Proceedings of the Subcommittee on Veterans Affairs
Issue 7 - Evidence - October 24, 2012
OTTAWA, Wednesday October 24, 2012
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 12:10 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: Welcome, ladies and gentlemen. We are continuing our study on the transition of military veterans and the possibility for them of returning to the workplace and being full-fledged citizens, while recognizing their limitations and the advantages they have to offer to civil society.
We welcome today Ms. Elizabeth Steggles, public affairs executive at the Canadian Association of Occupational Therapists (CAOT). She will be delivering her brief, and afterwards we will have a question period.
[English]
You may have some corresponding comments or an executive summary to it, and then we would like to have questions. We have until about 1:15 p.m.
Elizabeth Steggles, Public Affairs Executive, Canadian Association of Occupational Therapists: Good afternoon, senators. My name is Elizabeth Steggles and I am pleased to represent the Canadian Association of Occupational Therapists. Thank you for your invitation to share information about the role of occupational therapy in assisting veterans in their transition to civilian life and the challenges of providing occupational rehabilitation services in this context.
Engagement in meaningful occupation is a determinant of health. Occupational therapists, or OTs as we are often known, believe that occupation not only refers to paid employment, which is an important component, but also encompasses everything that we need, want, or are expected to do in life. It is about day-to-day functioning. This may include earning a living, but it may also include such occupations as driving to the bank, playing with the kids, watching a ball game with friends or brushing our teeth. Meaningful occupation is as individual as a fingerprint, and one cannot make assumptions about what another person finds meaningful.
Occupational therapy came into being in 1915 in order to assist soldiers who were returning from World War I in their transition to civilian life. OTs have worked with veterans for almost a century. It was recognized that injured soldiers benefited from engagement in meaningful occupation. Ward occupational aides, as OTs were then called, worked with injured soldiers therapeutically to restore function and to assist with their transition to civilian life. Today, OTs work not only with veterans who have sustained physical injury but also with those who experience depression, anxiety and PTSD as a result of their experiences.
OTs are highly trained to help individuals determine and address their occupational goals so that they may lead productive and satisfying lives with minimal dependence on family and society at large. Dependence may be physical, emotional or financial. I would like to provide an example.
Last week an OT told me that she was working with a modern-day veteran and his family. The man had always been the go-to guy, the guy everyone relied on. As a result of PTSD he became reclusive, unable to leave his bedroom and detached from his wife and two children. Having discussed the issues independently with husband and wife, the OT encouraged the man and wife to explain their fears and frustrations to each other. The wife explained that she felt overwhelmed by the burden of caring for the whole family. The man explained that he was fearful of situations that would cause flashbacks and intrusive thoughts and that staying in bed was safe, but that he felt guilt and fear of failure.
The couple agreed that the husband would try to get up, wash and dress each day. It was a start. Today, the couple, with the assistance of the OT, is setting small, new, practical goals each day. There are relapses, but the husband has now taken on most of the household chores and has started to drive his children to sports activities, which is one of his goals. The wife is working. Life is not perfect, but it improves each day. This is just one example of how OT intervention may help.
It is known that 48 per cent of veterans report difficulty in transferring to civilian life. They experience more chronic disease than the general population and they may also have sustained physical or operational stress injuries.
OTs work with their clients, including families, to identify personal goals, conduct capacity assessments and develop targeted and measurable outcomes that take into account the whole environment, with environment being physical, social and institutional. In other words, the OT does not focus on one aspect of the person without considering the whole context. A physician may prescribe a medication or a physiotherapist may fix a muscle. OTs work with individual clients taking the whole package into account. This is why OTs are often the catalyst that pulls together the parts. They see a person's real life in their home setting and not in an office. To go back to my example, the OT told me that she was the only professional to have seen the client in his home. She saw him unshaven and unwashed. He said, "I am sorry; I do not really look too good,'' and she said, "No, you do not. Let us talk about it.''
OTs are employed by Veterans Affairs, but I understand that there are three main areas of concern.
OTs are employed as policy analysts and case managers. Given the holistic view of OTs, this is a logical fit, but they fill a generalist role. There is no specific OT representative at the national or regional levels. This leads to a situation where the potential impact of OT is not considered or implemented in a realistic or cost-effective manner.
OTs are employed in some districts but not all, and only on a contract basis. They work on the periphery of the staff teams and are not included in decision making or even social events. I was told of an OT who was excluded from the Christmas social, for example. This limits the impact they could have.
