Proceedings of the Subcommittee on
Veterans Affairs
Issue 6 - Evidence - May 28, 2014
OTTAWA, Wednesday, May 28, 2014
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 medical, social and operational impacts of mental health issues affecting serving and retired members of the Canadian Armed Forces, including operational stress injuries (OSIs) such as post- traumatic stress disorder (PTSD).
Senator Roméo Antonius Dallaire (Chair) in the chair.
[English]
The Chair: Ladies and gentlemen, thank you for being here today as we commence this study on post-traumatic stress disorder, with a focus on where we're going to go with this as we move it into the new era.
I am glad that you are here, my colleagues. I am also quite honoured still to be able to chair this committee and thank you for that support. Thanks also to the team around.
To you, our dear guests, welcome. You are opening this thing up, and we are looking for a sort of clinical perspective, I think, of it. We look forward to your expertise to guide us as we commence an extensive study that's been in waiting, commenced by Senator Plett nearly a year ago as we discussed it. Now, with Senator Wells and Senator Lang in support, we are actually starting it.
Remember, we want to know what the problem is; what this injury is; how we have been handling it and its impact; and where we go to reduce its impact into the future and, ultimately, reduce the casualty levels, the scale of casualties, and provide all the more better support to those who have been operationally stress injured through their commitment to missions and the impacts thereof.
So welcome to you. Just a short word from both on who you are so that we get that properly. Then, we've got until only a quarter past one, so, in your opening statements, please be more disciplined than I am. Thank you.
Howard Chodos, (PhD), Director, Mental Health Strategy for Canada, Mental Health Commission of Canada: Thank you, Senator Dallaire. My name is Howard Chodos. I'm the Director of the Mental Health Strategy at the Mental Health Commission for Canada.
Jennifer Vornbrock, Vice President, Knowledge and Innovation, Mental Health Commission of Canada: I am Jennifer Vornbrock, and I am the Vice-president for Knowledge and Innovation with the Mental Health Commission of Canada, as well. I am pleased to be here.
The Chair: And eminently qualified, both of you, to give us the start. So, please.
Mr. Chodos: We certainly hope so, senator.
Our expertise is largely in the area of system change, policy, and the overall mental health system and structures in this country. I hope that this will provide you with some context, perhaps, more than a detailed, clinical look at the injury itself. Those are the remarks that we have prepared and sort of the areas where we hope we will be able to give you a start in thinking about mental health and mental illness in this country.
Just to let you know, prior to joining the Mental Health Commission, I really had the enormous privilege of having worked with Senators Kirby and Keon on the Social Affairs Committee's landmark study on mental health and mental illness, Out of the Shadows at Last. In those days, I was more used to sitting on that side of the table, as a research analyst with the Library of Parliament, than on this side of the table as a witness, but, when Senator Kirby started the commission, I was really honoured to be able to be with him at the initial stages and throughout the development of our Mental Health Strategy.
As many of you know, the commission is funded by the Government of Canada but operates at arm's length from government. We were given a 10-year mandate with three initial components: to develop a mental health strategy for Canada; to conduct a systematic effort to reduce stigma in the country; and to build a knowledge exchange centre that would facilitate the translation into practice of evidence, ideas and innovations from international, national and local sources of knowledge.
As well, shortly after its creation, in 2007, the commission received an additional $110 million from the Government of Canada to conduct a multi-year, multi-site demonstration study to test a leading approach to addressing homelessness among people living with a mental illness.
I'm pleased to report that we have made important progress on all elements of the mandate of the Mental Health Commission of Canada. The Mental Health Strategy, Changing Directions, Changing Lives, was released just over two years ago, and both our Opening Minds anti-stigma initiative and our Knowledge Exchange Centre have documented their efforts in recently released interim reports. The At Home/Chez Soi homelessness demonstration project was successfully completed last March and its final national report was issued this past April.
The progress on the specific elements in our mandate parallels advances throughout Canadian society over the past decade to move mental health issues out of the shadows. One has only to look at the investment being made in mental health on the part of many leading corporations, at the efforts made by the press to enhance coverage of mental health issues, or at the development of mental health strategies and action plans by the provincial and territorial governments across the country to see that much has changed for the better. We know that, while our work at the commission has contributed to this positive shift, this progress is by no means down to the commission alone but has been the result of the ongoing efforts of countless thousands of Canadians who work in the mental health system and advocate for change on a daily basis. At the same time, there is still an enormous amount that needs to be done to further change attitudes to mental health and mental illness, and improve access to the services, supports and treatments that people need. In our country, as in many around the world, it is estimated that two thirds of adults and up to three quarters of children who could benefit from mental health services do not, in fact, receive them.
The Mental Health Strategy and all of the commission's initiatives and activities are directed at improving mental health outcomes for everyone living in Canada. We are by no means experts in every dimension of mental health, and we undertake all of our work in a spirit of collaboration and partnership, because improving mental health and well- being is a job for all of us, for each and every Canadian.
The Mental Health Strategy for Canada reflects a broad consensus, and its six strategic directions provide a comprehensive blueprint for change for the mental health system as a whole.
