Proceedings of the Subcommittee on
Veterans Affairs
Issue 11 - Evidence - May 13, 2015
OTTAWA, Wednesday, May 13, 2015
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 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 Joseph A. Day (Chair) in the chair.
[English]
The Chair: Honourable senators, today we are dealing with the study on the medical, social and operational impacts of mental health issues affecting serving and retired members of the Canadian Armed Forces. These include operational stress injuries, sometimes referred to as OSI. OSI is a broad term which also includes post-traumatic stress disorder that many have heard about. We have been working on this study for a number of weeks now.
We are pleased to welcome today from Veterans Affairs Canada, Michel Doiron, Assistant Deputy Minister, Service Delivery; and David Ross, A/Manager, National Clinic Coordinator. We look forward to your presentation.
A little more than an hour is set aside for this meeting. Mr. Doiron, the floor is yours.
Michel Doiron, Assistant Deputy Minister, Service Delivery, Veterans Affairs Canada: Thank you, Mr. Chair. My name is Michel Doiron, Assistant Deputy Minister of Service Delivery at Veterans Affairs. I will keep my remarks short so that Mr. Ross can walk us through his presentation to explain the clinics and then actually have a good dialogue about that.
Joining me today is David Ross, he's a clinical psychologist working with VAC and he is charge of our Operation Stress Injury networks. He will be provide the overview of the presentation.
It is our pleasure to be here today to talk to you about the various works that VAC has been doing in the areas of mental health and PTSD.
VAC supports the study of mental health. I think anything that we can learn will be beneficial. Without further ado, I will turn it over to Mr. Ross, so we can get into the presentation and have more time for questions.
The Chair: Your information deck has been circulated to all of the committee members.
David Ross, A/Manager, National Clinic Coordinator, Veterans Affairs Canada: Excellent. Just to give you a bit of background, I got my PhD in Clinical Psychology from McGill in 1987. I have been working mainly in Quebec in the fields of mental health and addiction for almost 30 years now. I came to VAC in 2008 in the position of National Clinical Coordinator and about a year ago I became the Acting Manager. So that's where I'm situated.
The Chair: Are you based in Sainte-Anne-de-Bellevue?
Mr. Ross: Yes.
The Chair: This committee visited your facility some years ago. It is time to go again, one of these days.
Mr. Ross: You are very welcome. I thank you, Mr. Chair, and the committee for your interest and the energy that you are putting into this to try to come to a better understanding of the challenges that we face and the opportunities that we have. I will spend a couple of minutes going over the slide deck, just to give you an overview of the situation we're in, the network we are managing, and some of the opportunities we have. Then we'll open it up for questions.
If you would turn to slide 1, please. As everyone knows, Canadian men and women have served in a number of intense and dangerous peacekeeping and other international operations over the last several years. This has led to a steadily increasing need for mental health care.
The number of Armed Forces veterans who are receiving services is now greater than for traditional war services clients. The treatment for modern day vets with these conditions requires a sophisticated, evidence-informed and complex approach in every case. We need to take the science, move from the foundations, but it has to be tailored to the needs of each individual veteran.
There has been a general increase in VAC clients with the favourable Disability Benefit decision for a mental health condition and what you are seeing there is a reasonable metric of the gradual but steady increase in demand for mental health services since they started collecting data in 2002.
The OSI clinics are situated in a continuum of mental health services and supports. I will provide a brief summary of what those are. We can go into more detail later, if you would like. OSINN is the Operational Stress Injury National Network, which is the small but dedicated band that I belong to and is responsible to support, guide and performance manage the OSI network. The residential treatment clinic and the chronic pain management clinic are situated in Saint Anne's hospital. There are many communities specialized in patient treatment programs, which VAC has a relationship with and refers to. It's an application called OSI Connect that I believe most people are familiar with. It's an app that is on your iPhone or Android. Its purpose is simply to make services more accessible and more generally known.
VAC offers case management for individuals with complex conditions. They also have clinical care managers. A clinical care manager is brought on for a limited period of time to provide a special level of intense, supportive service to a person in need. There are also community mental health providers. I believe there are over 4,000 members registered with Blue Cross at this point. We have OSISS, which is the peer support network and the VAC Assistance Service, which now actually provides easy access to care for family members. PTSD Coach Canada is a version of PTSD Coach, the American application, which is really designed to support self-directed change. So it helps prompt people with how to cope and helps them measure how they are doing over time. Pastoral Outreach and Mental Health First Aid are programs that are just coming into their own now. These are programs that have seen great success, both in the United States and Australia, where in a relatively short period, you come in and coach a group of people how to recognize, not diagnose, but signs of distress; how to make the initial intervention; and how to support them, if they need more intensive care. It's a particularly useful introduction because what really works well is when you think through your mental health program in terms of step-care. You don't always try to crush a walnut with a sledgehammer. Most people with mental health problems are capable of self-directing themselves out of distress, if only they are given the right supports and they have the right options.
