Proceedings of the Subcommittee on
Veterans Affairs
Issue 6 - Evidence - June 4, 2014
OTTAWA, Wednesday, June 4, 2014
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day, at 12:17 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 David M. Wells (Deputy Chair) in the chair.
The Deputy Chair: Ladies and gentlemen, welcome to this meeting of the Subcommittee on Veterans Affairs. Before we begin, I would like our committee members to introduce themselves, starting with Senator White.
Senator White: Vern White, Ontario.
Senator Enverga: Tobias Enverga from Ontario.
The Deputy Chair: Thank you very much, and I'm David Wells from St. John's, Newfoundland and Labrador.
This is the subcommittee's second meeting for its study on mental health issues affecting serving and retired military personnel. Today, we are hearing from Dr. Greg Passey. He is a clinical psychiatrist at the British Columbia Operational Stress Injury Clinic. He spent over 22 years in the Canadian Armed Forces as a medical officer and has worked as a clinical psychiatrist with many present and former CF and RCMP personnel who live with PTSD.
Welcome, Dr. Passey. The floor is yours. After your presentation, we will go to questions from our members.
Dr. Greg Passey, Clinical Psychiatrist, British Columbia Operational Stress Injury Clinic: Thank you. It's a bit of a difficult subject to try and summarize in 10 minutes, so what I'm going to attempt to do in this 10 minutes is actually put flesh, blood and tears on the scientific descriptors of what PTSD is.
It's very simple: There is a book called Diagnostic and Statistical Manual of Mental Disorders. It lists all the criteria necessary to make a PTSD diagnosis, but those criteria are very sterile sorts of descriptors. PTSD is like a cancer. It can eat through your body, mind, family, profession and even society itself.
What's important is not necessarily the traumatic event but the person's personal perception of the event and the level of support they then receive after that type of exposure. It's been my experience that it is often the best and most empathetic military members who actually develop this disorder.
I'm going to try to give you a little bit of an experiential description here. PTSD is all about difficulties from the top part of the brain and the bottom part of the brain.
The bottom part of the brain is tasked with keeping us alive, fighting danger or getting us to run away. The lower part of our brain has no ability to use language or logical thought. It communicates only by emotion, so if the lower part of my brain perceives a danger, I'm typically going to receive that message by fear. It's very much like a smoke detector. A smoke detector will go off if there is smoke, fire or something like smoke or fire.
The problem with PTSD is that the top part of an individual's brain is no longer in control. In the military, we train people to go into harm's way. The reason they are able to do that is that we train the top part of their brain to really get control over the bottom part, to ignore things like fear and move forward when anyone else would be going in the other direction.
To understand how powerful the lower part of the brain is, I would like the members of the committee to try something. It will take only about 30 seconds, but it's a really good example of how the lower part of the brain takes over, not only in the example I'm going to give you but also in PTSD.
It's a really simple exercise. I want you to focus, and I want you to blow all the air out of your lungs until there is nothing left. But before you do that, I want to assure you that you should be able to hold your breath for three to five minutes and not have any brain damage. That's the top part of the brain talking.
Now what I want you to do is blow out forcefully so there is nothing left, and then I want you to hold your breath, and you let me know when you can't hold it anymore because that's the lower part of your brain saying, "I'm taking charge." And try to remember what that feels like.
So right now blow all the way out, and hold. And pay attention, because if you blow it all the way out, you will not last a minute, you will start to feel this sensation rise up, and the next thing you know, despite what the top part of your brain is saying, the lower part will make you breathe.
Now imagine that sensation being present for minutes or hours of every day of your life since your traumatic event, or replace that with overwhelming rage, which is the lower part of the brain in charge again. You then have an idea of what PTSD is like. It's that lower part of the brain in charge, so when you're trying to watch your daughter's graduation and the lower part of the brain is saying, "This is not safe in here; I've got to get out," guess what? That veteran will get up and leave, even though the top part of his brain is saying, "It is safe here; it's my daughter's graduation." The problem is the lower part of the brain uses only association and communicates only with emotion.
One of my best examples is a peacekeeper pulled out of a UN vehicle — a white vehicle — who was told he was going to be executed by the time he got to the other side of the road. At the last minute, the execution was halted. He was allowed to get back in the truck and finish his tour. He came back to Canada. He's walking down the street. He ends up seeing me after a little over a year. He was having huge panic attacks. When you were feeling like you couldn't hold your breath anymore, that's almost like a panic attack, except expanded.
He was having these all the time. The top part of his brain was quite clear. He was here and in Canada. The lower part is always scanning sights, sound, smell, touch, taste, your thoughts, your dreams. It's always scanning, and when it associates anything with past trauma, it warns you, and the warning was fear. As it turns out, a white truck had gone past him, and out of the corner of his peripheral vision the lower part of his brain — not the top part — saw the truck and immediately warned him. And there was the fear.
