ACVA Committee Report

INTRODUCTION

The Standing Committee on Veterans Affairs undertook its Veterans Independence Programme and Health Care Review study in February 2007 to examine the veterans health care review carried out by the Department of Veterans Affairs. The main focus of this departmental review is on the long term care and related services provided to Canada’s War Service veterans who served during the Second World War and the Korean War. Canada’s pledge in the original Veterans Charter of 1944 to meet the health services needs of its War Service veterans remains in place, but those needs have evolved with the advancing age of these veterans and the health services have to be updated to provide the most effective and timely services possible. The well-being of our elderly War Service veterans remains a major preoccupation of this Committee and the final report of this study will concentrate on this issue.

However, as part of this study, the Committee decided to hold a few meetings focusing on the health services provided to another group of veterans, the Canadian Forces veterans who have left the military in the last few years and who are dealing with Post Traumatic Stress Disorder (PTSD) or other operational stress injuries. A significant number of current and former members of the Canadian Forces are suffering from the effects of operational stress injuries following their participation in peacekeeping and combat operations around the world.[1] In a speech on May 8, 2007, at the Second National Symposium on Operational Stress Injuries held in Montreal, Quebec, the Minister of Veterans Affairs, Greg Thompson, pointed out that the number of operational stress injuries cases has increased by more than 400% over the last five years. He also stated that Veterans Affairs Canada has over 10,000 clients receiving disability benefits for a psychiatric condition.[2] The 10,000 total includes 6,469 clients with a PTSD condition, of which 4,026 are Canadian Forces veterans, 1,522 are War Service veterans, and 921 are from the Royal Canadian Mounted Police (RCMP).[3]

These numbers do not include individuals dealing with PTSD who are not yet clients of Veterans Affairs Canada or who are not seeking treatment or disability benefits at this time. In other words, a considerable number of individuals are dealing with PTSD and not all of them have obtained disability benefits or the treatment they need for a variety of reasons. Whatever the actual number of veterans dealing with PTSD, a number which will likely increase given the tempo of operations in recent years and the anticipated higher tempo in the coming years, there is no doubt that these injuries are having a significant impact on the quality of life of not only members of the Canadian Forces and veterans who have recently left the military, but also their families. With this in mind and in order to promote a better understanding of the issues, the Committee decided to communicate its findings at this time in an interim report rather than waiting until the completion of the whole study. Indeed, given the importance of these issues and the increased understanding gained every day through research on the subject, the Committee may issue another report on operational stress injuries in the near future.

THE COMPLEXITIES OF OPERATIONAL STRESS INJURIES

One of the barriers to a better understanding of these injuries is the complexity of the issues. For example, various terms have been used during the major conflicts of the last two centuries to describe the effects of traumatic experiences on the mental health of military personnel. Since the Vietnam War, mental health specialists in the United States have used the term PTSD to describe a group of symptoms which can be diagnosed hours or many years after an individual has experienced a traumatic situation or a series of such events. However, PTSD is only one of many types of operational stress injuries, as they are called by the Canadian Forces. Others include anxiety, depression, and alcohol or substance abuse. Combat operations can obviously feature a whole range of traumatic events which may leave some military personnel dealing with operational stress injuries. However, other types of military operations such as peacekeeping or rescue missions within Canada can also cause such injuries. Given the ever-increasing complexities of modern conflicts, Canadian military personnel can experience many traumatic experiences during peacekeeping operations, including a feeling of helplessness in the face of overwhelming human tragedies. No matter what kind of traumatic events are experienced, such injuries can reduce the ability of individuals to carry out military or other duties while straining their relationships with family members, friends, and colleagues.

One of the psychologists who testified before the Committee, Doctor Pascale Brillon, stated that there are in general three types of symptoms when someone is dealing with PTSD.[4] The first type is avoidance where individuals try to ignore anything related to the traumatic event they have experienced. For some individuals in the military, this could go as far as shunning their duties and anything else such as their base or unit which can remind them of their traumatic experience. Such avoidance behaviour complicates the psychotherapy because the individuals do not want to talk about their experiences. In the second type of symptoms, memories of the traumatic event cause flashbacks, nightmares, or other intrusive thoughts which can be provoked many months after the event by unrelated situations such as a noise heard while walking down a street. The third type involves hypervigilance where someone who, for example, lived through a violent incident, is constantly monitoring potential threats in the surrounding area and, as a result, often has difficulty sleeping and keeping an even temper.[5]