The priorities and recommendations in the strategy also set the stage for developing specific mental health strategies for specific populations. If there is a theme to my remarks today, it is that we need to pay attention both to the common features of all mental health issues and to the specific ways in which they play out in different settings and contexts.
To illustrate what I mean, I would like to begin with two overarching issues: the persistent challenge of stigma and its counterpoint, the hope of recovery.
We have often heard from people with lived experience of mental health problems and illnesses that stigma can cause as much, if not more, distress as their illness itself. Stigma inflicts pain, isolates and marginalizes people, and constitutes a barrier to help-seeking. Confronting stigma means confronting two realities about mental health: First, just as mental health is of concern to all of us, the stigma that still attaches to mental illness remains pervasive. That means that, no matter what the context, it must be addressed. Second, just as we are all unique individuals who may require different things to improve our mental health and well-being, so too must stigma be addressed in ways that are adapted to each setting and community. In other words, we have learned through our Opening Minds anti-stigma and discrimination initiative that there are indeed general lessons that can be applied everywhere. Most importantly, it is contact with people in recovery from mental illness that best changes people's attitudes, but this lesson must be applied in a way that is adapted to the context and needs of those we are trying to reach.
The same two realities inform the approach to mental illness that underpins the Mental Health Strategy and all of the commission's activity; namely, that everyone who confronts mental illness should have the hope of recovery. The Senate committee said it first — a recovery orientation must be at the centre of mental health reform in Canada.
But what do we mean by "recovery" in a mental health context? It means starting from the conviction that everyone who lives with a mental health problem or illness can aspire to improving their mental well-being, to achieving goals that they set for themselves, and to leading meaningful and contributing lives in the community of their choice.
Recovery in this sense does not mean the same thing as "cure." We do not yet know enough to suggest that everyone can fully eradicate the impact of mental illness, although many do. But we do know enough to say that our mental health system, in whatever setting, or with respect to whatever illness or condition, can and must instill in people the hope of progress and that it must walk with them and support them on their journey of recovery.
A recovery orientation asks us to see the whole person, their strengths and abilities, not just the challenges that they face. It asks us to see the person in the context of their community, their family, their culture and background, and to adopt a holistic approach to supporting them on their journey of recovery.
A comprehensive recovery-oriented approach to mental health acknowledges the essential role of the health system in contributing to people's recovery, but it also points to the importance of having a job, a home and a friend as factors that contribute to everyone's mental health and protects everyone from mental illness.
On all of these fronts, the commission has worked with partners from across the country to develop practical tools to advance mental health and well-being. I would like to give you just a few examples, not only to illustrate some of the successes of our work to date, but to underline the importance, again, of applying a consistent general approach while adapting it to the many particular contexts that affect our mental health and well-being, as you are doing as you undertake this study.
The commission initiated and helped guide the development of the world's first standard for psychological health and safety in the workplace. It is a voluntary standard, but one that has already been embraced by leading private and public sector employees. Recognizing the enormous diversity of workplaces in any complex economy, the standard does not prescribe a simple one-size-fits-all formula, rather it provides guidance on what procedures, processes and tools can be utilized to promote psychological health and safety, and to address potential hazards in workplaces of all shapes and sizes. Among these tools is an action guide for employers that the commission developed, and we have just initiated a three-year case study to document the impact of the standard in over 30 workplaces across the country, including government agencies such as CSIS.
In developing specific tools for the workplace, we have sought to build on the most promising practices, and one of these is the R2MR program developed by the Department of National Defence for the Canadian Armed Forces, with which I believe you are already familiar. Our Opening Minds team has worked with DND to adapt this approach to civilian workplaces and to pilot training and education based on the R2MR continuum.
We have also drawn on the experience within both the forces and Veterans Affairs with respect to providing access to peer support as a key component of supporting people's recovery from mental illness. I remember to this day the impact that Lieutenant Colonel Stéphane Grenier's story of his experience with PTSD had on me personally and on the work of the Senate committee back in 2005, as we were working on the Out of the Shadows report. His vision for making peer support widely available as an integral part of the mental health system was central to the development of guidelines for the training of peer supporters; it was released this past year by the commission. The great success of the recent peer support conference in Halifax stands in testimony to his pioneering contributions.
We must not forget that for every person, every veteran living with a mental health problem or illness, there is also a circle of families and caregivers who are too often left to fend for themselves. From the beginning, the commission has recognized the importance of addressing families' needs so they are in the best possible position to support their loved ones. Last year we released a set of guidelines to help in the planning and implementation of mental health services that recognize and address the unique needs of family caregivers.
The single biggest project undertaken to date by the commission has been the four-year At Home/Chez Soi research demonstration project that I mentioned earlier. It was the largest research project into homelessness and mental illness ever undertaken in the world and has since been replicated in France and elsewhere. The results of the project demonstrated not only that a "housing first" approach delivers better results than treatment as usual, enabling more people to remain housed, but also it does so in a cost-effective manner. "Housing first" is a recovery-oriented approach that offers people choice in accommodation, without precondition, and then wraps the services around people that they need in order to support them as they journey towards recovery.