Turning to the OSI Clinic Network, we now we have 10 clinics, soon to be 11. They are located across the country from Vancouver, Calgary, Edmonton, Winnipeg, London, Ottawa and Sainte Anne's. There are outpatient and inpatient clinics — one in Quebec City and one in Fredericton. They first opened their doors in 2002. As of Q3 of this year, we have received just over 10,600 referrals. So we're very glad to be used, although we are working harder to make ourselves more accessible, and we'll talk about more about that in a second.
I have a couple of words about the clinics. On the next slide you can see when the clinics were set up and that gives you an idea of the time sequence. But the thing that I want to make clear is that this is truly a Canadian operation. Why do I say that? I say that because it is a partnership based on a gentleman's agreement between the federal government and the respective provincial governments. We fund the clinics — every last dime. The clinics are staffed by provincial care people. They are managed operationally by their own internal care people. Why is that? This was a deliberate decision taken a long time ago.
These are ultra-specialized clinics. If they are going to serve the people who really need them the most, then they need to be well integrated into the local systems of care. If you bring them in and drop them on top of local system of care, it is much harder to establish the referral networks and to develop those hallway relationships that are so important in actually making it work. So for better or worse the decision was, from the very beginning, to go this path. And it has paid off in many ways.
We've recently opened some satellite clinics. You can see them described in the following slide. So Victoria, Kelowna, Greater Toronto, Hamilton, Pembroke, Brockville, Montreal South Shore, Chicoutimi and St. John's, Newfoundland, are all of course linked to mother clinics. Each will have a varying number of staff. The plan is to deliver collaborative inter-professional care to the people who are going to be seen in those satellite clinics by using Telehealth Liaison. We are very glad to have those clinics because it really improves our abilities to reach people. The closer you are to where they are, the more likely they are to come to your door.
I would like to say a couple of words about the scope of services for operational stress injuries. What you see here is a description of the substantive services: assessment and treatment one-to-one, couple, family and groups; modality, typically face-to-face; and often Telehealth, which is at the discretion of the veteran; and outpatient and inpatient stabilization and rehab. We are family-friendly and family-focused. We work hard to work closely with OSISS and with peer support groups, again because we work better when we work together. They are particularly helpful in helping us to reach the people who need us the most, but who are perhaps less likely to walk through a clinic door unless they are accompanied by somebody they trust.
We use an inter-professional interdisciplinary approach. We learned a long time ago in mental health that no one profession has a patent on reality and that we are more likely to provide comprehensive care to the broad scope of people who need us if we work as a team, acknowledge each other's blind spots and strengths, and share knowledge and skills. That's the explicit model on which these clinics are set up.
The services are based on evidence-informed care. This is a term that you will hear often and we want to be clear about how we are using it. It means that if we are using an assessment instrument or assessment procedure or if we are delivering a treatment to a veteran, we have systematically verified the support for that intervention in randomized group trials. We are quite aware that we don't have randomized control trial, RCT, data for all of the possible permutations and combinations, so we have a set of rules to use around the extra safeguards we add when we step off the evidence-based plank. The bottom line is that we are quite picky about this one because it has become clearer as time goes by that it is more and more important for people not to go off on tangents and at least to start on the science- based interventions, particularly with the most vulnerable people.
Finally, in terms of scope of services, we will do what we can to promote community awareness and to disseminate the knowledge we have to the community providers.
One other thing I will mention briefly about one of the pillars of our network is that it's important to use an evidence-informed assessment. Otherwise, the treatment plan will be a mess — garbage in, garbage out. It's important to define the treatment plan clearly and consensually with the client. It's important to build that plan out of interventions that have been validated. Even then, it's not a guarantee of success. What you need to do — the extra added element — is to continually track your outcomes. For example, if you go to see your physician and you have a problem with essential hypertension, he will require you to undergo a blood pressure test on a regular basis. He'll receive the feedback and so will you. That way, you can consult on whether your intervention is working.
CROMIS, which we developed, is the mental health analogue of a physical vital signs test. It measures the common distress and dysfunction that are common to all diagnoses or mixes of diagnoses — ages, gender. It's a metric you can use to see generally if the person is stable, reliably improving or reliably getting worse. It's based on informed consent so if the vet consents, it is completed before each session. The report is available instantly to the clinician reviewer and the client. It's usually reviewed in the first five minutes of the session, just as a safety check. The system has been shown to consistently outperform clinicians in terms of its ability to detect people who are at risk of deterioration or dropping out.
Clinicians are good at many things, but one of things we are not so good at is picking up the people who might disappear on us or who may be getting worse under our watch. When the system is used as designed, it reliably improves the outcomes of the most vulnerable individuals. And that's irrespective of the therapist effects or the treatments used. It's a separate measure with a separate influence. We also use it for our performance management. We will start to report our outcomes in terms of how we are doing with our people at the end of the first quarter. It took four years to get it through the gate and two years to successfully get it stood up, but the wheels are rolling now.
With that I will conclude the presentation. Thank you for your attention and interest.
The Chair: Thank you very much. We appreciate your comments and such a clear explanation of the network.
At page 4, you talk about the continuum of mental health services and supports. Am I to assume that each of these bullets you have listed is in some way under Veterans Affairs or are they partners of and supported under the auspices of some other organization?