With PTSD, that is part of the problem we struggle with. It is that disconnect and trying to get the top part to become in control again. One of the other very important pieces I need to convey today is that it's not just the traumatic event; it's the level of support an individual gets after that event. It is as important as or more important than any trauma event you're exposed to.
So the level of support from the Canadian Forces will make a difference as to whether or not a person develops PTSD and how severe it is — family members, the community, the government. A prime example in the news is the New Veterans Charter. Some veterans do not feel that it is supportive. What happens? Their symptoms get worse. They get angrier. They get more vocal.
I could spend a whole afternoon talking about the good parts of Veterans Affairs and all the difficulties veterans are having accessing care, things like OSISS, the Operational Stress Injury Social Support network, which is an excellent support network of vets themselves and members.
PTSD can occur virtually in the moment or it can occur years later. I had a World War II veteran in 1995 — 50 years after the end of the war — who had a car accident. He had been fine, some simple symptoms. After the car accident and being in hospital, he developed full-blown PTSD, not due to the accident. All the memories, all the nightmares went back to World War II. So there can be a delayed onset. Fifty per cent of PTSD will spontaneously resolve without treatment in the first 90 days. Two-thirds will get better in the first year whether we treat them or not, which is interesting because a lot of studies are saying they had great success in the first year. They may be getting better just on their own.
That leaves another third, though, where it is literally years that they may continue to have symptoms. Even when you get PTSD into remission, they are always vulnerable to stress or triggers that remind them of their past events, which means the symptoms can come back up. It's like diabetes. When you have diabetes, basically you have it for life. If you don't exercise, keep your weight down and eat properly, the diabetes comes back. With PTSD, if you're not sleeping properly, not exercising, you don't take care of your day-to-day stressors and you get triggers, like Remembrance Day, the PTSD will come back.
The other thing I wanted to talk about is that 46 per cent of people with PTSD will think of suicide. Up to 19 per cent will attempt. Individuals with PTSD are 90 times more likely to have physical complaints, and they utilize the medical system 37 times more than the community and military members without PTSD.
There are high rates of relationship dysfunction, and 15 per cent of relationships are in trouble. The divorce rate is double with PTSD, and it is triple the normal population for multiple divorces. PTSD is associated with cardiac disease, increased risk of chronic pain, autoimmune diseases, eating disorders, irritable bowel syndrome, stroke, cancer, bruxism or grinding your teeth; and about 80 per cent of people with PTSD also have another brain disorder like depression, et cetera.
I know I'm supposed to talk a little bit about treatment; we can discuss that. There is a website called www.istss.org. It's the International Society for Traumatic Stress Studies. They actually list the treatments that have clear evidence. There is a lot of so-called treatment out there that is not backed by evidence, and that's something else we need to talk about. There are new techniques, like quantitative EEG, where we can look at brainwaves and see where there are abnormalities with a disorder such as PTSD, and we can utilize the brainwaves as a type of feedback to try to retrain the brain.
There is a great deal of difficulty dealing with reservists because they disappear after their tours. It's hard to follow them. There is nothing in place at the moment that's tracking individuals, military members and veterans once they release, as far as how they are doing.
It's even worse with the RCMP. I know I'm not here to talk about the RCMP today, but their rates of PTSD are actually higher than the military, and veterans of the RCMP actually are taken care of by Veterans Affairs.
I'm very much aware that the military is very good at turning our citizens into soldiers. We have no program that retrains the brain back to being a civilian. That is a problem, and that is part of our difficulty.
I was in the military. The military was my family, and when I left, I left a chunk of my family behind, and I felt all alone. Even though I had civilian family, I felt all alone. There is no way of really combatting that piece.
The last piece I want to talk about is what I call the unknown fallen. In the First and Second World Wars we had soldiers who were not identified when they were killed in action, and as a result we have the Tomb of the Unknown Soldier.
I don't think government and I don't think our population are aware of the casualties I call the unknown fallen. These are individuals who have gone on their tours, survived their combat and have come home with physical wounds, with mental health issues, and who eventually succumb to those things, whether it's by suicide or by disease process, et cetera, and no one knows about it.
These are our unknown fallen. I have a number of individuals who have committed suicide or have died from their exposures on peacekeeping duty, as well as in combat, and they are not marked. They are not commemorated. Their names are not placed anywhere. Yet, they are casualties of their tours and of their duty.
On that note, I think I should probably end because I can continue talking all day on these things, and maybe open it up for questions or further direction.
The Deputy Chair: Thank you, Dr. Passey. That's a very compelling presentation. I will look to Senator White for questions.
Senator White: Thanks for being here, doctor. I truly appreciate it and apologize that we were a little delayed. I have a few questions, so I will start with them and the chair will stop me when I've asked too many.