One of the many complexities of stress-related injuries is the fact that individuals may have been diagnosed with symptoms similar to these, but they are not necessarily dealing with PTSD. Doctor Stéphane Guay, a psychologist who is the Director of the Centre d’étude sur le trauma of the Louis-H. Lafontaine Hospital in Montreal, Quebec, stated that individuals with acute stress response are often diagnosed within a month of the traumatic event they experienced. However, Doctor Guay pointed out that between 50% and 60% of individuals with symptoms of acute stress response subsequently have PTSD symptoms.[6] Predicting which individuals will be grappling with the effects of PTSD is difficult because of the similarity of the symptoms, so acute stress response is not a perfect predictor. Indeed, the whole issue of predicting who is resilient enough to deal with traumatic events without any problems and who might suffer from PTSD or another stress-related injury still requires considerable research. Doctor Guay also highlighted some of the questions raised about the value of what is called debriefing, a form of intervention that generally occurs 24 to 48 hours after a traumatic event.[7] He stated that there is a growing international consensus following a number of research studies that universal early intervention or debriefing does not prevent the development of PTSD.[8] However, Doctor Guay also noted that on this issue, little research had been done specifically on military personnel. In any case, while debriefings may not prevent PTSD, this does not necessarily mean that debriefings do not help individuals who have faced a traumatic event.

Doctor Guay is also an associate researcher for Veterans Affairs Canada at the Ste.-Anne Centre and has participated in research projects funded by the department with other experts. He noted that the published results of these research projects indicated that veterans and others who experienced PTSD waited, on average, seven or eight years before obtaining treatment.[9] This was not because of a lack of treatment services, but rather the result of the reticence of some veterans to seek treatment because of the stigma attached to the condition or because of the time needed to understand what was happening to them. Doctor Guay stated that PTSD can become chronic if not treated over a period of years. Indeed, Doctor Brillon and others have pointed out that the sooner treatment begins after a traumatic event, ideally within 24 hours, the better the chances of coming to grips with the condition. However, since one of the symptoms is avoidance of anything related to the traumatic experience, there is a tendency to delay seeking treatment where the experience in question will have to be dealt with.

INCREASED AWARENESS OF OPERATIONAL STRESS INJURIES

Family members and friends of individuals with such symptoms often notice a change in the way these individuals deal with them and others, but they, like the injured persons, often do not understand at first what is happening. Over the last decade, the attitudes of military commanders, colleagues, and the public towards individuals dealing with stress-related injuries have evolved, though not always as rapidly as the progress made by psychologists in understanding and treating the injuries. In Canada, some of the prejudices faced by individuals dealing with stress-related injuries have disappeared thanks in large part to the courage of individuals such as Lieutenant-General (Retired) Romeo Dallaire, appointed to the Senate, who explained in public their personal experiences with PTSD. Various reports have also contributed to a better understanding of the impact of stress-related injuries on veterans and members of the military, notably those issued by the Ombudsman for the Department of National Defence and the Canadian Forces.

As a result of changing attitudes and the increasing number of individuals dealing with operational stress injuries, the Department of Veterans Affairs and the Department of National Defence have recognized the need to cooperate in establishing a number of programs designed to provide help and support. While this Committee is mainly preoccupied with the problems faced by veterans, the measures taken to help currently serving members of the Canadian Forces are inevitably of interest because these individuals will be veterans when they leave the military.

MEASURES TAKEN TO ASSIST MILITARY PERSONNEL AND VETERANS DEALING WITH OPERATIONAL STRESS INJURIES

For example, in response to a request by the Department of National Defence, in 2002 the Department of Veterans Affairs established the Ste. Anne National Centre for Operational Stress Injuries at Ste. Anne’s Hospital in Ste-Anne-de-Bellevue, Quebec, which it administers. The Ste. Anne Centre is the hub of the Veterans Affairs network of five Operational Stress Injury Clinics located in major urban centres across Canada which provide evaluations and treatment to injured veterans and members of the Canadian Forces. The Ste. Anne Centre also promotes research, for example, by sponsoring conferences such as the Symposium held in May 2007. In order to meet the demand for care and services for individuals with stress-related injuries, the 2007 Federal Budget announced funding for five additional centres. Meanwhile, since the late 1990s, the Department of National Defence has developed its own network of five Operational Trauma and Stress Support Centres located on major military bases to assist injured military personnel.