Mr. Ross: They are either directly under Veterans Affairs or Veterans Affairs is a partner or has contributed to them materially. For example, OSI Connect was created by the Royal Ottawa Hospital OSI Clinic in collaboration with us.
The Chair: Does Veterans Affairs have access to that app?
Mr. Ross: Yes. It has been disseminated across the country. It's actually on the Apple Store site.
The Chair: We're wondering about what veterans have access to. If they came to the network, would they have access to all of these items through Veterans Affairs?
Mr. Ross: Yes.
The Chair: Do they have to be referred somewhere else?
Mr. Ross: No, that would be through VAC.
Mr. Doiron: It is through VAC, which offers even more services than those enumerated here in terms of mental health. As David mentioned, we have over 4,000 contractors in the field that we utilize for specialized care in mental health. We maximize the provincial health systems where we can and the OSI clinic is an example of that. The Government of Canada pays the entire cost of the clinics, which are managed by the province. Veterans are under our care so they can go to any of the clinics and use the peer support. We collaborate with our friends at CAF and DND to try to maximize as much of the network as possible — our network and the CAF network. A veteran can go to any one of those clinics. If there is no clinic in their area and no help available — because they can be from anywhere across Canada — and if Telehealth is not available, we have resources across Canada where we can refer the individual.
The Chair: You have a good story to tell. We'd like to tell it in our report as well, so if there are any other services you haven't told us about or haven't listed, you can let us know about it in writing so we could incorporate that as well.
Going now to honourable senators, we'll begin with the deputy chair, Senator Stewart Olsen from New Brunswick.
Senator Stewart Olsen: We understand through our meetings with various people that VAC and DND are beginning to integrate more services toward better transition and that it's much more reassuring for veterans who are transitioning out. Can you give me an update on how that's going?
Mr. Doiron: Actually, that's not just for mental health but for everything. I co-chair a VAC transition committee with Lieutenant-General David Millar, who has appeared before this committee. We are looking at all the ways to improve transition. We know that when someone leaves uniform life, which has been structured for so many years, they have to find a provincial GP of some sort. We are trying to eliminate "the seam," which you probably heard the minister talk about. We are working diligently on that to streamline our case management services with case managers on the CAF side.
We are also working on health records. In many cases when someone applies for a disability award at Veterans Affairs, we need their health record. Well, health records, depending how long they have been retired from the Armed Forces, are either with Library and Archives or with the Armed Forces. We've invested money on that side to improve that so we can get the records faster and render decisions faster.
We are also working with the Canadian Armed Forces to try to figure out where we do not need the health record. We are calling it evidence-based decision making, and we are using that a lot for PTSD.
We're looking at their military operational codes. I am probably using the wrong terminology. That's the one that sticks in my head. I think they have a more formal word, but it's like the classification. What does a pilot do? What does an infantry individual do on a daily basis? We input that into our system. So when you come to us and say, "My knees are gone," and you were a jumper and had a thousand jumps, a logical person would say, "It's probably normal that your knees are gone." We're working very closely with CAF to use the same codes, the same terminology, so that (a) we don't have to reinvent the wheel and (b) it accelerates our service.
In the case of mental health specifically, for PTSD, we are doing something called evidence-based, which is, if you have served in a special duty area, an SDA, and have a current clinical diagnostic, then we're skipping a couple of steps in the process. We don't have to look over your 30-years-of-service medical record. So we're trying to accelerate that service to ensure that the individual gets the service faster.
As in one of our previous Treasury Board submissions, we are adding 15 peer counsellors to the network, and that's with DND. Some military people feel comfortable talking to other military people. Also, some of those resources are used for the promotion of the network because what we're seeing is that there are a lot of services available but that some people don't know they are there and they are not using some of the services.
Those are just some of the examples where we're working hand in hand with our partners at CF. The clinics also work with their counterparts, and I believe the military operational stress clinics have brought in CROMIS.
Mr. Ross: They are actually working on that now.
Mr. Doiron: Then we will have the same data. We will be using the same data points to advance the science and the technology.
Senator Stewart Olsen: It sounds like this is coming together, and I'm really pleased to hear it. One of the things that I noted from many of our witnesses is that there is perhaps a shift in attitude as well within the departments, DND and VAC, so that, when a veteran comes before a board, much as in the United States, the veteran is taken at his or her word, rather than, "You have to prove this." So treatment begins immediately. You don't have to wait until you get records and things. Am I wrong in that? Or has that been moving along?
Mr. Doiron: It's moving along. We have to recognize that our act still says that you have to prove the issue is service related. We have this legislative, clear marker. But, that said, the benefit of the doubt, if I can use that terminology, goes to the veteran. We are seeing that a lot more in our boards. Internally, because I have all of the adjudication processes in addition to clinics and the offices, we are actually working very hard with our adjudicators and our nurses to accept that evidence.