There are a number of organizations in Canada right now that are looking at presumptive PTSD. I know you know what it means, but I will describe it just because not everyone here may; it is where it is expected that based on the interaction or work you're in already and the things that occur to you, if you end up with PTSD it's presumed that it came as a result of that occupation. I think Alberta was one of the first provinces and maybe the first to have actually accepted it in their workers' compensation package.
Dr. Passey: Correct.
Senator White: The Province of Ontario is fighting it, or at least police leaders are fighting against it. Some would argue the validity of presumptive diseases of almost any kind, with the exception of firefighters and lung disease. Do you have a perspective on presumptive PTSD?
Dr. Passey: I think we need to be a little bit careful. Not every soldier that's exposed to combat — in fact, the vast majority, probably in the neighbourhood of 85 per cent — are not going to develop something like an OSI or PTSD.
It's difficult. I think one needs to do a proper assessment. One cannot just presume that an individual has something as a result of their employment. Often there is a history of trauma or traumatic exposures in a person's background that makes them more susceptible to develop PTSD. I know at Veterans Affairs they have this five fifths assessment, where they may say, well, your childhood, that was pretty brutal, so maybe three fifths of your PTSD is due to that and two fifths of it is due to your military service.
I don't like the idea of just presumptive, but I think there are certain occupations — who knew — doctors, nurses. The hospital that I used to work at has a 12 per cent PTSD rate in our emergency department, and we were told by WCB that that's just expected. You're expected to be exposed to these things, so you're not going to get compensated for that. First responders, ambulance attendants, firefighters, police are actually higher than military with things like PTSD and suicide.
Senator White: That leads, if I may, Mr. Chair, into the second question, around secondary PTSD, and some would refer to it as emotional trauma stress disorder, so not necessarily in a position where your life is in jeopardy but continuously in a position where you see other people's lives in jeopardy, and 911 operators, for example, would argue that they never see it but they hear it every day and sometimes 20 and 30 times a shift.
Is there a separation between PTSD and secondary PTSD, or emotional trauma stress disorder, as some experts would call it, and should there be a separation of those when it comes to what we're dealing with in relation to Canada's military? RCMP I do include because they are covered by the same program, and in fact many of them who are facing PTSD are coming back from the same theatres of operation.
Dr. Passey: It's an interesting question. As it happens, when the American Psychiatric Association actually released the DSM-5, there is now a qualifier in there that counts as a traumatic exposure, experiencing repeated or extreme exposure to adversive details of the traumatic event. So this includes police officers repeatedly exposed to details of child abuse, for instance. I think I would include the dispatchers because they are often on the line when someone dies, and they are asking them to hold on.
It doesn't have to be personal. It's this ongoing exposure. One of the worst traumas a military member can go through is actually Yugoslavia or Rwanda, where the rules of engagement prevented the individual from actually stopping the slaughter. I question whether or not it's even a legal order to do that when morally and ethically you should be intervening, but to have them trained to act and then be forced to only observe, it was very destructive.
Senator White: Do you say that there is a difference in managing the people who have PTSD from secondary or ETSD, or is it the same process we follow after?
Dr. Passey: It's a little bit difficult, because every individual is a little bit different. Characteristically, for some people, there is a lot of fear, for instance. For another person there may be characteristically a lot of anger to have to deal with. Perception of self and right and wrong and safety in the world has to be dealt with. A lot of individuals, where they are not able to act or run away, get into dissociated states. Those individuals don't necessarily feel anger or fear; they feel nothing. So you have to individualize your approach and treatment, and you may find that you get the person to feel again and then there is all the anger and fear and then you have to deal with that aspect. It's not so much the cause, it's the presentation; what parts of the brain are dysfunctioning?
Senator Enverga: That was a great presentation. I learned a lot.
What is the percentage of our troops getting PTSD when they come back here?
Dr. Passey: I'm sorry?
Senator Enverga: What percentage of our troops when they come back from their tour of duty are affected by PTSD?
Dr. Passey: I've missed the first word.
The Deputy Chair: What is the percentage of the troops.
Dr. Passey: I'm getting old; my hearing is going.
It depends on which research you're looking at, but somewhere between 5 and 15 per cent.
Senator Enverga: So 5 and 15 per cent.
Dr. Passey: Part of the difficulty, though, is that there are several issues. If it's not done anonymously, if the person actually has their name on there and they are filling in the questionnaire, there is a problem with that because there is still stigma in the military. It may still affect a person's career; it may affect the way others interact with that individual. So they may not necessarily tell the truth about that.
The other problem is in the U.S. they have done research. If you screen for those individuals within the first month or so, you are actually going to miss a significant proportion because the PTSD will show up three months, six months down the line. There is this delayed aspect. What I found in the 1990s in dealing with our peacekeepers out of Yugoslavia, Somalia or Rwanda, et cetera, is that often there was a five-year lag period between the time the individual actually developed it and when they were actually to a point where they would come forward for treatment.