Direct OT service is provided efficiently by privately contracted individuals. These individuals report to the district level to either contract OTs or nurses. The contracted OTs tend to be used in order to review reports from the private OTs — which is a duplication of service — or reports are reviewed by nurses who do not understand the recommendations, which often leads to unnecessary questioning and delay in service. It is appropriate to employ OTs at the district level, but they need to be included as part of the staff teams and have the opportunity to recommend the inclusion of appropriate and effective OT service.
I have deliberately focused on providing you with an example of a veteran with mental health issues because the public is not as generally aware of this area of OT practice. However, I would like to conclude by providing an example from my own clinical experience.
I worked with a young man who had sustained a spinal cord injury that left him paralyzed from the neck down. He was not a veteran but he could well have been. My OT colleagues provided a motorized wheelchair that enabled independent mobility and worked with architects and contractors to design and build an accessible home that met his individual needs. I worked with the rehabilitation technologist to provide him with voice activated electronic equipment so that he could operate a computer and all that implies, control his TV and other audiovisual technology, use the telephone, answer the front door and change his position in bed. The last time I heard from him, he said, "The doctors and nurses saved my life, but you gave me a life worth living.''
Thank you.
The Chair: Thank you for being brief in the overview of your paper. If my colleagues give me two minutes I may have a question or two.
Senator Plett: It will not be as a result of my questions that you will not get your time, chair.
Thank you for being here and for your presentation. I think you kind of answered one of the questions I was going to ask with your last story, but are you also an occupational therapist?
Ms. Steggles: I am, yes.
Senator Plett: Do you work with Veterans Affairs as well?
Ms. Steggles: No, I do not, and I do not have experience with veterans.
Senator Plett: With the first illustration you gave — and it is a great success story, or at least sounds like it will be a success story — how did the family go about contacting the therapist? Normally, what is done? It sounded like maybe the wife did the contacting because the man was kind of down and out; is that right?
Ms. Steggles: No. The occupational therapist was one of the privately contracted occupational therapists, and I understand she was referred from the district level. Sorry — the family was referred by the district level to the private occupational therapist.
Senator Plett: This was all privately done; this was a completely private —
Ms. Steggles: But covered by Veterans Affairs Canada.
Senator Plett: Covered by Veterans Affairs Canada.
The Chair: In the district.
Ms. Steggles: Yes.
Senator Plett: Do you know to what extent they cover? Is it until the occupational therapist determines that they are no longer required, or what would be the extent of that coverage?
Ms. Steggles: I understand in this particular instance that the occupational therapist was referred for a period of time. However, if she, working with the psychologist, felt that more time was needed, that would be considered. In fact, in this particular case, I happen to know that the occupational therapist has been working with this gentleman for five years.
Senator Plett: You said "together with the psychologist.'' Are occupational therapists not psychologists?
Ms. Steggles: No, it is a different profession.
Senator Plett: Is this mostly just physical therapy, then?
Ms. Steggles: No. As I tried to explain, occupational therapists work with people with both physical and mental health conditions, as well as chronic diseases. However, we focus on the day-to-day activities of life; we focus on anything that they need or want to do in life. Rather than focusing on changing a mental health condition or providing a medication, we focus in on what it is the person wants and needs to do in life. We look at an individual; we talk to them, work with them, and identify what their passions are in life and what is meaningful for them in life.
In this particular instance, the man obviously would like to transition back to the work environment in whatever capacity. However, you have to set baby steps along the way. From my own experience, for example, someone with a spinal cord injury might say, "I would like to walk.'' We know that is unrealistic, so we have to work with the client to go through the baby steps of finding what it is that they need to do. If they say to me, for example, "I want to walk.'' I say, "What is it that you want to be able to walk for?'' and if they want to take their dog for a walk, you say, "You could do that with a wheelchair.'' You look at alternate ways of doing things.
I am not sure if I am answering your question.
Senator Plett: Yes, you are. Indulge me here.
Ms. Steggles: Occupational therapy is often a difficult concept for people to understand.
Senator Plett: Clearly. You are doing a good job of explaining it, though. Would you not be a physical therapist, then?
Ms. Steggles: No.
Senator Plett: In your example of the person with the physical ailment, if they could walk again, would you not help them with that aspect of that?
Ms. Steggles: No, but sometimes there is a bit of an overlap in that we do provide some rehabilitation, which is more remediation. For example, if someone had a hand injury, we might do some remediation work as well, but it is always focused on occupation. Rather than, "I will make this hand work,'' it is, "What do I need to do with this hand?''