Let me just note that in this study, out of a total of 2,298 participants, 99, or 4.3 per cent, identified themselves as veterans. The study found that while the veterans in the homeless population who are living with severe and persistent mental illness did not differ much from other Canadians who are homeless, they were indeed 1.4 times more likely than other Canadians to suffer from PTSD. The study also concluded that the intervention tested through the At Home/ Chez Soi research project could help end homelessness in veteran populations and would also have other benefits regarding quality of life.
Another initiative that the commission has supported is the development of a continuing medical education module on PTSD for Canadian physicians under the auspices of the Canadian Depression Research and Intervention Network, CDRIN. It is currently in the final approval stages with the Canadian Medical Association.
We have also made suicide prevention a priority, working alongside the Public Health Agency, members of Parliament and the broad stakeholder community to raise awareness, disseminate best practices and strengthen collaboration.
In closing, the Mental Health Commission of Canada takes pride in being a trusted adviser to government on mental health in Canada. We are honoured to be here today to speak about some of the initiatives of the MHCC that may be of interest to the subcommittee as it undertakes its important study on operational stress injuries.
Looking ahead, we are optimistic that advances in knowledge and in our collective ability to apply it in a humane and caring way offers a brighter future to all Canadians who are confronting mental health challenges and, in particular, those who have sacrificed so much to serve our country at home and abroad.
Thank you and we welcome any questions and comments you may have.
The Chair: Thank you very much for the comprehensive overview of the work that you have been engaged in with this strategy.
Would you just articulate R2MR for our viewers?
Mr. Chodos: Road to Mental Readiness. That's the program that's based on a continuum of moving from good mental health through various challenges to experiencing mental illness. We have included in the kit that we distributed to the senators the civilian version of that continuum that's being developed for civilian workplaces.
The Chair: Very good.
Senator Lang: Before I begin, you have indicated you will be announcing your retirement from the Senate, and there will be a time and a place to speak to that, but as a member of this subcommittee and as chairman of the National Security and Defence Committee, I am just going to say, Mr. Chairman, you are going to be missed.
From your perspective, since you have some history now, I would like to examine the question of how we are looking forward at advancing ideas and implementing them. The reason I ask this is, first of all, I do believe that, as you indicated, you have accomplished in part your mandate in bringing the question of mental health/illness to the attention of Canadians. As one who has observed this over the last 10 years, it's become more and more evident, especially when you witness the Clara Hughes of the world, and various individuals like that who are coming out to the public and speaking of very real issues they have personally faced and know others have faced, but the others have not been prepared to bring it forward. I think the chairman can speak to that as well. It's very healthy for our community. I don't think there is a family in Canada that has not been affected in one manner or another. As families, we all struggle with how to deal with those who are close to us and to be able to help them help themselves.
You spoke earlier about the importance of jobs, friends and family. I couldn't agree more with how important they are, but I want to ask from a practical point of view. In your presentation you talked about the provinces and the territories; I think you mentioned them once. The reality is that, for the most part, they are the delivery system for any of our social programs across Canada. A program tailored in Prince Edward Island might be much different than one in Yukon, looking at the demographics and the problems we face, although the objectives are the same.
I want to ask how you view the provincial and territorial governments and their roles with regard to putting the necessary programs in place. What responsibilities does the Government of Canada have in that area? Perhaps you would like to comment.
Mr. Chodos: It's certainly a question that preoccupied us greatly in many ways when we were developing the Mental Health Strategy for Canada. We were mandated by the Government of Canada to develop a national strategy in the context of a country where, as you rightly note, the delivery of health care, the organization of health care systems, and the delivery of social programs are primarily the responsibility of the provinces and territories. Our approach in addressing this was to try to engage as best we could with the provinces and territories. We created an advisory panel so that they were informed of the progress we were making in developing the strategy as we moved forward.
We also recognized that anything we were to develop would have to appeal to them on the basis of "it's the right thing to do; it's the right way forward." We don't have the power, any more than the federal government has the power, to instruct the provinces on the way to conduct what are constitutionally their respective areas of responsibility.
We tried to develop a plan that moved forward in sync with where the provinces and territories were headed, provided guidance to them, worked with them to understand the recommendations and strategy, and worked to see them move forward in different ways in different provinces and territories. For example, I mentioned the issue of peer support as one element we recommend in the strategy as moving a little bit outside the box to develop ways of providing support to help people move forward in their journey of recovery that isn't a traditional way within the mental health system.
Recently — and this was reflected at the conference in Nova Scotia I mentioned at which Senator Dallaire was one of the keynote speakers — the Government of Nova Scotia implemented a program to embrace peer support. It wasn't exclusively because it was a recommendation in the Mental Health Strategy, but I'm convinced that the work we've done at the national level to open the door to these kinds of initiatives has had an impact on the ways in which the provinces and territories have moved forward.
New Brunswick is in the process of rolling out a reorganization based on the recovery approach that I mentioned. This is a significant change that is designed to put the control of the journey of recovery for each person into their own hands as much as possible, to view the system as a support, and to not dictate to people how they should pursue their mental health and well-being. The Government of New Brunswick has chosen to roll that out in a systematic way with a province-wide orientation. That's different. I wouldn't say that other provinces have done exactly the same thing.