Part of that was stigma. In part of the research that I did, when I asked people with PTSD to rate their emotional or psychological health, 50 per cent of the people I identified with PTSD said their health was excellent, which indicates to me they don't have the awareness that they have a problem. It is often family members and fellow soldiers who actually pick up the changes and suggest an individual goes in. The last thing to go is the person's career. Family and friends will all disintegrate, and the soldier will often not come in unless their spouse or partner says, "Go in or it's over." Or when their career starts to go down the tubes and they can no longer actually manage being a military member, then they come forward.
That's a problem with those stats.
Senator Enverga: We train our soldiers to use their upper brain more than their lower brain or sort of vice versa. Is there a study that shows we can train them back to who they are after their tour of duty? Is there anything like tags that say, "Okay, if you feel this, make sure you meet us or make sure you get training or medical treatment"? Are we developing this kind of prevention?
Dr. Passey: First off, there are screening procedures for everyone that goes overseas as well as comes back. There are information sessions for the family members to also help them identify and cope with the difficulties when members come back home. I am not aware of a program that basically deprograms the brain.
I got a double whammy. In medical school, I was trained not to feel. To do emergency, I don't want to feel sorry for this person. I need to take care of them, so I don't feel. Then you throw military training on top of that where you go forward, never mind the fear. We suppress that. Our brains in the military are very good at that.
The problem is we don't have a process where we lift that back off. A lot of military members are very strict. They don't have a lot of empathy; they're not huggy, lovey-dovey individuals. Again, I'm generalizing, but a lot are like that. Well, how do we take that away?
Now PTSD basically rips the top of the brain off and the lower brain is in charge. The problem is it is usually only fear and anger. It is not necessarily a loving connection that is there. That's lost.
I wish there was some sort of program that takes a soldier and turns him or her back into a civilian-thinking individual.
Senator Enverga: Are there some people or groups studying how to do this? Are there ongoing studies to deprogram this?
Dr. Passey: I'm not aware of anything in Canada. I know Marv Westwood's Veterans' Transition Program attempts to do a transition, but the reality is it is not really doing that. It is not really treating PTSD either, but it does get individuals together and attempts to help them transition to becoming a civilian.
It is the brain piece. I was an emergency medicine doctor for a number of years, and part of the reason I stopped doing that is that I had my emotions turned off. I had trouble turning them back on when I went home at night. There was no program for me. I eventually just said I can't do this anymore.
Senator Enverga: Would you suggest that some study should be done to prevent this?
Dr. Passey: I think it would be great. I think it would be worthwhile. There may be something happening in the U.S. because they have got way more funding than we do. I am not aware of anything at the moment. This is a common complaint, namely, how do you so-call deprogram a soldier back to becoming a civilian.
Some can do it. That's great for them. But if the military was your career, even leaving that and coming back to the civilian side is never the same. It is never the same. The trust is not there. The level of connection is not there. If I could give anything back to the soldiers, I would give them that piece back so they become the person that they were before they entered the military. That's not to say the military is a bad place. There are a lot of good things about the military, but this piece, I wish we could undo.
Senator Enverga: It's not that I don't believe that a lot of the veterans have PTSD; I believe all of them. How easy is it to say, "I have PTSD," just to get some more support from the government? How easy is it or how hard is it not to be detected by a practitioner?
Dr. Passey: The reality is anyone can say it. Anyone can read the book, and they can sit down and say, "I have nightmares and I get really angry and I can't concentrate and — gee, I can't sleep, and, you know, I avoid people and ta-dah, ta-dah," and all that sort of stuff.
Let me tell you, I have done this for 21 years, and in those 21 years, I had three people that fooled me, but they didn't fool me indefinitely. Within six months, I was able to pick up. It is not just a matter of knowing the symptoms. It is a matter of how they present and the emotional piece that is there or not there. There are questionnaires that also attempt to help with those sorts of things.
A lot of us that are very experienced know. They present, and you look at their eyes, in the room, the emotion, the level of anger, the level of rage, the tearfulness. Is it possible? Of course it is possible. Is it probable? Not really.
The reality is, like I said, I have seen in excess of a thousand people, and I had three that tried to fake me out, and I caught them.
The Deputy Chair: Thank you, Senator Enverga.
Dr. Passey, some of the things you are saying are very compelling. It is obviously troubling to a civilian to try to understand the difficulties that sufferers of OSIs and PTSD in particular go through.
You mentioned the division between the upper part and the lower part of the brain. Is that a synaptic division or is it something else? Is it a physical divide for sufferers?