Senator Plett: I have one last question. What is your training; what do you need to become an occupational therapist?
Ms. Steggles: It is a clinical masters program. You need an undergraduate program and then it is a two-year clinical masters program. That has changed in the last six years or so.
Senator Plett: Is there a shortage of occupational therapists?
Ms. Steggles: There is. The shortage tends to be more in the less-serviced areas, such as remote areas. There tend to be enough in the urban areas.
Senator Plett: Toronto and Ottawa would have sufficient numbers, for instance.
Ms. Steggles: Yes, but if you look at the projected statistics, we are anticipating that there will be a crucial shortage of OTs, along with most other health care professionals, between now and 2031.
Senator Day: Due to retirement?
Ms. Steggles: Yes, mostly because of the population demographics.
The Chair: That is a good segue into the milieu to get the information.
Senator Nolin: Thank you for accepting our invitation. Were you with your president when she appeared in front of the House of Commons Standing Committee on Veterans Affairs in 2009?
Ms. Steggles: No, I was not.
Senator Nolin: Regarding the care of veterans and injured soldiers, she stated that the occupational therapy profession was underutilized by the Department of National Defence, the Canadian Forces and Veterans Affairs Canada. Do you think that is still the case?
Ms. Steggles: I think so. I am actually new in my job, so I have been trying to get up to speed quickly. I have been talking to occupational therapists who are working with veterans, and they tell me that they still tend to be used as the equipment prescribers. However, you can tell from the first example I gave that, in fact, we do a lot more than that. We look at the whole person. Often in a case management role, we are good at seeing the whole big picture and seeing where different pieces of the puzzle need to fit in.
My understanding is that, yes, OTs are still being underutilized. I think that probably relates back to what I was saying in that there are no occupational therapists at the higher levels within Veterans Affairs Canada, so there is no oversight for the role that occupational therapists can play.
Senator Nolin: Let us look at the situation from a different angle. What level of cooperation exists between your association and the two departments that I just mentioned?
Ms. Steggles: I am not sure I can answer that question, because I am, as I said, new to this role, but I can certainly find out for you. I know that it is an area of great interest for the Canadian Association of Occupational Therapists, because we see such a natural fit with working with veterans, but I can certainly find that information for you.
Senator Nolin: How many members do you have working within the two departments I have mentioned?
Ms. Steggles: I am sorry — I do not know those numbers, either. I can find out.
Senator Nolin: If you can find that information, it will help us understand the need. Thank you. I will come back on a second round.
Senator Day: I am interested in knowing if there are any occupational therapists who are employees of National Defence or Veterans Affairs Canada.
Ms. Steggles: I believe there are. In fact, I believe the head of rehabilitation is an occupational therapist, so there is representation. I am sorry I cannot give you exact numbers.
Senator Day: Therefore, it is not just that this is an outside service that is retained from time to time, as needed, is it?
Ms. Steggles: In terms of the clinical intervention, my understanding is that contracted individuals are brought in for a specific purpose. Those people who are working at higher levels tend to be working more around policy and that kind of thing. However, within Veterans Affairs Canada, I understand there are no occupational therapists at those higher levels.
Senator Day: You just described one person.
Ms. Steggles: I am sorry, what was the first organization you mentioned?
Senator Day: Department of National Defence and Veterans Affairs Canada. They work together with respect to injured soldiers who will become veterans.
It is happening that you have some people who have the background, is that not true?
Ms. Steggles: To a limited extent, yes.
Senator Day: Would you just like to see more?
Ms. Steggles: Yes.
Senator Day: There is a relationship you would like to see growing from a clinical point of view — namely, occupational therapists who are independent and who hire out their services on an as-needed basis. You would like to see that grow, as well, would you not?
Ms. Steggles: At the district level, I think we would like to see occupational therapists employed as staff members rather than being on contract.
My understanding is they come, they go, and they change according to policy. I think to contract people at the actual service delivery level is probably not a bad model.
Senator Day: Thank you for providing your background material. You are shown as Public Affairs Executive with the Canadian Association of Occupational Therapists.
Ms. Steggles: Yes.
Senator Day: Are you fairly new to that position?
Ms. Steggles: Three weeks in.
Senator Day: Congratulations to you. This is baptism by fire here.
Ms. Steggles: It is.
Senator Day: Did you work in the area you just described to us in the private industry providing services to individuals previously?
Ms. Steggles: I am a bit long in the tooth, so I have worked in many areas of occupational therapy, both in private and in health care in hospitals and home care services.