British Columbia focused a lot on mental health promotion and illness prevention in a population health approach, which is also in accord with the recommendations and the strategy.
We've seen that each province is at a different place, has a different set of resources, and will have a different set of immediate challenges that it has to confront. The Mental Health Strategy was designed to have recommendations that would enable the provinces to work on different aspects so that together we would row in the same direction toward fundamental change in the way mental health and mental illness are viewed in this country.
The Chair: That's quite a complete answer.
Senator Lang: I want to follow that up from a pragmatic point of view in respect to the responsibility of the federal government and the provinces and the territories. I get concerned when I hear sometimes that the federal government's going to solve all our problems, especially when you live in, say, Yukon or Manitoba. At the same time, they have their role, obviously.
Do you see our role, at the end of the day, involving financial agreements with certain understandings in principle of how those programs are going to be delivered? If not, how do you see the role of the federal government going forward in respect to putting into effect the strategy that you talked about?
Mr. Chodos: That's a challenging question, in a way. The history of our country over the past few decades has been an evolution, as best we can tell, in terms of the approach that different parties in power have taken toward such questions as: What is the role? How can the contributions that the federal government rightly makes to support health care across the country be leveraged in a particular direction? Are these monies distributed to the provinces to utilize as they see fit?
To be frank, in the Mental Health Strategy we did not take a firm position on this. However, we noted that there is a gap in terms of funding for mental health issues and mental health programs that puts us behind other leading countries in terms of the amount of public dollars being spent on mental health and mental illness in this country. We recommended that all governments contribute to closing that gap and increasing the amount spent on average across the country form 7 per cent of public dollars to 9 per cent, which still wouldn't have us leading the world but it would get us up to where some of the leading countries are, such as the U.K. and New Zealand, in terms of their overall spending on mental health.
I refer back to the report of the Standing Senate Committee on Social Affairs, Science and Technology, Out of the Shadows at Last, which recommended that the federal government initiate a transition fund that would have a fairly broadly defined set of criteria for provinces to have access to move mental health out of institutions and into community supports and services. The report used that framework to try to encourage the federal government to, in a sense, ring fence some monies for mental health in order to make up the gap in spending, which everybody realizes is the result of the neglect of mental health issues over the past number of decades.
I don't think we can provide you with a specific formula for that. Certainly, if there is to be progress in closing that gap between what's spent on physical health and what's spent on mental health, it will require in some way a concentration of effort on mental health in terms of funding priorities.
The Chair: This session is very helpful in setting the backdrop for us as we bear down on the area we're particularly interested in. Thank you for the completeness of your answers.
Senator Day: Mr. Chodos, welcome back, albeit at a different end of the table. Ms. Vornbrock, I don't know if I'm welcoming you back or welcoming you.
Ms. Vornbrock: First time.
Senator Day: Welcome.
There are 26 priorities and 109 recommendations, sounding like a comprehensive grouping. Luckily for us, you've grouped them into six strategic directions. We'll have a chance to delve into those.
With that kind of broad brush, did you have an opportunity to narrow down the areas that we're particularly concerned about, such as post-traumatic stress disorder not only for military but also first responders, police who have come across difficult accident situations, and the medical profession? Within this big group, do you have a grouping and focus on that particular area?
Mr. Chodos: Not specifically in terms of the recommendations, as such, but certainly in terms of the work the commission has done subsequent to the development of the strategy and the work around other areas. As I mentioned, there are things we have tried to do in each of those areas. We worked with the Canadian Association of Chiefs of Police recently to co-host a conference that focused both on interactions between police and people experiencing mental health challenges, as well as on the mental health of first responders themselves.
So, there are particular initiatives we have undertaken subsequent to the development of the strategy that concretize and work in the same direction you're heading with your study today.
As you can appreciate, we were not focused on specific types of mental health problems in the Mental Health Strategy, because otherwise there would be no end to what we would have to cover; we would have ended up with not just 109 recommendations, but 1,009 recommendations. We had to set a framework for that which would also be relevant to the whole country. That explains the breadth of the focus of the Mental Health Strategy.
At the same time, as I said, we tried to set the stage so that it provided a context or a framework so that the work on all of these other specific issues right across the mental health system could be developed.
Senator Day: You indicated during your remarks, Mr. Chodos, that military personnel have 1.4 times the likelihood of post-traumatic stress over other occupations. That got me thinking about focusing in and detecting; maybe there are special things that can be done to reduce that multiplier if we knew beforehand that first responders and military personnel are likely to suffer post-traumatic stress unless they are prepared in some way.
Are you working on that area of preparing them beforehand to handle the stress in a way that does not result in mental illness?
Ms. Vornbrock: I can talk a little bit about that. As Howard said, in our attempt to develop the Mental Health Strategy, we tried to make it large enough and comprehensive enough so that there was something for everyone. In terms of the way we really landed on the work, in the last year and a half to two years, we have worked very closely with Veterans Affairs Canada, the Department of National Defense, the RCMP and, as Howard noted, the Canadian Association of Chiefs of Police to begin to develop what we think might be some ideas for early identification or early intervention.