Dr. Passey: It is basically evolutionary. We sort of have a reptile brain, and on top of that we have evolved into a mammal. Reptiles have no emotions; it is all reflex. On top of that you have mammal brains. Dogs and cats, for example, have some level of emotion, and they can grow attached to you and so forth. Then there are us and our executive function and the things that make us an advanced species. That's the top part. It's an artificial division, and I'm simplifying things. The divide is the emotions and on down versus the top part, which makes us civilized, politically correct, able to do rational thoughts and solve problems.
With PTSD, the control that modulates those emotions and so forth is lost. That's very disturbing to military members when we have spent our life ensuring that we control our emotions, and now the emotions are in control of us.
The Deputy Chair: Is an explanation of that to the sufferer part of the treatment or management?
Dr. Passey: It is part of it, but knowing that doesn't fix it. That's part of the problem. For instance, for my individual who had the white vehicle, it wasn't just white vehicles. It was white cars and it was his partner's white shirt that would cause him anxiety. Knowing that and then exposing him to it is possible. There are ways of actually desensitizing that piece, but the problem is that not everyone can do that.
There are ways where we attempt to get better connection between the upper brain and the lower brain. Medication, to some extent, allows the top part of the brain to have a bit more control. It kind of dampens down the intensity of the emotions. We can use various medications to help with that.
Treatment will also involve things like diet and exercise. We know that exercise actually improves those areas of the brain that our talk therapy and medications improve. There are new fields like neurofeedback, which looks like it may enhance the pathways. We're trying to use neuroplasticity. Where pathways have been damaged, we try to regrow them and strengthen them so that the control comes back over time.
It is a process. The reality, again, is that if there's enough stress, a big enough reminder of the trauma, the lower part takes control again.
The Deputy Chair: It is safe to say there are treatments and, for the rest of the sufferers, there's just management of the PTSD?
Dr. Passey: I think everyone can benefit from treatment. What we often don't know when we start treatment is how far along a person can come and how quickly it will be. I usually tell my patients, "Let's see where you are in six months to a year." I have had people where, literally, within 20 weeks they have done really well and away they go. I have had other people where I have seen them for 10 years; they have plateaued. With that individual, unless we develop some new treatment strategies, that is probably as good as they're going to get.
Having said that, for instance with First Nations people, I got an individual to a certain level, but he was missing the spiritual piece which we normally don't talk about. He got hooked back in with his elders, et cetera, and that took him to another level.
I have seen individuals where it was almost impossible to get them out of the house despite medication and our talk therapy. I got them a service dog and, all of a sudden, they're out, they're going to the mall, they're able to go to a theatre and they're able to fly on an airplane. With a service dog, it is interesting because the dog is on guard. Often, that allows the individual to feel a little bit safer.
I have another individual where their dog wakes them up whenever they get a nightmare. That veteran is no longer afraid to go to sleep now because he knows the dog will stop the nightmares which he wasn't able to stop before.
The Deputy Chair: That's fascinating. Veterans Affairs' treatment — the Department of National Defence, I'm sure, is part of treatment. There's also an option for a degree of prevention. Do you have any ideas on prevention?
Dr. Passey: The prevention piece really goes to the level of training an individual and a unit have. The better trained the unit and the individual are, the more resilient they're going to be. The better the leadership is, and in that regard not just militarily competent but also supportive of their members and, beyond that, supportive of the family members when an individual is deployed — all of those things will make a difference.
There is also realistic training. I don't know if they still do this, but the recruits for the New Zealand police force actually used to go to a slaughterhouse, for instance, so that they could smell blood and be around it. They would then take them eventually to the morgue, et cetera. That was all in preparation for their police work so that they were a bit more resilient and it wasn't quite as big a shock to the system when they were at a suicide or a murder scene.
There are ways of doing that. We're now starting to find that there are certain genetic predispositions for PTSD. That doesn't mean you are going to get it, but it means you might be a bit more vulnerable to that. That may be something in the future that we actually will screen for.
Those are the sorts of things I see. Realistic training is essential. The other piece I mentioned is the level of support.
Senator Roméo Dallaire (Chair) in the chair.
The Chair: We're just doing a handover.
Dr. Passey: It is very good to see you again, sir.
The Chair: Thank you. Thank you, Senator Wells.
Dr. Passey: Senator Wells was just asking me about prevention and resilience in regard to PTSD. I was speaking about training morale and competency. The other big issue, as I mentioned earlier, is the level of support an individual receives and the family. That goes at all levels, not only in the Canadian Forces but also in the community itself, in the government and in Veterans Affairs. All these things can potentially make a difference to the development and severity of PTSD.
Senator Wells: You mentioned that the last thing to go is career. Oftentimes, the first thing to go is family. It seems to me there are other victims aside from the military case. Could you comment on that, please?