Senator Day: If we were to go to a large hospital, would we likely find occupational therapists working there?
Ms. Steggles: Yes, you would.
Senator Day: If the doctor managing the case felt that this particular patient could use the service of an occupational therapist, he or she would prescribe that?
Ms. Steggles: That might happen. However, because we are our own, independent professionals, anyone could ask for our service. It does not have to go through the recommendation of a physician. From my own experience — I have been in Canada since 1982 — I have never once worked under the direction of a physician.
Senator Day: Do insurers from time to time ask for the services of an occupational therapist?
Ms. Steggles: It varies, and it depends on which insurer. It varies a lot across the country. Under auto insurance, it tends to be covered. Another area of interest for the Canadian Association of Occupational Therapists is that we do want to encourage private insurers to be covering more occupational therapy services.
Senator Day: What about workers' compensation, for example, in other areas?
Ms. Steggles: They do cover occupational therapy to a certain extent, I would say.
Senator Day: Insurers for long-term disability would like to see someone get out and get back to work, at least to become more mobile?
Ms. Steggles: Yes.
Senator Day: All of these questions are fairly basic because we are trying to understand the program.
Senator Plett: As a short supplementary, do you work for medicare on occasion?
Ms. Steggles: Yes. You mean public health?
Senator Plett: Public health.
Ms. Steggles: Yes.
Senator Day: Going to the specific example that you gave us, and it is very helpful when you give that kind of example, you talked about the individual who was in bed and he apologized for not looking so good, and it sounded to me like that occupational therapist was using some tough love here by saying "You are right; you do not look very good and let us talk about it.'' Is that the kind of approach you would anticipate all occupational therapists would take, or is this an individual approach? I might have said, "Well, yes, but do not worry about it; we can look after that,'' or that kind of thing.
Ms. Steggles: I think it would be an individual approach of the occupational therapist and gauging what she knows about the person and whether she thinks it is appropriate to take that approach with someone. I think the purpose of doing that was to say, "You are not covering anything up.'' The point of that example is that very often if people are going into an office to talk to someone they will get spruced up, they will pull things together, and they will go in and talk to people. If you see someone in their own home, you see the bad stuff as well, and it is acknowledging that there is bad stuff and that we can talk about it; you do not have to cover up.
Senator Day: The patient, if I may refer to that person as the patient, was concerned about that; and the occupational therapist was not giving any quarter in that regard, saying, "Yes, you do look rather dirty and unkempt, but let us talk about it.'' Is that the approach you would normally expect?
Ms. Steggles: Again, as I said, I think it depends on the individual therapist, her knowledge of that particular client. That is part of our expertise, to change our approach depending on the person with whom we are working and what we have learned about that person and how much they can take and accept.
Senator Day: It is an individual thing. The example was not intended to lead us to believe that occupational therapists are tough and frank.
Ms. Steggles: We are not all tough. We try to be frank but try to do it in a realistic and accepting way. I think it is more being accepting.
Senator Day: Thank you. Your answers have been very helpful.
Senator Wallin: This is the same sort of line of questioning. I am trying to figure out what it is. Most of your members work either in the civilian world or the military world on contract, and you would like more of them to work on staff?
Ms. Steggles: Yes. That is one of the messages, yes.
Senator Wallin: What is the reason for that?
Ms. Steggles: There are a couple of reasons, actually. One, if they are being contracted by someone who is not an occupational therapist, that person does not necessarily know what occupational therapy services are required, and it goes back to Senator Nolin's point about OTs being often underutilized because they are seen as the prescriber or gatekeeper of equipment.
The other point, and the main point that I am picking up from occupational therapists that I have spoken to in the last week, is that those contracted occupational therapists or the occupational therapists who are contracted at district level are not seen as part of the decision-making team. They are seen much more as an outsider, so they are not consulted; it is not an inter-professional team; it is not particularly collaborative.
Senator Wallin: Why is that different in the hospital setting? As you said, in your experience, you have never taken a directive from a physician.
Ms. Steggles: The tendency is to work more in an inter-professional capacity. If I am sitting around the table, it does not mean that I am not talking to a physician, for example. In an ideal world, in inter-professional practice we would all work on the same goal for a particular individual. The physician would look at his contribution to the particular goal; the nurse would look at her contribution to that goal; the occupational therapist would look at her contribution to that particular goal.