Another example of the cooperation between the two departments is the joint funding for the Operational Stress Injury Social Support (OSISS) programme established in 2001. Social support is important because individuals with stress-related injuries can become uncomfortable dealing with other people and become reclusive. Some individuals do not always understand what is happening to them and have difficulty communicating with others unless they have shared experiences or similar attitudes. For example, a veteran will find it easier to discuss issues with other veterans with similar experiences. Thanks to the pioneering efforts of a number of persons, notably Lieutenant-Colonel Stéphane Grenier who was himself dealing with an operational stress injury following his participation in the United Nations operation in Rwanda in 1994, the need for peer support was recognized by the departments and a network of peer support coordinators has been established across Canada. Many of the coordinators have dealt with operational stress injuries themselves. In short, while the medical and mental health specialists provide treatment, OSISS fills a gap by providing social support.

In addition to bolstering the services available to help injured individuals, often with the assistance of Veterans Affairs Canada, the Department of National Defence has taken measures to improve the preparation of Canadian Forces personnel prior to deployments overseas and to monitor their health after their return to Canada. The aim of these efforts is to raise the awareness of Canadian Forces members about operational stress injuries so that they can determine more quickly if they or their colleagues are showing signs of such injuries. More education on the issue also helps to change attitudes and to remove the stigma still attached by some to these injuries which discourages some individuals from getting the help they need. However, the Committee believes that much more can be done to prepare military personnel, starting as soon as they are recruited into the Canadian Forces, for the traumatic events they may face during training and deployments overseas. The number of hours provided for training and education on how to deal with stressful situations and how to help others dealing with operational stress injuries should be increased.

THE VALUE OF THIRD LOCATION DECOMPRESSION

Steps have also been taken to ensure that military personnel, at the end of a deployment overseas, have a more gradual transition from the turmoil of a conflict zone to the peace and tranquility of home. Such measures do not by themselves prevent stress-related injuries, but they can give individuals more time to evaluate their situation upon leaving the theatre of operation as well as easing their reintegration with their families and friends back home. In the 1990s, military personnel often ended their tours of duty in difficult peacekeeping operations such as the one in Bosnia with a direct flight to Canada which in a matter of hours transported them from the intensity of a theatre of operation to the comforts of home.[10] While happy to be back in Canada, some soldiers found reintegration with their families and the daily routine of life in Canada more difficult than they expected. When Canada began to deploy troops to Afghanistan in 2002, senior military officers recognized that soldiers needed a transition period between operations in Afghanistan and their return to Canada. At first, some soldiers were not happy about delays in reuniting with their families. The military ombudsman at that time, André Marin, also had reservations at first, but after some study, he recognized the merits of the stopover and issued a report on the issue.[11]

For the current operations in Afghanistan, military personnel returning to Canada spend approximately five days in Cyprus for what the military calls third location decompression before completing their journey. After compulsory arrival briefings, the soldiers who were part of a recent rotation attended two mental injury sessions chosen out of the five offered to them. The topics of these sessions included critical incident stress debriefing, healthy relationships, and coping with stress and anger. Furthermore, mental health professionals met with approximately 300 individuals.[12] The mental health team included peer support coordinators from the Operational Stress Injury Social Support (OSISS) team. In addition to the mental health sessions, the soldiers were offered a range of half-day and full-day recreational activities arranged by the Canadian Forces Personnel Support Agency (CFPSA). Even when the soldiers arrive back in Canada, the gradual reintegration process continues since they often work for three half-days before going on extended leave. For example, the 99 soldiers of the Lord Strathcona’s Horse who returned to Edmonton on March 12, 2007 after four months in Afghanistan were scheduled to work three half days before starting their leave.[13] The reintegration process with its various phases has been described as a “deliberate effort to ease them back into home life”.[14]

Indeed, family members also play an important role in helping a soldier dealing with PTSD, notably during the reintegration process. As Colonel Randy Boddam, then Director of Mental Health Services, Department of National Defence, noted in 2002, the presence or lack of support can be a factor in the development of PTSD after a Canadian Forces member has experienced a traumatic event. He added: “the better the member reintegrates with the family, the more likely the family will be able to recognize changes. Being better aware of problems can help the member or his or her family take advantage of resources. Earlier intervention means better long-term outcome.”[15] However, family members also need to be prepared for the reintegration process especially since one soldier dealing with an occupational stress injury can affect an average of 3.8 immediate family members. As a result, further emphasis is now being given to post-deployment programs for family members.[16]