A critical piece Howard mentioned in his opening remarks is thinking about the workplace standard. Whether it's policing on the job or being a member of the Canadian Armed Forces abroad, working in a work environment where your employer — whether that may be your superior officer, staff sergeant or anybody working with you as a first responder — is sensitive enough to understand what is going on in your work at any given time. It is about having the kind of culture of work where you can identify those issues early on and seek support and help to return you to work and to full duty.
We have had some really enlightening and helpful conversations, and we see our role at the Mental Health Commission of Canada to offer that advice when it's asked for. We were at a roundtable this past week with Veterans Affairs Canada regarding the use of service dogs around post-traumatic stress disorder. We were pleased to be a part of that roundtable. As Howard noted, we have also worked with the RCMP on the R2MR work. We also work with the Canadian Association of Chiefs of Police; we will be hosting an entire conference with them in the new year specifically on the mental health of their officers in the workplace. It wasn't the intention of the conference that we held earlier this year, but it ended up being the primary topic of conversation. We had RCMP and officers in police jurisdictions across the country — there were about 250 delegates — coming up to us and saying, "Thank you so much for this opportunity to share what it's been like for me to work in this environment for years."
The workplace standard and other real tools like that are a real value added for folks so we can get to that place where you're talking about where early identification can happen, and where early intervention can also take place and people can get the support that they want to continue on.
Senator Day: That's great. Maybe I will go on round two.
The Chair: Yes. I am surprised that you are going from a strategic perspective, which you articulated as a consistently general approach, that can be adapted to going into some tactical solutions. But I will reserve a question for that later on.
Senator White: Thanks to both of you for being here. I have two questions, if I may. One is probably quicker than the other.
The first one is around the records of those who are interacting with the police. I know you have been meeting with the CACP in relation to mental health, and the fact that those records are being accessed in some cases at borders, exiting the country, even though no criminal aspect often is attached to those records. Have you been successful in finding a solution to the access or the maintenance of those records and the fact that they are being utilized and accessed by people not for the intent that they were originally collected?
Mr. Chodos: That is one area we actually did specify in the Mental Health Strategy for Canada as an issue that had come to our attention that we felt was really important to address. It was a reflection of the stigma attached to mental illness, in general, and just some specific practices.
I don't know the details, but my understanding is that there was some success in some provinces in removing reporting on those kinds of records from —
Senator White: Criminal records.
Mr. Chodos: — criminal records and background checks. Saskatchewan, I believe, has made progress in that area. I don't know if you know the details of how that was done.
Senator White: Nationally, we have not seen a success story in this.
Ms. Vornbrock: No, we have not.
Mr. Chodos: It is positive that this issue is now out in the public domain and that people are aware of it. In the most recent news reports that I've seen, it's almost been broadened, as well, such that it's related to mental health and mental illness, but also that there are other dimensions of interactions with the police being reported, which are also subject to disclosure.
By making that kind of broad front of people who are concerned about this issue, we could see some increased public pressure to address it and not see it as isolated cases of just a few people who may have experienced a mental health challenge.
There have been some positive developments, although we've not yet reached the point where there is a national solution.
Senator White: I apologize. I know it stretches beyond OSI, but I think it is of interest to the Canadian public, in particular.
My second question refers to the comments earlier around housing, in particular the Housing First model. I am sure you are familiar with the Common Ground model out of New York that is very successful.
The fastest growing number of homelessness is coming from the military in the United States. Now, that's a little bit of a red herring, because in the United States, I think the average career of a soldier is four and a half years. A lot of people join at 18, leave after they serve their four years and have access, they believe, to other opportunities. That is unlike in Canada where it is often a career.
Are we seeing Canada a large growth of homelessness? Having the experiences I've had, I know about the number of homeless people who also have mental health issues or challenges. Are we seeing that same growth, or any level of that growth, in Canada among homelessness and our military obviously in connection to mental illness?
Ms. Vornbrock: I will comment on that one.
Out of the little more than 2,000 participants of the At Home/Chez Soi study which was in five jurisdictions in Canada — Montreal, Toronto, Vancouver, Winnipeg and Moncton — only 5 per cent of those were veterans. We did have that conversation, because I was asked by one of the departments to comment on whether there has been a growth in veterans' homelessness over the last number of years, and there is no definitive answer, unfortunately. Because of the At Home/Chez Soi study and because we did some specific questions surrounding veterans, finally now we are starting to have some research. So it's something that we will keep an eye on and be mindful of. I think 5 per cent is still a significant number.
Senator White: Sure, it is.
Ms. Vornbrock: What is interesting to perhaps explore as a piece of research is where do veterans tend to go? This was in four fairly large Canadian cities and then, of course, you had one smaller centre, Moncton, which I visited yesterday. This is to know whether veterans would choose to return home to their community, do they stay in cities, and do they have the same sort of "migratory" patterns of moving around as other homeless in Canada? There are some interesting questions. Unfortunately, I think the At Home study only gave us a few bits of really helpful information, but it raised a lot more questions for us about veterans and homelessness.