Senator Wallin: What I am trying to get at is in the real world we would all love to have continuity of service on all fronts, but my father, a vet, accesses home care. There is a different person every day. When you go to your doctor's office, you may go to Dr. A or Dr. B if Dr. A, who is yours, is away that day. Nurses rotate and go on and off shift. The medical services profession does not guarantee on any other front that you get the same person or that there is some continuity.
Ms. Steggles: I think you would find a different approach in rehabilitation. Primary health care does tend to be that you see whoever is available. In rehabilitation I think you would find a different approach, that if you are admitted to hospital for rehabilitation you would see the same occupational therapist and physiotherapist throughout your rehabilitation. It would change when they go home because it is very often a different service once people go home.
Senator Wallin: What I do not see as an answer here is to have the Department of Foreign Affairs grow into some health care delivery service any more than it should grow into a financial advice delivery system. When a soldier transitions out, one would want them to get good advice about how to spend their money or how to invest it or what they might do. You do not have to have a person in-house always to do that. You may say in your community, which is hundreds of miles away, go and see Joe Blogs, he is the person to deal with. Do you really envision that Veterans Affairs would grow to hire on-staff occupational therapists? Is that the proposition?
Ms. Steggles: I think so, yes, because there is not always an understanding of what an occupational therapist can do. By having an occupational therapist on staff, they can help that process by recognizing the kinds of things we can contribute to changing someone's life. You have nurses on staff; they know about nursing, about the care of wounds and about the provision of medications. They know about those kinds of things, but they do not know about helping people attain their everyday goals and activities.
Senator Wallin: Did you tell us that the head of rehabilitation is actually an OT?
Ms. Steggles: I believe so. I only found that out today from my assistant.
Senator Wallin: There is presumably someone there, then, who understands?
Ms. Steggles: However, they tend to be more in a generalist policy role. It does not filter down.
Senator Wallin: Thank you.
The Chair: For clarification, this person higher up that we are talking about is in the policy area at DND but not at Veterans Affairs?
Ms. Steggles: That is my understanding, yes.
The Chair: I am trying to comprehend exactly where you fit into the exercise. We have both physical injuries and psychological injuries. You have the physiotherapists and doctors who handle the physical side during the primary care, as you described it. On the psychological side, you have the psychiatrists. We know the friction that exists between psychiatrists and psychologists, who does what and so on.
In that pecking order, within, as you say, inter-professional or interdisciplinary, is there a problem in regard to where you and your OTs fit into this exercise and whether or not there is a desire of being complementary among the three, or are you the new person on the block in this area?
Ms. Steggles: We should not be the new person on the block, having been around for a century, but occupational therapy is a small profession. We have 13,000 in this country, so when you compare us to the numbers of psychologists and physiotherapists, we are a small profession.
We do cross boundaries in that obviously many people are not in a box of having just a mental health issue, just a physical issue, just a chronic condition. We would be able to work with people regardless of those issues. We are not working with people in those boxes of "I work with someone who has PTSD'' or "I work with someone who has had an amputation.'' We would be able to work across the boundaries.
Having said that, obviously there are people with more expertise in certain areas than others.
The Chair: As a follow-up, regarding the skill sets and the knowledge that you provide during care, we are involved with a study on transitioning back into society. We know they are getting care from these other professional groups that provide specific services. I am trying to understand exactly where you fit in. You actually go to the individual's home, which other professionals do not particularly do.
How are you delegated a client for you to then step in and to start assisting that person in moving to employment or meaningful occupation?
Ms. Steggles: I think it again comes back to a referral being made often for a specific purpose that may not take into account the whole gamut of what an occupational therapist can do. I would hope that the occupational therapist would work with the client to identify his or her goals and then report back and say, "This is what I can offer; I can help this person back into employment,'' if that is what it is, and work through the processes toward that goal.
The Chair: You bring a different element than, say, a psychologist, whose aim is to bring people back into a framework where they can be stabilized for employment. Your angle to that would be what, then?
Ms. Steggles: Much more on a practical level; much more looking at what is the important occupation for that person, what it is they want to do and achieve and what it is their family hopes they will do and achieve.
We are focused much more on the functional side of life. We are not just looking at fixing a specific piece but trying to get someone into a much more functional and engaged place within their lives.
The Chair: You are in the trenches, the front lines with the families and the individual. Thank you very much.
Senator Nolin: Ms. Steggles, I am concerned. I am becoming more and more convinced that you can help. However, I presume it is part of the purview of your mandate to establish the relationship between your association and the two departments that we are dealing with. Is that right?
Ms. Steggles: Yes.