THE NEED FOR CONTINUED SUPPORT

The emphasis on new post-deployment programs for family members highlights the importance of helping military personnel and veterans dealing with operational stress injuries to recognize the need for and to have access to treatment. The impact of such injuries on an individual is significant, but the effects on the well-being of others such as family members and friends are also substantial. Canadian society in general losses out when individuals dealing with a stress-related injury do not seek treatment or cannot obtain it. These injuries can greatly hamper the ability of these individuals to do their work, to contribute to their communities, and to help ensure the well-being of their family members. In short, it is in the interest of all Canadians to ensure that all individuals dealing with such injuries obtain the care and support they need. At the same time, it must also be recognized that their families need care and support. In an article written by persons involved with the OSISS programme, it was noted that it is now generally accepted that in order for individuals with PTSD to attempt a meaningful recovery, their family must also be included in, not to mention provided with, the necessary treatment.[17]

Over the last decade, considerable progress has been made in establishing various programmes to assist and support injured individuals and their families. However, the testimony the Committee heard also indicates that much more remains to be done. Because of the nature and complexity of stress-related injuries, individuals often have difficulty realizing that they are suffering from such injuries and that they need to seek treatment. There is also a tendency by such individuals to rely on self-assessments where the extent of the injuries is minimized or it is assumed that self-treatment will take care of the problem. In general, only between 40% and 50% of people with mental health problems seek help and these individuals often delay getting treatment, sometimes for years. As Doctor Stéphane Guay noted, this is the situation in society in general, not just within the ranks of military personnel.[18]

The tendency towards self-assessment also creates problems even if individuals seek treatment because they often decide that they have received enough help and can stop seeing a psychologist even if the latter still considers more treatment sessions necessary. Other factors come into play such as the problems faced by veterans and others who live some distance from the treatment centres which are located mostly in large urban areas or near military bases. Some reservists and a number of veterans who live in areas far from large urban centres can become discouraged by the frequent trips to areas with treatment centres. Thus, the Committee welcomes the announcement made in the 2007 Federal Budget concerning the funding provided for five additional operational stress injury clinics, but in a country the size of Canada, more resources are needed to ensure that veterans can have reasonable access to treatment no matter where they live. (Veterans and members of the Canadian Forces and their families can obtain information on the services available from the Department of National Defence-Veterans Affairs Canada Centre for the Support of Injured Members, Injured Veterans and Their Families by calling 1(800)883-6094 (during office hours). Members of the Canadian Forces and their families also have access to a confidential service, the Member Assistance Program, offered by the Employee Assistance Services of Health Canada in partnership with the Canadian Forces, which has a 24 hours a day number, 1(800)268-7708, or a hearing impaired number, 1(800)567-5803).

Even if injured individuals have relatively easy access to treatment centres, they may face other problems such as the limited number of psychologists available to provide treatment. The health care system in many parts of Canada is dealing with a shortage of doctors and nurses. Psychologists also appear to be too few in number to deal with the demand for specialised treatment not only from military personnel and veterans, but also from members of police forces and firefighters as well as other citizens. A number of witnesses have indicated that there is a need for more trained psychologists in general and for psychologists who are knowledgeable about the kind of situations military personnel and veterans have experienced.

People can react differently to a traumatic event, but individuals serving or who have served in the military have certain common personality traits or experiences which make them react in certain ways. For example, soldiers dealing with a series of traumatic events can develop a cold and macho attitude in an attempt to protect themselves against the psychological effects of such exposure. As one expert described it, soldiers often build a wall around their “tender emotions” in order to function in a combat environment or other stressful situations.[19] However, there is no guarantee that this attitude will prevent chronic PTSD months or years later and it can hamper relations with loved ones and friends upon the return to Canada. Thus, psychologists have to understand the different influences on the attitudes of military personnel in order to give them the best treatment and advice possible. Furthermore, as explained by Doctor Robert Belzile, a doctor with experience in occupational medicine who for a number of years dealt with members of
the RCMP deployed overseas to participate in peacekeeping operations, it is sometimes necessary to indicate if a soldier or RCMP member should not be deployed because they are likely to suffer a stress-related injury.[20]

However, for some injured members of the military, exclusion from their units can sometimes do more harm than good because it removes a major element of support either because they identify with the unit or because their colleagues can help them come to grips with their stress-related injuries. As Doctor Brillon noted, many who join the military do so because of the esprit de corps or team spirit they find within the organisation, so if admitting that they have a stress-related injury means the end of their military career, they will likely avoid doing this, especially if the military is their whole life.[21] There was some controversy recently about the fact that some military personnel dealing to some extent with stress-related injuries may have been deployed to Afghanistan for another tour of operation, but in a few cases, this could help some individuals who, while dealing with a mild form of stress-related injury, would still have difficulty dealing with their situation if they felt abandoned by their colleagues or if they were viewed as a burden. There may also be cases where military personnel with a stress-related injury deployed on another tour of operation in Afghanistan either do not realize that they are dealing with such an injury or are hiding the fact because they are afraid of what other people will think of them or of being forced to leave the military.