It has to be based on evidence, right? In the example I gave about PTSD now, if you've gone to an SDA, if you've served in a couple of tours in Afghanistan and come to us and have a clinician who says, "My client has PTSD," in the past, we would have requested your health records. It takes six to nine weeks to get the health records and do a full assessment. Now we check your service record. It's true you have been in Afghanistan, and there is a certified doctor or clinician saying, "My client has PTSD." Unless there is something really funny, generally speaking, you are in. That's giving the benefit of the doubt and saving some steps because it is very clear. It's not only David telling me this. But it's very clear that the faster we can get the people into treatment, the more chance of success and getting better they have. If it's going to take 16 weeks for me to do that assessment, that's one thing. But sometimes they may have already been two or three years out before they come to somebody. We are trying to facilitate that. That attitude is clearly moving in all areas, not just mental health, but it is moving. I know the various boards are taking that into account. As proof of that, our first-level approval has gone up from 70 per cent to 79 per cent. So that means that when somebody applies for a disability award, that's a 9 percentage-point approval on your first application, which I think demonstrates the movement.
Senator Stewart Olsen: On the Telehealth question, in speaking with quite a few members of the Armed Forces who are veterans now, I found that they were uncomfortable with the idea of talking to a camera. Is that improving? Or how are you finding that kind of interview?
Mr. Doiron: It depends on the generation. It is truly generational. Some people will never like to talk to a screen. It doesn't matter their age, but the younger people are more used to doing Face Time and everything else. So they are a little more comfortable with that process. They are not all comfortable talking to screens, but we have more uptake. You may have more statistics on that.
Mr. Ross: It's interesting because we tried to implement Telehealth. We started around 2008. We stood back a couple of years later and asked, "How is this going?" There were a couple of take-home lessons. First, we looked at the literature, which continues to show that the outcomes are as good as you can get with face-to-face, but, on the other hand, it's absolutely true that some people find that strange.
We decided to take the following tack: We offer Telehealth as an option, but we also make a point of inviting people in for the face-to-face contact so that they can get a feel for us, so that they can get a feel for the assessment. If it's easier for them, then, to complete the assessment via Telehealth, fine. If they want to start treatment face-to-face, sometimes they realize, "I don't think I really want to drive four hours in a snowstorm. On the other hand, I don't want to miss my session." So they have that option. Our experience is that the more they use it, the more comfortable they are. As long as the connection is reliable and, depending on the technology and which part of Canada you're in, this could be quite the challenge. What you don't want is a broken connection when you are trying to call whoever you call.
That having been said, the more experience people have, the more they tend to become okay with it, especially if the alternative is a long wait or no access.
Mr. Doiron: It's also one of the reasons we have the satellites. We will send a psychologist or a mental health professional to a location one day a week, one day a month depending on where it is, or maybe three days a week to help us with that. There is a certain segment of individuals who are not comfortable with the technology, so we are trying to give them all of the options we can. In some provinces, it works well, and, with some technologies, not as well.
Senator White: Thanks to both of you for being here. I appreciate you taking the time. Looking at your PowerPoint presentation, I was very pleased with the header. It has a photograph of an RCMP officer. So now I'm going to ask questions about that because, over the past couple of months, I've heard that the RCMP don't have exactly the same access that retired military members do. In fact, I learned last week that they couldn't access, for example — officially couldn't access — OSI unless they were actually on a disability pension. I think a disability pension takes about 18 months or more for approval and is never approved the first time around I understand from RCMP veterans' organizations. There has never been an OSI approval the first time around, and I do understand that you do open the door for them at times.
I'm trying to figure out the number of RCMP officers accessing OSI and the number of them accessing it but do not have formal approval — that is, they're doing it because you're being nice guys, and I'm sure you are — so we can make recommendations around changing that.
Mr. Doiron: We have to distinguish between the veteran RCMP and the serving member.
Senator White: No, the retiree.
Mr. Doiron: There is a difference. We do serve serving members, but they have to go through a different process. Perhaps Mr. Ross can talk about the veterans.
Mr. Ross: Our mandate is to treat the people referred to us. We really have no authority to take people walking in. In the case of a retiree, it would be somebody referred to us by VAC, usually the case manager. In that case, typically the person is referred to us for an assessment. When it becomes clear very quickly that there is a need for intervention, we get in touch with the case manager right away and ask him to authorize us to proceed with the treatment. Again, treatment is a separate benefit. Unfortunately, we're not authorized to make those decisions. However, we have a good relationship with the case managers. The fact that we can just pick up and phone and consult quickly is helpful in those situations.
Mr. Doiron: We have an MOU with the RCMP. For military veterans, it's our mandate. It's in the act; it's clear. It's still on referral, but it's paid from our budgets. If one person appears or 1,000 appear, the money is there; we take care of them. With the RCMP, it comes from their budget. We bill them.
Senator White: Contract service, then.
Mr. Doiron: Yes, contract services. We have an MOU with the force to provide the services and they have to be referred to us. The agreement is different as to how they work. As for the services they receive, once they're in, it's the same.
Senator White: I appreciate that. I will walk through like I'm a retired RCMP officer. Tomorrow, if a doctor referred me, I still wouldn't have guaranteed access, even though I'm a veteran of the RCMP, unless I was receiving a disability pension for an OSI incident, correct?
Mr. Ross: Yes.
Senator White: This is not a slight of reply. I want to make sure we're giving the same service to our retired Mounties that we are to our retired veterans.