Senator Nolin: The kind of questioning we have, they will have. It will be your role to fill in the blanks and explain.
I understand that after only three weeks on the job you probably do not have the answers yet, but I just want to pick your brain and try to understand the master plan that you will develop to present your association and the work of your membership in order to support the mandate of those two departments in trying to achieve, you and them commonly, the well-being of our soldiers and veterans. What is your master plan to achieve that role? I think that is critical.
After 45 minutes of questions, I think that is the problem, trying to understand where you may fit into the continuum of services.
Ms. Steggles: I take your point. Certainly we need to look at that. As I said, we are a small profession with few resources, so it is difficult to focus in on one area where there are so many.
I would say this is an area of priority for occupational therapists. We have been trying to make small inroads. Senator Wallin was kind enough to present at our national conference a couple of years ago to help raise awareness. We are trying to make inroads and talk to people who matter, which is why we were very excited to be asked here today. That is important to us.
If you can give us any advice as to how to move things forward, that would be very helpful, too.
Senator Nolin: I think the first thing will be on your part. You will need to develop your own plan by establishing what you have to offer and how to promote yourselves. I do not think it would work if you just knocked on the door of the deputy minister and asked, "What can I do to help you?'' "Well, what do you have to offer?'' That is the kind of homework you will have to complete before moving into promotion or meetings with the various responsible people and departments.
Ms. Steggles: Thank you. That is helpful.
The Chair: I am a bit taken aback by the fact that the other professions in the realm of assisting people get back into a normal framework of life are not seemingly recognizing your profession as being essential and what you could do in providing that asset. That is why I asked earlier whether frictions exist that we are not aware of.
Ms. Steggles: I see what you mean. I do not think there is friction; I think it is more a lack of understanding of what we are able to contribute.
Senator Plett: Thank you. Senator Nolin really touched on the area that I wanted to get into. This is why I asked earlier, "Does public health cover your services?'' I understand that public health covers your services. Workers' compensation would, as would different insurance companies.
You said earlier that Veterans Affairs had recommended that you help this individual. I am also trying to find out or trying to get a handle on who is asking for what here. I do not want to be cynical because I certainly believe you are doing a great job. Let me be clear on that. I think organizations like yours are needed.
Is it your organization that is trying to tap another source, or is it the veterans that feel they are not being served well enough? Where is it coming from? From what I understand, and the comments that you have made, veterans have a number of different areas to go to for help from your organization. Where is the ball being dropped? Where is it lacking?
Ms. Steggles: I am not sure I can answer that. It is obviously something that someone else in my organization could answer. I am not sure that I can.
Senator Plett: We have you here, though. Maybe you could, through the clerk, send us some information on that, if there is someone else who could answer that.
Ms. Steggles: Yes.
Senator Plett: I am really curious as to whether it is the veterans asking for the help or whether it is your organization that needs another client.
Ms. Steggles: From the occupational therapists that I have spoken to, who are working within Veterans Affairs, they feel that their services are underutilized and that in some areas, in some district areas, there are no occupational therapists.
Senator Plett: Could you give us something in writing through the clerk to let us know who it is who thinks that? If it is your organization that is being underutilized, I would like to know. They might be underutilized, but are they seeing people out there who need them or are they just feeling that they do not have enough to do in one day and that they do not have enough clients to work with?
Ms. Steggles: I will certainly get some more information for you and will submit that.
The Chair: We are thankful that you are here with us. The depth of your experience is there, it is just that you have a new function.
However — and Senator Plett and Senator Nolin have asked for it — the information we are asking of your association is of great significance to us achieving our aim and possibly yours. It would be quite complementary to the paper you have given us.
Senator Nolin: There is a lot there.
The Chair: Yes. Between what is in here and what you can provide, that will give us a more effective picture to be able to provide our assessment of how you will, hopefully, be properly utilized to achieve the aim of transitioning those veterans to employment. Thank you. We look forward to that response.
Senator Day: My questions, Mr. Chairman and colleagues, sort of flow from what has been asked previously.
The first point I wanted to make was that there may be other professionals who think that they are equally qualified to provide some of the services that you have outlined that you can provide. As Senator Nolin has pointed out, it will be important for to you define why you are uniquely qualified to provide the suite of services that you have outlined.
For example, I think it is unfair to suggest that nurses are only there to put bandages on and clean bed pans. I think they would be quite offended if that were suggested. Many work in areas like public health nursing, geriatric nursing and as nurse practitioners. There are many specialties within nursing that get involved not in prescribing what equipment is necessary for physiotherapy, but in the psychological aspects of patient care. You know that, so you are overlapping there.