Dr. Passey: Very much so. At our clinic in B.C., we do a fair amount of couples counselling, or therapy, as well as counselling for family members, so we get the kids in. It has a huge impact. With PTSD, when it is at its worst, the ability to engage with your partner, with your family members and emotionally be connected, be empathic, be happy and be loving — all of those things — if not inhibited may actually be destroyed. Again, divorce rates are two times those of the rest of the population for a single divorce, and three times those of the population for multiple divorces.
Individuals with PTSD have a great deal of difficulty maintaining relationships, whether with friends, with family or with a personal partner — parents, even. All of those are being affected. That, then, has a ripple effect into society itself. I didn't quote the billions of dollars this type of disorder costs, but it does have an effect way beyond the immediate individual themselves.
Senator Wells: Thank you, Dr. Passey.
The Chair: Very interesting; thank you. Senator White, we are on the second round. You are up.
Senator White: Thanks again for your responses. I appreciate it. Some parts of the military have very specialized units that have very low rates of PTSD. Yet, looking at the work they do, we would suggest that they might be a lot higher. I'm saying that because I'm told that by those units; whether that's something you agree with is a different question. Some parts of policing are the same.
Dr. Passey: Yes.
Senator White: The ERT tactical teams have much lower rates of PTSD in comparison to many other units. Some would argue that it's the multiple times they respond to different circumstances versus the one traumatic event on a Friday night at two in the morning when you go to a hostage taking with a shootout. That may not have as great an impact as the others. Some would argue that it is the team atmosphere. That is, there are 12 of you arriving at the call versus one.
What's your perspective? Do you believe some are better at handling it? Is it the team piece? Is it the activity following the call that you spend three hours on debriefing versus 30 seconds on your way to the next call? Or is it all of those things?
Dr. Passey: It is interesting because I have a number of individuals seeing me. Again, there are the specialty areas. With JTF2, for instance, when I went into Rwanda I went in with individuals from that unit. Speaking with them, I found that part of their difficulty was they couldn't come forward because it would jeopardize their position on the team.
Are the rates lower in those specialized units? I would say while operational, I would probably agree with that. The difficulty is that individuals with PTSD are able to continue doing their job. It is very rare that anyone is ever sent back off of deployment with PTSD. The difficulty is when they come home, are no longer task-oriented and have time to think and feel again.
I would like to see because, particularly in the police force, the RCMP for instance, there are no stats. No one is doing anything with that. I'd love to see it because we are getting swamped with RCMP officers coming forward. In fact, we will soon have more RCMP than actual veterans at our clinic.
I think what probably happens with that is that they are very well trained, good leadership, good morale, very supportive. I can say one thing about the IRG team and the individuals I have seen. The officers involved in supervising them have been very supportive of their individuals and are quite happy to get them back.
Having said that, it's interesting that I have heard that, in Alberta, anyone diagnosed with PTSD on IRT is taken off. So you are getting mixed messages there, but I think, with specialized units, good morale, great training and good support, people are less likely to develop PTSD. I would like to see those guys five, 10 years down the line, particularly once they are out of the military or the RCMP, because that's when they actually become most vulnerable.
Senator White: May I ask a follow-up?
The Chair: Yes.
Senator White: Thank you very much. See, he doesn't remember how many questions I asked, which is good for me. Great response. Thank you very much for that. I served on IRT and oversaw IRT teams. As a police chief in Ottawa, I had tactical teams. Our issues around PTSD or similar were much lower in those specialized units in comparison, so I appreciate that because maybe it is about timing. As well, I had a number of officers who served as reservists in Afghanistan and other places and a number of officers, up to 80, who actually served in Afghanistan in a civilian police role with the RCMP. Our numbers from those people coming back were very low as well, and we were into the seventh year — while I was there — of that happening. I'm trying to figure out. Maybe you have an answer. They come back and are thrown right back into their civilian life of being a clerk at the Government of Canada versus coming back, still being in a uniform and working on the streets in a team atmosphere in a similar task-oriented role. Should we be bringing them back and graduating them through some sort of task orientation to correct it, I guess, rather than to change it? When I gave up my uniform, I found it challenging for six months, and I wasn't going through those challenges. I didn't come back from Afghanistan. So is there something we could do about a graduated removal from task-oriented roles that would change it?
Dr. Passey: That's a really good question.
Senator White: Write it down because it's the only one you get.
Dr. Passey: Again, for members that are continuing to serve, for a lot of the individuals I see in the military and the RCMP, the way they cope is to remain busy, head down, full speed ahead. So, if that's the way that individual copes, typically, I'm not going to see that person for maybe five years down the line, seven years down the line, if they develop it. Again, we need to be aware that probably 85 per cent of individuals who are exposed to traumatic situations in the military or with the police are not necessarily going to develop PTSD. So we're looking at a small but significant proportion. What do we do with that? It's difficult, because, for the person, if that's their coping strategy, then you don't want to take that away from them because they will remain productive in the force, whatever force, while they are able to do that. I saw it with the World War II veterans because I assessed and treated a lot of World War II veterans when they retired and were no longer able to be busy 12 hours a day or sometimes 16 hours a day. Now, they are retired and have all this time on their hands, then it all percolates to the forefront.
