detection and prevention, are you asked to write some kind of a manual on how to detect?
Mr. Ross: To detect?
Senator Nolin: In advance, way in advance.
Mr. Ross: No.
Senator Nolin: First, is it possible?
Mr. Ross: Yes. Well, it is a challenge. There is a lot of research being done now into what predisposes people to develop these conditions. I would have to describe that as nascent and emergent. Could you base a clinical program on that? Not at this point, no. I want to stay within my own scope of expertise, because at VAC, by definition, when we get involved, detection is not the challenge.
Senator Nolin: That is why I am asking the question. I was unsure whether I could ask that question, but you have the knowledge.
[Translation]
Mr. Lalonde: As Dr. Ross said, research is being done in this field, but not enough to draw conclusions that would put in place specific detection tools for military personnel who might develop symptoms.
Senator Nolin: Or even when they are recruited.
Mr. Lalonde: Perhaps you will have or have had an opportunity to hear from Canadian Forces representatives; they would be in a better position to answer that question.
Senator Nolin: Thank you.
[English]
The Deputy Chair: Gentlemen, on behalf of our committee, thank you very much for appearing here today. There has been a lot of good information, and we appreciate that. We look forward to including much of what you have said here today in our report. We encourage you to keep up the wonderful work you are doing on behalf of all our veterans and indeed our country.
On that, I declare the meeting adjourned.
(The committee adjourned).