The second comment I wanted to make was with respect to special practices with respect to veterans. We know that veterans, or injured defence personnel who need some assistance, have perhaps a different mentality than the normal person on the street. They have come through some difficult personal exposure, but they also, by virtue of their being in the armed forces, are people who will often deny a personal injury or deny that they have a problem, physical, or psychological, or mental, just because of the nature of the occupation.
You probably do not have a critical enough mass of occupational therapists working within the Department of National Defence and Veterans Affairs Canada to develop these best practices, but is that one of the areas that you hope to be developing that would make you uniquely qualified to work with veterans?
Ms. Steggles: You prompted me to think of an example as you were talking. One of the areas that occupational therapists do work in is driver rehabilitation. We do know that often people who have learned to drive in combat are actually very aggressive drivers and have a difficult time once they transition into civilian life. They tend to have more accidents than the general public. I think that is an example of where we recognize that, yes, people do come out with a different vision and a different set of skills and, yes, we recognize that there may be a different view of life for people who have been in the forces. They do need a different approach.
Senator Day: Let me end on a comic note. I was in Kabul, Afghanistan, a while back and being driven around by British drivers. They had been given the job of drivers in Kabul because they had experience in civilian life in driving in London.
Ms. Steggles: Yes; I love driving in London.
Senator Day: That is the other side of this.
The Chair: Thank you, senator. As we conclude round two, and I do not have names right now for round three, we have an individual who is going to therapy every week, most often to psychologists and, maybe every month or so, to a psychiatrist. However, between these sessions the individual is back home and the family is affected by the state of mind of the individual and the impact that individual has on the family.
Is it your field work to actually go into the family and assist them in living with this state of affairs so that the family can assist in stabilizing the individual who is injured, and also prevent the family from going catastrophic under these conditions? Is that an area of your expertise?
Ms. Steggles: Yes, I would agree with what you have said. If we go back to the example I spoke about, it was actually the psychologist and the occupational therapist who told me about that particular person. The psychologist was seeing the man in her office, but things were not changing because they were talking about the issues but no one was there actually addressing them on the ground. That was when the occupational therapist became involved so that they could work on what was specifically not working for the client and for the family — that is, to start with baby steps and to work on practical goals to get through the difficulties, one step at a time.
The Chair: This is not an insignificant role. Many crash during or between these sessions, and the families are under enormous stresses.
You could be deployed by the psychiatrist or the psychologist to actually cover getting your boots dirty in the trenches with the family to assist them in applying what is being worked on?
Ms. Steggles: Yes.
The Chair: Let me then push that into the other area. What about transitioning into the workplace? Does industry want you to assist an injured veteran, coming in with some limitations, to adapt both the workplace and the individual to each other to make that effective employment?
Ms. Steggles: There certainly are manufacturers and businesses that employ occupational therapists. One I am familiar with is Toyota. They have occupational therapists on staff to, I think, primarily help their own staff who have been injured to get back into the workplace. I am not sure that there is as much willingness by employers to help people who have not been their own employees to get back into the workforce. I think that needs some advocacy for people to see the value of it. However, the occupational therapists' role would be, if someone has identified that they have skills in a specific area, to help that person to work towards that. There are vocational occupational therapy services where people can work towards specific work-oriented goals.
The Chair: This is what I am getting at. You have subspecialties there, vocational ones and others more involved with trauma and adjusting to life. Those are elements that you provide to assist people transitioning into stabilizing and then being employable, correct?
Ms. Steggles: Yes.
The Chair: The forces have a lot of psychiatrists, but they have very few psychologists and tend to contract them out. However, they have recognized, as has Veterans Affairs Canada, that there are difficulties when people are moved either from one place to another or from one service to another, DND to VAC. They get a different therapist. They are conscious of trying to prevent that. They have potential therapists from VAC already working within DND so that there is no change of therapy because this is long-term work.
You have been at this for a hundred years. If anyone in DND and VAC should have a strong foothold in what is required for veterans, it has to be your outfit, and yet you are giving us the impression that you are the third man or the blank file that is not there. I am just trying to comprehend why your profession has not been far more engaged in that process if you have that much history.