Mr. Ross: The short answer is yes. A community physician cannot refer to us directly. The only referrals we can take are through either VAC or our MOU partners within the stipulated limits, and it's the MOU partner who determines those at this point.
Senator White: Without the disability pension, who knows?
The Chair: I didn't understand your last answer. Is there any movement toward changing that?
Mr. Doiron: Maybe not exactly that point, but we are talking to the RCMP presently about the entire MOU, the services we offer and how we offer them. I can't preempt what's going to be in the final copy because I don't know, but we are talking about mental health with them and other services. They have access to other services that we offer. Having that disability award is the trigger.
The Chair: We as a Senate committee are always looking for opportunities to help push things along. If there are points on which you think a shove from the committee would be helpful, let us know.
Senator White: I appreciate the service you provide and I really appreciate where you've come from and where you are. My problem is that RCMP officers serve in 800 communities that typically aren't where there are military bases. It's already tough enough to get help after they retire. Most retire where they've worked in the last two postings or they return where they came from, Cape Breton or Newfoundland. I'm trying to figure out how we can make it easier for them. The disability process is not easy and I'm not suggesting it should be. There is a reason it's arduous because you want to make sure they're actual disabilities. However, the period of time and having to go through that process in getting that help may not be the answer if they just want to get the help. From my perspective, Mr. Chair, I would like to see us make a recommendation that they have the same access. I don't care who they bill — you can bill who you like. Paying is one thing, but providing that same level of service to retired RCMP officers in the same accessible way we do for our retired military is essential to ensuring that they get that post-service care we're arguing for.
The Chair: Senator White, you make a good point and the witnesses made the point earlier, namely that the faster you can get treatment, the more likely there will be a successful outcome.
Senator White: For sure.
Senator Stewart Olsen: To that point, I'm a bit concerned that RCMP members have to go on disability. That's quite concerning because often times that would take a long time and so treatment would be long in coming. You probably know yourself that someone with, say, PTSD, would ask for help but not necessarily consider himself or herself disabled. I'm a bit worried by that. Do you think we should perhaps be recommending a change in that as well?
Mr. Doiron: We have to recognize that Canadians do have access to provincial health care and they can get mental health help there. Although they may not have access to an OSI clinic, they do have access to mental health. I tell that to veterans often when they say they can't get to an OSI clinic. In most communities across this great nation, there are psychologists and psychiatrists that you can see. I understand it's not easy.
In our home Province of New Brunswick, in Fredericton, there is a real challenge to recruit, maintain and retain mental health. We can get into all the reasons why but it's a reality that we contend with. I think it's no different, but if you see somebody and it's not an OSI clinic but they have a shingle on the door and they have a licence, we will pay for those services. The RCMP would have access to that same service.
When it comes to the OSI clinic, I think the attraction is the specialization. They have served in 800 communities, but a lot of RCMPs have also served with our military colleagues on various Afghanistan missions. I don't recall the number, but we had an RCMP officer from New Brunswick die in Haiti on activity. They are there, front and centre. It would always be positive to do anything we can for our colleagues in uniform in the RCMP.
Senator Stewart Olsen: I think we should look at something around that, chair.
The Chair: Our Library of Parliament scribes have already made a point of that for further consideration.
There is a parallel in this situation. Some of you who have been around in Veterans Affairs will recall that for traditional war veterans to get on VIP, the Veterans Independent Program, they had to have a disability. They didn't want the disability pension, they wanted VIP, but the Legion and other advisers were helping them get some sort of disability. It didn't make sense. Loss of hearing was the typical one — 5 or 10 per cent — so that they could then get the VIP. It cost more out of the public purse to allow them to get on VIP because of these rules. We worked hard to change that.
Senator White: I know of cases where RCMP officers are not retiring from the RCMP because they get access now and they won't get access the day they retire like a military employee would. Not only is it costing more, it's costing a hundred thousand more to keep somebody at home sick or not fully functional and not wanting to be employed anymore. The programs provided are spectacular and I want to commend how far you have come, honestly — I mean that. I talk to a lot of people from CANSOFCOM, in particular, who talk about the importance of the programs. But ensuring that all of our federal serving members of other agencies, including the RCMP, are covered is essential for us as a committee as well. Thank you for coming here today.
The Chair: Covered equally.
Senator White: Absolutely.
The Chair: I think that's a good point, and that has been a good discussion.
Senator Beyak: I'm just a replacement on this committee; I don't come here all the time. I have a friend who is retired from the military and he found a great breakthrough in his treatment when they started to look forward instead of back, to stop focusing on what had happened to him and move ahead. Could you elaborate a little bit more on that, the victor rather than the victim mentality?
Mr. Ross: Again, the trick is to focus on the evidence. We have an international effort going on to better understand what works. It's 2015, people, we know that most mental health conditions will probably improve to some extent if you give non-specific support. Our challenge is to be more effective. Our challenge is to help people get better more quickly.
One of the keys is to put a focus on coping and competency. That's why, if you look at the evidence-informed treatments, they all involve teaching, working with the person so they can gradually acquire skills they didn't have when they started. We're talking about a short period of time here; we're taking about 12 to 16 weeks. But the focus is on helping them learn how to take care of themselves, gain control over some of these symptoms that otherwise were corralling them into a tighter and tighter space.