I know that the military has used, basically, a graduated step back to Canada as an attempt to sort of deal with some of these things, but the reality is that it's nice but doesn't really work.
Senator White: Three weeks in Germany.
Dr. Passey: Yes.
Senator White: Thank you very much.
The Chair: Before Senator Wells, because we have time for a second round, I have gone down to the U.S. Marine Corps, which was discovering that it was having casualties appear that it had never seen before — alcohol, drugs and so on amongst its officer core. What I was able to explain to them is that, in fact, being a marine officer is already being a workaholic and that people would literally push themselves to the extent of trying, ultimately, not just to be busy but to actually kill themselves at work. They have had casualties of people where their whole system has broken down. That's good until you actually destroy yourself.
Do you see, in the work that you are doing, a difference in the impact of this injury on the officer commanding levels versus the more junior and sort of lower rank, implementing, tactical people?
Dr. Passey: You guys all have great questions. I know, when I did the research on the peacekeepers, back in 1993, out of Yugoslavia, there was a lower rate of PTSD among the officer corps. Part of the way I explained that is that the reality is that it's the corporal and the private out there on the front lines for the majority of it. I thought, okay, that made some sort of sense. I think Afghanistan certainly is different, and what the Marine Corps is exposed to is different. The Marine Corps now actually builds in a suicide rate as far as casualties with their deployments. So, when they deploy I don't know how many thousands of individuals, they already calculate, ahead of time, how many are likely to die from suicide when they come back. There are all sorts of attempts to try to find and treat individuals or provide them with different coping strategies. The American army was actually, for instance, using yoga. Who would have thought, but they were using yoga prior to and during and after coming back. Part of that is being able to relax and not have to go, go, go. The adrenaline when you're a workaholic is high. Throw PTSD on top of that, and the adrenaline is through the roof all the time. You're at risk for all sorts of disease processes — cardiac disease, high blood pressure and cancer and all of those sorts of things.
I think we need to look at, perhaps, some other innovative ways of providing to our troops and, particularly, our officer core and our senior NCOs. The reason I say this is that they are the leaders. If we can get them to buy into resilience training or other coping strategies, then the troops will follow. I don't have the answers for that piece because I'm so busy struggling, trying to deal with assessments and treatments. The whole prevention piece needs to be looked at.
The Chair: There is work being done on looking at the impact of PTSD and what creates PTSD amongst commanders versus amongst subordinates, and some of the stuff that's coming out is indicating that you need two different treatment methodologies because the problem is created differently, as you've described. Thank you.
Senator Wells: Thank you again, Dr. Passey. Can you tell me about your staff? Your staff deals with folks who have significant problems that are life threatening and, in many cases, life ending. Can you tell me how your staff handles that at your clinic?
Dr. Passey: Our staff is a little bit different — or so we've been told — than in the other OSI clinics within the network. We are very collegial and very supportive. We promote an atmosphere of self-care, whatever that looks like. We had a retreat there yesterday. It is very difficult, and I will tell you that part of the problem we have right now is that there has been a change in the adjudication and appeal process within Veterans Affairs in the last couple of years. I never used to have my write-ups denied, and now — it's very interesting — there are denials of claims. They even say that there is no medical, military evidence connecting service to this disorder. However, when I go through the military medical file, I find eight entries saying that this person's stress has caused these symptoms and this diagnosis.
We don't mind doing the work. I will bend over backwards for a vet as far as assessment and treatment go; but we're getting killed by all the paperwork and by all the denials. I don't know why or what is happening, but there has been a shift. I've been doing this now for 21 years, and in about the last two years there are all sorts of denials coming through.
The other problem we have within the OSI clinics is the way they're funded through the health authorities. You have to realize that the health authorities do not value psychologists. They actually pay them less than social workers, or thereabouts, and nurses. They are in about the same range. A good psychologist can make three to four times as much money in private practice as they can make working for an OSI clinic. The professionals we draw on when we hire, and there is turnover, although not at our clinic at this time, are junior people right out of school. I can tell you right now that it takes about two years to bring that person up to speed so that they are doing everything I think a psychologist should be doing, not that it's my job to do that. I am confident that they are competently handling the veterans' files. We've got some real issues with regard to our recruitment and our retention.
This is hard work, and if you're getting paid a quarter of what you could get paid just going across the street as a private professional, it's difficult. Having said that, our clinic has great professionals, but it's taken time to build them up to that. I keep my fingers crossed that we don't lose them.
Senator Wells: Well, it's important for us to know that — more than good for us to know. While families are on the front lines in the war back in Canada, you and your team are key to what is necessary. Thank you for that.