Senator White: As it may for us. Thank you very much.
The Chair: That percentage is high when you consider the number of veterans in this country.
Senator Plett: Thank you, chair, and let me first of all echo what Senator Lang already said. I had the privilege of working side by side with you for a couple of years, and they were a few of my best years in the Senate. I appreciated the time and everything that you have done in the Senate, and specifically everything you have done and are continuing to do on issues like those we are discussing today. I want to wish you well.
We'll have further opportunities in the chamber to speak about this, but let me just say what a privilege it has been. I'm happy I could be back here today substituting for Senator Wells.
The Chair: You are using up your time.
Senator Plett: I am using up my time, I know.
The Chair: Thank you very much for that.
Senator Plett: I also have two questions, if I could. First, as Senator Day already pointed out, there is a much larger percentage of mental health issues through PTSD, veterans, so on and so forth. Do you have any statistics that would indicate, out of the number of veterans who have mental health issues, a way of determining how many of them would have had mental health issues if they had been a plumber all their life instead of working in the Armed Forces or being a senator all their life?
Would many of these would have had mental health issues anyway, or is this entirely related to their service?
Mr. Chodos: That's a tough question.
Ms. Vornbrock: That's a tough one.
Mr. Chodos: We can start from the observation — and this is not just Canadian data; it's pretty well worldwide — that one in five people every year experience a mental health problem or illness, and that's on the continuum. Around 3 per cent of those are what usually are called severe and persistent mental illness: severe unipolar depression, schizophrenia, bipolar disorder. The most prevalent concerns are depression and anxiety, and then there is a whole range of other conditions and illnesses from anorexia through ADHD for kids and so on.
That's the makeup of the portrait, so for us it's a really important statistic and, as Senator Lang said at the outset, there is not a single Canadian family, because of that degree of prevalence of mental health problems, which remains unaffected by it.
My sense would be you're already starting from a one-in-five basis in the population as a whole, and unfortunately I have not seen statistics that allow us to look sufficiently at specific populations — like the veterans' population or the population within the military — to know whether that's higher or lower. Although, I think in some of the background material that we reviewed on the Armed Forces, because of the psychological screening that people undergo, there is probably a chance that there is a lower rate of prevalence of certain conditions among people joining the military. It's just a process of the screening, the eligibility criteria and so on.
Beyond that, I don't know if we have seen anything else that gives us an indication of the relative prevalence of mental health problems in the civilian population as compared to the military, how they might interact, or the conditions that people face in the military.
The statistic from the At Home study about being at least 1.4 times more likely to experience PTSD is an indication that the illness presumably comes from the conditions of work and the circumstances that serving members of the forces face in their day-to-day jobs. We know that there is an impact on their mental health and well-being, but part of the problem of being able to fully compare it to what might have happened had they remained outside is that we don't know enough about why one person who experiences a particular situation will develop PTSD and another won't.
All mental health problems and illnesses are complex and multifactorial. They all have some components of biology, genetics, environment, history, social and cultural. All of these things play in it, so it becomes a very complex job of detecting what it was that led to something in a particular individual.
Senator Plett: Thank you. I appreciate the answer and that there are not statistics out there to show that. I would just make the point that for somebody who is prone to having mental illness, if that individual then goes into a high- stress position, such as the military, that person would more easily succumb to post-traumatic stress disorder than others, but thank you.
I was browsing through your book and got to the fourth and fifth of your strategic direction priorities.
First of all, I echo also Senator Lang's comments that there probably isn't anybody around this table or in this room who has not been affected in one way or another by mental illness issues. One of the reasons, as Senator Dallaire pointed, that I suggested a study such as this is because we have all been affected, either by family or friends.
But you seem to be zeroing in on a whole lot of different groups, as opposed to making this a general problem. I don't want to be cynical of that, but I think even I come in here somewhere when it says minority language communities, francophone and anglophone. Well, I guess we are one of those, but for Metis, Inuit, First Nations, ethno-cultural and racialized groups, refugees, immigrants, this is a fairly encompassing problem. Are we making a mistake by saying, "Well, because you're a Metis that's one of the reasons why you're experiencing these problems," or is that not what we are doing here? If you could touch on that a little bit, I would appreciate it.
Mr. Chodos: Certainly. I think those chapters need to be seen as following from the previous chapters, as well, which were all focused on the entire population, starting with how we can best prevent mental illness and promote mental health. The subject of strategic direction one is to focus on people's ability to recover and be able to improve their own mental health and well-being. That's across the whole population, which was strategic direction two. The third one was looking at ways that we can improve access to services across the continuum for the entire population. The first three sections of the strategy addressed issues from the population of Canada as a whole.
Senator Plett: Don't start a book at the back is what you're suggesting?
Mr. Chodos: Your comment is an important one because there is no evidence to suggest that there is a population group that is inherently more or less likely to develop mental health problems or illnesses. What we were trying to focus on was that there may be circumstances in people's lives that we need to address in order to create better, more favourable conditions for their mental health and well-being, and that the focus on particular groups is also that these are groups that may be challenged in having access to appropriate services.