However, that represents a significant departure from the mainstream of psychotherapy, which tends to be focused on the older analytic model, with no disrespect intended, but I'm only speaking about evidence-informed care for the OSIs. If you look at the ones that work well relatively quickly, they focus on building confidence.
Senator Beyak: Thank you very much.
The Chair: Could you comment on reservists? Particularly when we look at the Afghanistan mission, reservists were called up and providing the same services as regular force members but then they returned to Canada and get back into their civilian jobs, maybe not in the same community where there is a large base, so it's not convenient to go to Fredericton like the Base Gagetown people.
Are you providing attention to the reservists to make sure they are getting the same mental health treatment as regular force members? If not, what services are needed that are not being provided now that we might be able to make recommendations about?
Mr. Doiron: Excellent question because reservists, I forget the exact number, something like 25 per cent served in Afghanistan of the forces that went across. That's the number that comes to mind. I may be off a little on the number, but it's around that.
In the recent past we put a lot of effort towards our reservists. There are some challenges with the reservists because they join, they serve, they go back to their community and they disappear.
The services are accessible to reservists, and if they have a diagnostic we take care of them. When they come forward, we're okay. I think our big challenge is having them come forward and serving them in their various communities, as you've raised.
I come from northern New Brunswick. I know the Edmundston 1RNBR, my dad was a reservist up there. A lot of the kids I know served. They went to Afghanistan for all kinds of reasons. We are working with senior leadership at CAF to ensure that reservists are aware that the services are there. We are open for business.
There are a variety of ways they can get those services, but they have to come forward. I think our biggest challenge is getting them to come forward. So Lieutenant-General Millar has been very open, although he's not in charge of reservists, but he's been extremely supportive. They've put out a Canadian Forces general. I don't know if I would use the term "directed" because I'm not sure that he did that, but he was clear with the senior leadership of the reserve forces. I've met with some of the senior leadership of the reserve forces to make sure they're there.
The other challenge we have is a transition interview for a full-time military person is mandatory. So we sit with the serving member and we have a transition interview. That means, prior to them leaving, having an interview. As part of the changes we're making we want to improve that interview.
The challenge we're having with the reservists is they walk in, they come in Thursday nights and Saturdays, they decide they're no longer interested in coming in Thursday night. They bring in their kit, leave it there and they leave. And we don't have the transition interview. The direction is they're supposed to have the transition interview, but how do you control somebody who decides they're out and walks in and turns in their stuff and they're gone?
We're doing a lot of work with CAF to make sure that the services are available. We are open for business. But our big challenge is making sure the reservists know.
Anyone who has been injured, anyone we know, we have the same services we would do for the full-time members. That's not the issue once they come to us, but I think the gap, if there is a gap — and I think there is — is getting them to know the services are available. We'll do Télé-Soins. We'll do whatever can be done in their location. We'll pay for them to see a local psychologist like a regular force. We just hope they come forward.
The Chair: The Veterans Ombudsman some time ago brought to our attention that there are a lot of reservists and some regular force personnel who have retired, who are in rather poor physical and mental condition living on the streets. They're not going to be able to get this information. Post-traumatic stress is something that often manifests itself many years after the event. How are you communicating with these individuals, and are you doing something proactive to try to get them off the street?
Mr. Doiron: Absolutely. Are we doing enough? But we're doing a lot.
For the homeless, interestingly, my deputy minister, who most of you probably know, actually walked the streets of Ottawa a couple of weeks ago on a Sunday morning and found nine homeless veterans.
The Chair: Nine in Ottawa?
Mr. Doiron: We knew they were there, but they were still on the street. We're working with the homeless communities. We're working with ESDC, which has a homeless project. We have a homeless project that we're assessing now that is being conducted jointly with ESDC. We're working closely with the Legions. The Legions have put out an initiative for homelessness. We've actually partnered with vets Canada. They have boots on the ground, retired military or RCMP officers, who patrol the parks and streets in this great country and identify folks.
A lot of our homeless shelters now, they will actually ask the individual "have you served?" If the individual says yes, they refer it to us, to one of our various locations, so we can do a follow-up. Not everyone who says they have served has served, but at least we do a follow-up. Vets Canada, the Legion — just to name those that come to mind — have access to us also.
We have also put out posters to say there are services available to try to identify, as much as we can, if homeless folks are serving members. Once we identify that they are a member, then there are a series of programs that kick in, whether it is our programs, CAF programs, the Legion. We work as a cohesive team to try to get these people off the street.
It is not an easy process because there are a lot of mental health issues, addiction issues and physical issues. We also notice that some people have pensions coming in, and they're still on the street for all kinds of reasons. But there are mechanisms there to try to identify and get them into various programs.
The Chair: Good. The extra effort is worth it. You will obviously have to provide extra effort and a special type of individual to be able to handle that person.
Mr. Doiron: Absolutely. That's why we've partnered with a group like VETS Canada. They're a volunteer group, but we do provide them some funding. We do not have the resources to be on the street and be where these people may be when they are there. VETS Canada has a national network. They are out there with colleagues from various police forces.