While this is mostly a military issue, it is important to recognize that the attitudes of others are still a major influence on what injured individuals, whether they are in the military or have become veterans, think about their situation. If there is still a stigma attached to people who seek treatment for an operational stress injury, it is almost certain that many injured individuals will remain reticent to seek treatment or to even admit that they should consult a psychologist. The fact that, for example, the stairs leading up to offices dealing with operational stress injury at CFB Valcartier, are called by some the “stairs of shame” indicates that there is still work to be done to educate persons within and outside the military and to change attitudes.

THE NEED FOR MORE SUPPORT FOR FAMILIES AND ESPECIALLY FOR THE CHILDREN OF VETERANS AND MILITARY PERSONNEL

More support for the families is also an important issue and as some witnesses pointed out, notably Doctor Guay who has done research on the issue, the spouses of injured military personnel can play a crucial role in the treatment process, although more research is needed. However, support for the families also implies assistance to the children. When a large number of soldiers from CFB Petawawa in Ontario were deployed to Afghanistan, there were reports of an increase in the level of stress among some of their children. Many of the children became more agitated and had more difficulty with their school work. As a result, increasing demands were put on the mental health services provided by the regional centre near CFB Petawawa, the Phoenix Centre for Children and Families in Pembroke, Ontario, and frustrated by delays in receiving additional resources from provincial authorities, the centre’s director lodged a complaint with the Ontario Ombudsman, André Marin. The Ombudsman’s investigation in the spring of 2007 attracted media attention and in the wake of his recommendations, the government of the Province of Ontario announced a significant increase in funding for mental health services for children.[22] The federal government also announced increased funding to help resolve the problems faced by military families seeking assistance for their children.

This issue illustrates the complexities of military life where military personnel can obtain most if not all of their health care from the military while their family members have to rely to a large extent on provincial services for their mental and other health care needs. In a backgrounder on the issue, the Ontario Ombudsman quoted an expert who noted that one of the most traumatic events for a child is to have a parent in a far away war zone. The situation does not necessarily cause PTSD, although children can suffer from such injuries.[23] However, it does cause stress which affects the well-being of the child and can lead to a stressful situation for the parent away in the theatre of operation. This is another reason why the reintegration of military personnel returning from a deployment with their family has to be given careful attention. However, above all, it demonstrates the need for all involved, including federal and provincial authorities as well as the military, to ensure that there are no gaps in the mental health services provided to military personnel, their spouses, and their children. The fact that many members of the military and their families do not live on military bases because they prefer to buy homes in the neighbouring communities or live near large urban communities offering many housing choices besides those available on the base complicates the task of ensuring that the children of military personnel have access to the mental health services they need.

Many witnesses and published studies have noted the importance of the family which can provide assistance and support to an individual with an operational stress injury. Much of the impact of the efforts deployed to help injured military personnel and veterans could be lost if their family members, including their children, have limited access to the mental health services they need. Thus, more should be done to ensure that the mental health needs of not only the individuals dealing with a stress-related injury, but also their family members are taken into consideration when developing and expanding the operational stress injury programmes and services.

Finally, the Committee welcomes the federal government’s commitment to the establishment of the Canadian Mental Health Commission as announced in the 2007 Federal Budget. The Commission will play an important role in improving the mental health services available to all Canadians and in promoting much needed additional research in all aspects of mental health. It is the Committee’s hope that the Commission will keep in mind the problems faced by Canadian military personnel and veterans dealing with operational stress injuries, not to mention those of their families, especially their children, and that it will contribute to the development and improvement of treatment and support programs designed for individuals who are serving or who have served in the Canadian Forces.

CONCLUSION

The mental health needs of the children of military personnel deployed overseas are yet another example of the complexities of operational stress injuries. This interim report does not claim to provide the answers to all the issues related to this complicated but important subject. The major points it is trying to make is that there is a need for continued support at all levels of government for the measures put in place to help individuals dealing with operational stress injuries, for more resources for these measures, for more research, and, above all, for strong efforts to continue the progress being made in changing attitudes, including those of every individual in and outside of the military and those of Canadian society in general. The Committee believes that a proactive approach is required to ensure that all veterans with operational stress injuries obtain the care they need. Future veterans, as well as present and future members of the Canadian Forces and their families, and members of the RCMP can benefit from the lessons learned in recent years and, if injured, they should seek treatment as quickly as possible to significantly improve their chances for recovery.