When we looked at our First Nations, Inuit and Metis population, it's the importance of cultural sensitivity and adaptation so that there is a combination of respecting traditional and cultural approaches, but also utilizing the latest in our own scientific and medical understanding of mental health problems. It is a question of trying to bring the best of both worlds for populations that approach these issues in a particular kind of way. There is also acknowledgement that in many northern, rural and remote communities the challenges of access are multiplied many times over. When we complain about access in the South, in the mainstream population, we know there are serious problems of people finding the right services at the right time. The problem in the North is often that those services are not in existence. We wanted to draw attention to the particular circumstances that were confronted by particular segments of the population in order to have that comprehensive view of what needs to be done. But, as I said, we really tried to set it up in a universal way, those issues ranging from promotion and prevention, to how we approach mental health care, to how we can better build an integrated, coordinated and seamless service delivery network intended for the population as a whole.
Senator Plett: Is mental health hereditary?
Mr. Chodos: I would say in part. Indications are that there are genetic components and susceptibilities, but I don't think you can make a blanket statement that for everybody who suffers from a mental illness it comes about because it is hereditary. There are too many instances, I think, of our seeing people who have experienced trauma of one kind or another, whether it's in the battlefield or sexual abuse at home, to think that it's exclusively hereditary. Even if it is hereditary, in many instances it won't be exclusively a function of that biology. There will need to be triggers in the environment, experiences and people that set it off in many cases, although in some cases not.
It is a diverse set of conditions, and the term — I don't know if we refer to it in the strategy — is a long word, "biopsychosocial," as being the factors that contribute to mental illness. Biological factors are always there, as are psychological as well as all of the social factors, and it's a complex interplay amongst them which makes it very difficult to know which individual has that right combination of experience, hereditary and proclivity to actually experience a mental health problem.
Senator Plett: Thank you.
The Chair: Thank you. Dr. Chodos, you would be great at question period.
I want to know what the future of your body is and who is giving you priorities in terms of effort. In that context, you've got the Canadian Institute for Military and Veteran Health Research as a body that's been created. Were you involved in bringing that about?
Can you actually treat a person who has a mental deficiency, an injury and so on, and divorce them from the family? Should the family not fall under the same treatment envelope as you were alluding to, I believe?
Ms. Vornbrock: I will start on the future question. The commission is seven years into its ten-year mandate given to us in 2007 by the Government of Canada. I think we are at a place where we are open to dialogue and conversations with all of our key stakeholders, including the federal government.
You mentioned it, and I think it's a valuable conversation with the provinces and territories, as well as all of the national, local and international stakeholders. The commission has become a fairly significant player on the international stage working with the U.K., Australia, New Zealand and other G8 countries, and mental health has become a significant conversation globally, not just nationally.
The commission is at a place now where I think there is a dialogue beginning to happen about what happens next. I think it's an interesting conversation and one in which we will be looking to a number of stakeholders to help set that new direction. We feel our job is to value-added, whether that's to the Government of Canada and to the federal landscape, to our provincial/territorial partners and, of course, to everyday Canadians.
I think things have changed significantly in the mental health movement over the last seven years since the launch of the commission, whether it's Clara Hughes' ride and Bell's work, or other public or private sector. Honestly, if you look at the scope and the number of recommendations in the strategy, we have got a long way to go yet.
So in terms of the future, it looks bright to me.
Mr. Chodos: Just briefly on your question about families, when the commission started, we had a series of advisory committees, one of which was a family caregiver advisory committee, so I think from the very beginning of the commission's work, we were deeply aware of the importance of families and of the challenges that are associated with family involvement at times.
We've tried to walk a balance between saying that, for every individual who is experiencing a mental health challenge, we strive for them to have as much control over their own course of recovery, including who they choose to involve — whether it's family members or other caregivers or peer supporters — but at the same time, starting from a favourable bias towards family involvement and recognizing that it can be an environment that can be especially supportive to people facing challenges.
The Chair: It's a challenge for us when we are taking care of the troops and the veterans federally, but the families fall provincially, so you can imagine the complexity.
Senator Day: Ms. Vornbrock, I can't help but let you know that I'm from New Brunswick. You mentioned Moncton being a small community. In fact, a lot of times small communities and regions with a small population tend to do more than their fair share of populating the Armed Forces. That may be a factor that you will want to look at when you talk about all the factors that go into this from the point of view of susceptibility or otherwise to post- traumatic stress.
My question is whether you have, from a stigma point of view, looked at whether in the Armed Forces individuals develop this macho attitude, "I'm okay. I can't say anything to anybody because if I do I will be looked down upon by my colleagues and the other people in the troop." Is that something that is developed after one joins the Armed Forces, or is that an attitude that prevails in those that apply to become members of the Armed Forces? What factor does that have in trying to deal with this stigma issue?
Ms. Vornbrock: That's a doozy of a question. I think what I would comment on is that it's hard to know. I think it's all of those things. I think you perhaps have that when you sort of decide to join up. I think you have it, perhaps, if you join a particular part of the organization and it's particularly prevalent there. But what I have been impressed with in in the conversations that I have had, whether it's been with police officers in the police forces or RCMP, or even with Armed Forces members or veterans themselves, is the openness and willingness to talk about that issue, to talk about that culture, and to talk about that it may exist and how we work within that to sort of move forward.