Last fall, we also sent a letter to all police chiefs across the country, because the police working in the various towns and communities often know who the homeless people are. They see them and are sensitized to them. They also ask them if they served, and, "Here is a number you can contact. Contact them, and they'll set the mechanism in place."
We're really trying on that side. It's not something we publicize a lot, but we are out there with our partners.
The Chair: I commend you and encourage you to continue with that.
Senator White: I don't know if you have looked at the Common Ground program out of New York. They have had a spectacular program in place for about two decades for homelessness. But in the last five or six years they have been focusing primarily on the fastest growing homeless population in New York, veterans, and very young veterans. To be fair, unlike our definition, their idea of veterans is four to six years, not 20 to 24. It's called Common Ground. They have a great website and a good program, if you're looking.
The question I have around mental health is particularly around spouses of soldiers. I happened to have someone send me a report about the health of the families of our soldiers. I'm wondering if there has been any movement towards mental health when it comes to spouses and the issues that I know we're seeing with spouses.
Mr. Doiron: I'll let David talk about the OSI clinic but, as a department, we have extended some of our services to family and children, not just spouses. David mentioned the 1-800 number, our VAC assistance line.
Following the OAG report, we've increased from eight to 20 sessions that we will pay, no questions asked, and that is accessible to family members.
When we do transition interviews, we encourage the family to be there because the soldier may tell us everything is fine. When you talk to the spouse or look at the reaction of the spouse, then you realize maybe it's not as fine as the person says it is. We do encourage them to do the transition interview or come to the OSI clinic.
It is the decision of the veteran if they bring the spouse or not, but the 1-800 line is specifically aimed not just at the veterans, but also to give the spouses an opportunity to call and get their own help. Dealing with somebody that has mental health problems is very difficult and does cause its own issues, but often there is another series of issues that may come into play.
I also know, and I'm not well versed, but on the military side they have a lot of services available to spouses and families. I'm just not as well versed on all of them.
Mr. Ross: I met with all the managers of the clinics last week, and we did a round table. I asked specifically the gut- check questions: What are we doing? Is it adequate?
I verified that we provide screening assessment and couples therapy in all of our clinics. In some of our clinics we are also providing help to adolescents. It depends on our staffing. If we don't provide it, then we work with the local network to make sure it gets provided.
Sometimes the OSI clinic is not necessarily the best place, especially if you're dealing with young children, but there is a responsibility to ask. It is our responsibility to accompany and, where indicated, to provide the service.
There is no question in terms of how important the families are. Whether you're talking about OSIs, other issues or other areas of mental health like problem gambling — if you look at that, they show for every problem gambler, you have up to five family members, five CSOs, who were being negatively affected. So family can help, and family is impacted. It really underscores the importance of your question. Thank you for asking.
Senator Stewart Olsen: Just a question on the referrals. I understand that they have to be referred and, generally speaking, a case manager would do that referral. How does a VAC, a retired veteran, get a case manager, and how would the RCMP get a case manager to do that referral?
Mr. Doiron: We do a risk assessment.
Senator Stewart Olsen: Who does that?
Mr. Doiron: VAC.
Senator Stewart Olsen: Who would they call?
Mr. Doiron: They can call our 1-800 number, not the number I was talking about for the VAC assistance lines. We call it the NCC, National Call Centre number, and they say, "I need help," or whatever the dialogue. The analyst on the phone will have a chat, make an assessment and refer them to one of our offices, which then will more than likely be a client service agent, not a case manager, who will then meet and talk with the veteran. We have various tools and we will put the information in our assessment tools and determine the risk.
If you are in a medium or a high risk, then you are assigned a case manager. That case manager will then prepare a case plan for you.
It's not just for mental health. This would be for any illness now. A high percentage of our case-managed veterans — we have about 7,000 case-managed veterans and increasing — do have mental health issues.
The case manager then prepares a case plan. Is the best place for you the OSI clinic, a pain clinic? What is causing your issues? Before going to an OSI, is there a health issue that should be dealt with first? Does the person need psycho- social rehab? There is a whole assessment done and a case plan established.
Senator Stewart Olsen: How long is that process from the first call I would make to the 1-800 number?
Mr. Doiron: That could be 45 to 60 days presently, which was identified by the OAG as being too long. Our minister announced a few weeks ago that we're changing the ratio, because our case managers had — today still have — a ratio of 1 in 40, so one case manager for 40 case-managed veterans.
Especially with mental health, that ratio did not take into account the complexity and the intensity related to managed mental health clients. You get into homelessness issues and all kinds of issue which before didn't take that much time. Today there is a real effort.
The Government of Canada has agreed, and we're bringing that ratio down to no more than 30 to 1 which will greatly increase that. We would like to really cut down from that. Forty-five days is the standard to get the case plan, but we'd like to bring that down much faster.
Senator Stewart Olsen: That's from the initial phone call to a case plan.
Mr. Doiron: Yes.
Senator Stewart Olsen: What about the RCMP? Who do they call?
Mr. Doiron: It would be the same number.