Ms. Steggles: I think there are a number of factors here. One is that, in the past, we have not specifically looked at outcomes of our interventions. We are much better at that now. We are much better at providing statistics, looking at evidence-based practice and being able to provide good supports, not only the outcomes for the individual client but also financial outcomes. I would say that, in the past, we have not been particularly good at that. We are now. In fact, around the world, Canadian occupational therapists are seen as leaders in the profession. We have developed the Canadian Occupational Performance Measure, which is used worldwide now. I think that that is helping. I know from my own practice that being able to provide statistics that show, in number form, the success that someone has achieved makes a difference.
I think we are getting there in that respect. Again, we are a small profession and are often outnumbered by some of the other professions who may not have as good an understanding of what we do.
The Chair: You are going to have to get rid of that paranoia about numbers because you have a quality product that it seems to me others are not providing — you are going into the families, into the trenches, between these formal sessions, in order to assist and alleviate. I think that between you and peer support, you are probably of enormous assistance. That requires both the profession and us to recognize that. Thank you for that information.
Senator Nolin: One point, if I may. Being a profession means that in each province there is an order for your profession. Everyone who practices ergothérapie, as we say in French, in the province of Quebec must be registered.
Ms. Steggles: That is correct.
Senator Nolin: Across the country, there 13,000 members?
Ms. Steggles: Yes. They are not regulated in the territories, but they are in every other place.
Senator Nolin: Being regulated means that you need to go through specific schooling or studies and through an examination. Is it possible to send to the clerk and to our researchers documentation on the kind of classes that you go through, the type of exam you go through and any kind of information you want us to know to convince us that you are professionals in a specific field?
[Translation]
The Chair: They all have a master's in occupational therapy.
Senator Nolin: That is what I want to know.
The Chair: That is useful because it will provide us with another point of view.
[English]
Senator Nolin: What is the annual budget of your association?
Ms. Steggles: I am sorry; I cannot give you that number off the top of my head.
Senator Nolin: That is the kind of information that you should send us because you have quite a challenge in front of you, and you will need resources.
Ms. Steggles: That is difficult.
Senator Nolin: Yes.
The Chair: Would I be correct in saying that both DND and Veterans Affairs call upon your occupational therapists to help the families as much or more than the actual members who are injured?
Ms. Steggles: I think that because we see people not just in isolation as the person but also as part of a family, part of society and part of their environment, yes, we would include them.
The Chair: I know you have been saying that the sooner we get people into the workforce the better. Therefore, the Canadian Forces should probably not be keeping people long and should be transitioning them earlier. However, the forces have an incredible loyalty link and culture that you do not break just because the individual is broken. They are, I gather, in their three-year accommodation programs and the joint support units that we have seen, employing them. They are not just sitting at home moping. Maybe your association might want to take a second look at that dimension of how DND is taking care of its people and see whether you still hold that position. We would love an answer from you on that point. Any last comments, Ms. Steggles?
Ms. Steggles: No, thank you. Thank you for listening.
The Chair: Thank you for being candid with us on this.
Honourable senators, I just have two points before I close this session. I bring to your attention the Auditor General's report on the transition of veterans that came out yesterday, Chapter 4. If you do not have it, I will ask the clerk to get it distributed to you. It will be a worthwhile read because it will get right into what we are doing; the timing is impeccable.
Senator Nolin: There are many chapters in that report.
The Chair: Yes, there are other ones also, but I bring up this one.
Senator Plett, you have delegated the steering committee to do the vetting of the draft report on the New Veterans Charter that we have done. We are now down to just the last couple of phrases to review. Senator Plett and I will come to a conclusion by Friday, which means that next week you will get the draft copy in English and French. Although we were aiming for next Wednesday to review it, I do not want to do that because it does not give you enough time to read it. We do not want a useless exercise of line by line. We want people coming back having read it. We will shift gears a bit if that is okay, Senator Plett. Next week, we will have Veterans Affairs come, and, the week after that, we will do the review of the charter. It will give you about 10 days to review the document.
Senator Plett: After the break?
The Chair: After the break, sorry. That is right, so it gives you another week.
I remind you that you did delegate enormous responsibility to the two of us. Our staff has been working on this for nearly a year, reviewing line by line many times. The staff has done exceptional work, so I am not looking for people to tell me, "I do not like a comma here or there.'' I want to know are we out to lunch or not? We will start the review with the recommendations and then the text if that is okay.
Senator Plett: If it is a good report, Senator Dallaire and I would like the credit, but, if not, as he said, the staff did most of it.
The Chair: If it is not, I will put it to the full body of the committee. It will be the committee's problem, not the staff's.
Thank you again, Ms. Steggles.
(The committee adjourned.)