I don't have any clear solutions or answers to where that culture comes from, but I do see an awareness and openness to address that stigma, even in the most unlikely places, like the military, where you think, "Geez, can we really talk about that?" I'm seeing brave individuals come forward talking openly about their mental health problems.
Senator Day: I think that's positive.
Senator Lang: This is the first day of our study, and it's going to take some time to review all the information that we were provided with and come to conclusions. Can you tell me, in your experience or knowledge, if there is a standard definition of PTSD? Do you have a full list of all the programs available, in our case, to veterans, that are in place at the present time? If you do, could you make it available to the committee?
Mr. Chodos: I think the short answer on the second one is no, we do not have that information on the programs. If I recall, as well, from the days of the Senate committee study, which I reviewed briefly before coming, one of the recommendations in that study was to compile that kind of list, and that wasn't available back in 2006 when the Senate committee report was issued. To my knowledge, I have not seen that since then. That was certainly for both the military and Veterans Affairs. Some of the key recommendations that date back to that report were to get a complete reporting on the services that were available. Let's have this information available to parliamentarians so we know what was actually going on.
So I can't comment on how well or poorly the departments have lived up to that recommendation, but to my knowledge, at any rate, we haven't seen that comprehensive list.
On the clinical side, unfortunately, that's not my area of expertise. I'm sure that in the clinical reference bible, the DSM-5, which was just released by the American Psychiatric Association, clinicians will have a relatively clear definition. The issue with all of these definitions of mental health problems is that they are all based on symptoms that are displayed. We don't yet have the ability, as with cancer, say, to understand the internal functioning of the mind and to be able to pinpoint the causality of these things. What we rely on, in general, is what these look like, how they present in practice, and what are the clusters of symptoms and syndromes that people who have these conditions display.
I think the challenge is that there are often symptoms that can be present in multiple kinds of mental illnesses, which is all down to the skill of clinicians to be able to decipher what the appropriate diagnosis is, but certainly we know that people go through a lot of trouble to get an accurate diagnosis.
Senator Lang: Mr. Chairman, before we leave this, could I ask that we have the clerk perhaps correspond with the authorities and see if there is a list of programs?
The Chair: Yes. I think we can do that.
Senator Lang: Okay, thanks.
The Chair: Also just to inform you, over the next couple of weeks, we are going to get expertise on the clinical dimension of the injury, and I think that will be quite helpful.
Thank you for your response. Senator White?
Senator White: Thank you very much. When I heard the question around whether it was hereditary, I remember my dad saying "You got it from your kids," when I was young.
The Chair: A lobotomy, right?
Senator White: Sorry, a little bit of levity.
My question actually surrounds two parts, and one is presumptive PTSD. I think the Province of Alberta has been the first province that has accepted and passed legislation around presumptive PTSD, and that is that it's anticipated, if you're in certain occupations and you have PTSD, that you would have automatically expected to have received it from your employment as a police officer or from the military and others.
Ontario is fighting against it. A number of organizations, including police service boards and police chiefs, are fighting against presumptive PTSD. My question is around if you have given any thought to it or done any work on it.
Second, have you done any work on secondary PTSD, those people who end up with PTSD as a result of dealing with people who have PTSD?
If the answer is "no" and "no," I'm okay with that because I will chase somebody else for it.
Mr. Chodos: Actually, on the presumptive, you just told me something I didn't know. On the secondary, I'm aware of it, but we haven't really done any work on it.
Senator White: Thank you.
The Chair: Thank you very much.
I wish to thank you for being here and very succinctly wish to bring to your attention that we are discussing a group of people that work within a very Darwinian environment, those in uniform or within these organizations. It's a very intolerant environment with regard to anything that might not be 100 per cent, so that in itself creates a pressure.
Second, these injuries are often not visible, and you are working with people who are essentially visible, so they, again, are not attuned to making it easier.
That brings me to the leadership pressure and things like the self-stigmatization comments that we are hearing from leadership. Do you see leadership of the structures, of those organizations, by themselves creating pressures on people to not come forward or maybe even exacerbate a scenario versus facilitating it? Have you done any work on that type of thing, on the structural sort of impacts?
Mr. Chodos: Certainly, in general. When Jennifer was speaking about the workplace standard, which is another context in which people experience many stresses, one of the keys is engaging the leadership in every organization, getting them on board, doing the educational work and getting that organized in each organization.
I think the leadership question is absolutely central, that you don't get change unless you have it coming from the top. I think that's the simple message, and I hear the bells ringing, so I will be succinct.
The Chair: Thank you very much for that.
Senator White: Recess is over.
The Chair: Colleagues, thank you very much for your questions and, again, we look forward to probably touching base with you again.
Mr. Chodos: It would be our pleasure to offer any background information or connect you with witnesses at any time during your study.
The Chair: Thank you. That ends this session.
(The committee adjourned.)