The Chair: If you were trying to set up an organization that developed the expertise and had all the programs for mental health issues, would it make sense to divide this group into regular Armed Forces and those who are RCMP veterans, veterans of the Armed Forces, or would it make more sense to keep that expertise together?
Mr. Doiron: Personally, I think it's keeping them together. I think we can learn from each other.
About a year ago I was in New York meeting with our partners, the Five Eyes — New Zealand, Australia, U.K. and the Americans — to talk about mental health. What we're learning — and David touched on it earlier — is that we all have the same challenges. The States has a huge amount of soldiers who served and they have been in conflicts a lot more than Canada has, but we are trying to learn from each other.
In my personal view, it should be the closer we are the better it is. I think we can learn and get some efficiencies from each other.
We talk a lot with our colleagues at CAF. She's not here today but my DG of health services — my surgeon general — is a retired doctor. She was DG Med Pol, and her name is Cyd Courchesne. She was supposed to be here, but when the date changed she couldn't make it today. She works very closely with the head of their organization, not only in mental health but the entire medical side.
If I was to blue sky, there should be no cliff. It should be a seamless transition for the individual, whether it is mental health or any other service.
What happens often is that the soldier knows they will be leaving six months, one year, three years in advance. Our CAF colleagues work with them during that period. With the new authorities we have received in the new act, we will be working upstream. With Veterans Affairs, our authority starts when you become a veteran. With the new act, we can now start working with the individuals much earlier. That means we do have IPSCs and JPSUs where, except for the uniform, you do not know who is who. They work in the same building. If you have been to the one in Halifax, it's a beautiful building and the soldier is assigned there but they can get Veterans Affairs assistance or CAF. I may be making it more simplistic than it actually is, but they are in the same building.
To me, the model would be seamless, to learn from each other. We haven't talked about employment, but as the person is moving forward in their transition, and they've got 35 years and they're retiring, just make sure they have the health care. But if they are 30 years old and they served 12 years, do they have a job? We know that if you have a job, your mental health condition is much better. We know the junior NCOs have a harder time transitioning than officers. We also know about junior NCOs in combat arms. I believe Dr. Pedlar was here not long ago talking to you about the Life After Service Survey, which has identified this, but it's working with these folks to make sure when they take off that uniform, they know what to expect, they know where the services will be and they know what the future is.
I am a little passionate about this.
The Chair: It is important for us to think ahead, as well as to assess the situation.
I'm wondering if either or both of you saw the coverage on the weekend of the former Sergeant-at-Arms receiving an honorary degree from Mount Allison University in New Brunswick?
Mr. Doiron: I did.
The Chair: That's clearly a stressful situation that he went through after the unfortunate incident on October 22 here on Parliament Hill. It brought to mind the non-traditional type of public servant, like the Sergeant-at-Arms, the border services people who are now armed, CSIS and the work that they are doing. As that role expands, and it expands significantly, is there any movement toward providing mental health services to these individuals?
Mr. Doiron: That's an excellent question because it's something I'm concerned about. My first job with the government was with customs. I was a custom inspector and I did some drug ops stuff, and I know these guys. You didn't mention one department, which has the greatest problems now, and that is our friends at Correctional Service Canada. I have been contacted by CSC to see if we could give access to OSI clinics and we can't. I don't have the mandate, the manpower or the funding.
Far be it from me, but I think the government as a whole should really look at that because with our correction officers, there are some hard issues. With the RCMP at least there is a link, but for CBSA, especially since the arming incidents, they have had shootings on the West Coast and there have been incidents. So I think it's a sign of our success because 20, 25, 30 years ago nobody spoke about mental health, right? It was taboo, it was in the closet, you didn't talk about it. Over the years, you start talking about burnout and depression. It is more public. We have Bell Let's Talk Day, and there are all kinds of initiatives. People are a lot more aware and the stigma is — I hate saying disappearing because I'm not quite sure it is — not as it used to be. People are now coming forward with their mental health issues.
The Mental Health Commission of Canada says that 20 per cent of Canadians will deal with mental health issues. It's not just a Veterans Affairs issue or an RCMP issue and it's not just an employee of the Government of Canada issue. We have an issue, but when you look at some other ones, how do we maximize and see they get the service? I was contacted and we did give help to some of the people who were here that unfortunate day in October. Veterans Affairs did provide services. We helped out in Moncton after those terrible incidents. I had some people on the ground available there, but it's there and how do we address it?
The Chair: We appreciate your comments on that and I will go to Senator White for a follow-up question.
Senator White: I'm glad that you jumped into CBSA. I think their mandate over the last decade has gone from being revenuers to a police agency in many ways. I agree with you. In discussions with Commissioner Head, I see the challenges at Correctional Service Canada. I realize the position you're in, but if we were to suggest a whole of government approach to this issue federally, would you see that as potentially giving us an understanding of the issues to develop the long-term solutions?
Mr. Doiron: I think so.
Senator White: Good.
The Chair: Thank you very much. Seeing no other questions and seeing the clock ticking away on us — we have the Senate Chamber in 15 minutes — on behalf of the Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence, we thank you for being here and being so frank in your answers. That is very helpful to us.
This meeting is now concluded.
(The committee adjourned.)