Senator Enverga: How would you rate the support that the government has been giving our veterans with regard to PTSD? How would you compare it to the RCMP and other roles that we have?
Dr. Passey: Boy, that feels like a minefield. The government has come a long way from when I started. Certainly it's attempted to be innovative and provide new programs. Some parts of the system work quite well, and some parts don't. If you're not particularly ill and want to get an education and stuff, and if you can navigate the system, then it's great. The problem is that the people I see are not like that. Let me give you a couple of examples of where there are problems.
I had an individual that I treated for two years. I finally got him up to the level that he could go to school. He found a program that was going to pay him really well when he finished at the British Columbia Institute of Technology. To get into that program, VAC said he had to have CanVet's approval. He has already applied and then this happened three months before the program started. He couldn't get into CanVet to get their approval, so his options were to wait another year, which clinically would have been disastrous, or to pay out of pocket. I said, "If you've got the money, pay out of pocket, and we'll attempt to get funding later. This individual completed his program. He's now employed. Two months into his job, CanVet finally comes and says, "I guess we won't have to do an assessment beyond what we've done; and we'll pay for your program." If this vet had not had the money, he would not have gotten in. That's one of many instances.
I've also heard where CanVet has worked very well; but there are problems in that regard. There is an expectation also that veterans should be able to apply. I can tell you right now that a lot of my vets cannot open up their mail, especially from Veterans Affairs because it's so triggering. It brings all their symptoms back. Sometimes they'll come in with a stack of mail, and I have to sort of help open it. There are issues in the transition from being a military member to being a veteran; and there are problems with the lump sum payment.
Senator Dallaire and I were actually on a committee once upon a time. I had hoped for a blended system where there would be a monthly stipend but also some sort of lump sum that would allow a veteran, if severely injured, to maybe have a down payment on a house or something while still having the monthly amount. I've got vets who have gone through the lump sum.
Senator Enverga: You cannot rate the level of support as good, bad or very good?
Dr. Passey: Well, it depends on what aspect of the programs you're talking about. Some of the case managers are excellent, and then others should work for Revenue Canada, to be honest with you. They've no empathy at all. Depending on where you're looking, the New Veterans Charter, there are some major issues and some parts that I think are good.
At Veterans Affairs, some individuals are quite excellent, while others I shake my head at. I will tell you what the problem is with Veterans Affairs. Veterans Affairs has no quality assurance program. That means an individual, if you're an adjudicator or you're on the appeal panel, can continue to make the same mistake and deny a veteran a claim and there are no repercussions, no accountability and no responsibility. It's the same thing for the front lines — the case managers. I've had people downright disrespectful not only to the veteran but also to me when I got on to advocate. That individual continues to handle cases, and I don't think they should.
I would like to see a quality assurance program where the investigators are actually veterans. It would run under the ombudsman, and they would have the ability to change Veterans Affairs internally. Then the veterans would have a voice. Then you would be empowering them. The way it is, a lot of this is very paternalistic. If you're a veteran, you cannot go to school until you see this college or university graduate who says, okay, I think you can go. Otherwise, you're out of luck because if they say, IT security, you're not going to make money at that, so we're not going to fund that, well, that guy is out of luck. You're actually treated as lesser than the rest of our civilian population.
The Chair: Thank you, Dr. Passey. You indicated at one point and we realized, to our chagrin, that people who are injured with this simply cannot handle normal staffing. You can't handle normal decisions because you literally can't read it because you can't retain what you're reading. In fact, just looking at it creates such trauma that you don't even want to do that.
Building a system to assist in that is significant. That's why I believe that the self-stigmatization as a concept is horrifically erroneous because the injury causes you to not want to get help or to stay away from help.
Dr. Passey: Yes.
The Chair: Thanks for coming all the way from B.C. I hope it was informative to colleagues to hear from someone with such a background who has seen this from the inside and the outside. I will articulate in front of everyone that he is one of the pioneers in the arena of operational stress injury perceived as an honourable injury, not a disease or sickness that some still believe. Thank you for your candour — well done.
Dr. Passey: Thank you.
The Chair: I am very sorry to have been late, but I was able to get us the budget for us to do what we want to do next fall. All the best.
Senator Wells: Chair, before you bang the gavel, if I may while we're still in public broadcast and on record, I would like to say I believe this may be your final appearance as chair on this subcommittee. I'm not sure what your immediate plans are for next week.
The Chair: That's correct.
Senator Wells: I just wanted to say that it's been a pleasure, and at times a challenge, to serve with you.
Senator White: You did a good job.
Senator Wells: Senator, you have served the committee with skill, the Senate with distinction, and the country with honour. You're to be thanked for that.
The Chair: Well done. Thank you very much. I like your new haircut too — it looks pretty smart.
Thank you.
(The committee adjourned.)