Veterans Affairs Committee on March 22nd, 2007

[The Chair, Conservative, Rob Anders]

Thank you, Mr. St. Denis.

Now we're on to Mr. Sweet for five minutes.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

Thank you, Mr. Chairman.

Dr. Guay, thank you very much for your time here.

I wanted to ask you a question specifically on one of the earlier statements you made, that in the military population there is a prevalence—his is from a study—of 6.8% who would have experienced PTSD. What is it in the general population? Can you give us a number on that?

[Dr. Stéphane Guay]

Unfortunately, we have not conducted studies in the general population here in Canada. As a result, I cannot draw any comparisons with the Canadian population. These studies were conducted in specific areas, including Edmonton and Winnipeg. I can tell you that in those studies, the rates were relatively lower—around 3% or 4%.

That is an excellent question, and it's extremely complex. Let me try and give you some answers in that regard. In the United States, the prevalence of post-traumatic stress in the general population over the course of a lifetime is also 6.8%. One is tempted to conclude that it is equivalent. However, another study was conducted in 2005. It is an excellent epidemiological study carried out in accordance with accepted practices.

The same thing was done in Europe, but the prevalence over the course of a lifetime was about 2% or 3%. That is quite surprising. There is a great deal of variation from one European country to the next in terms of prevalence. As you can see, this is a complex matter. Epidemiologists who conduct these studies have trouble explaining why there is so much variation from one country to the other on the same continent. They also have trouble comparing these results to those obtained in the United States.

Furthermore, I should also point out that the prevalence of PTSD among military personnel is somewhat underestimated in this study, for methodological reasons.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

You did mention that PTSD is very complex. In fact, PTSD is a very broad spectrum disorder. The disorder covers all kinds of consequential behaviour after someone's exposed to a trauma. Is that correct?

[Dr. Stéphane Guay]

Yes, exactly. Post-traumatic stress is obviously one of the main disorders caused by exposure to a traumatic event, but there are also other disorders that can develop. They include depression, other anxiety disorders, panic disorder with agoraphobia, for example, or simply panic attacks, and so on.

Mental health issues at National Defence or in the Canadian Forces do not only involve PTSD. In fact, there are others that are far more prevalent than post-traumatic stress.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

I'm listening to all the evidence, and I would like to clarify something on an earlier question from Monsieur Perron.

There is no better training that could be deployed right now for individual soldiers, and what's required now is more research. In other words, you weren't saying earlier that there was better training and we were refusing to give it to soldiers for recognition of PTSD. There's more research required on the whole complex issue.

[Dr. Stéphane Guay]

Yes, absolutely.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

I also want to clear up one other thing, because your testimony is actually contrary to that of a group of witnesses we had here. The four witnesses we had from OSISS were quite impressive, and they said one thing that's of concern to me.

I have three military bases in my riding: the Argyles, the Royal Hamilton Light Infantry, and the HMCS Star.

One of the big barriers to PTSD, at least for a soldier to recognize it quickly and, of course, come forward, is a concern about careers. OSISS has made it very clear to the soldier that their mandate is to get the soldier healthy in order for him or her to have the mental capability to again function well and to go back to his or her career, which is very honourable. As well, it combats one of the major barriers or one of the major stigmas of coming forward.

But you suggested earlier that soldiers who had significant mental issues were actually being sent back to theatre. I need to know this. Is it conjecture on your part, or as a clinician, have you actually had soldiers in your care who were mentally dysfunctional and were sent back into theatre?

[Dr. Stéphane Guay]

In fact, no. It is an inference on my part, because we have not treated people who were redeployed subsequently and had problems again. This is something that can be inferred from the studies—when you see, for example, that someone who had been suffering from post-traumatic stress disorder for six years was deployed in the last four years. So, one can obviously infer from that that this individual was deployed even though he or she had symptoms. We can see that from the data base we have, particularly the Statistics Canada one. We can see that if, on average, individuals that have been suffering from PTSD for eight years went on a mission twice in that eight-year period, there are most definitely some among them who were deployed in spite of their mental health problems. But that is an inference. I have not actually seen people that it happened to.

[David Sweet, Conservative, Ancaster—Dundas—Flamborough—Westdale, ON]

Yes, I think the fact that it's a hypothesis is necessary for clarity. Statistics are at what I would call a 30,000-foot level compared to actual experience and practicum on the ground.

You mentioned developing a process for de-stigmatization. In fact, there's one question that my colleague has asked every witness, and I get the joy of asking it now. From the research you've done, what measures do you think Veterans Affairs and the Department of National Defence could take right now in order to begin the process and enhance the process of the de-stigmatization of PTSD?

[Dr. Stéphane Guay]

Yes. I don't know exactly how to go about it, but I think it's something that requires a lot of resources, because the fear of losing one's job is not only very strong, it is also very realistic. If you are deemed to be dysfunctional and cannot be deployed after six months, I believe the risks of becoming a veteran increase; they are practically 100%. So that is a well-founded fear.

At one point, I heard Gen Dallaire saying, in an interview on television, that what is traumatizing for soldiers is not only being exposed to these events on deployments and coming back with these problems, but also to be thrown out of the Canadian Forces, even though they have given their lives and dedicated at least part of their life to that service; their families, as well. So, the simple fact of having to leave gives rise to a lot of distress.

When you ask me what we can do to destigmatize PTSD, I guess my answer would be that major organizational changes will probably be needed. Perhaps we will have to try and find duties other than military deployment if, for psychological reasons, some people cannot go on missions. That is one of the things that we may want to consider.

Another option would be to promote systematic screening. That way, we would not target only people who are at risk or could be perceived as being weaker by their peers. We would target everyone and, that way, everyone would go through a screening process that would allow us to achieve the desired result, without stigmatizing anyone.

Those are two examples. We could go even further than that, but I believe the most important thing that has been done thus far to destigmatize operational stress, as soldiers call it, is really what Gen Dallaire said in that regard. There is no doubt that when a senior commander suddenly talked about what some consider to be a weakness, that most certainly prompted a lot of people to go and get some help. At the same time, I believe there is still a great deal of work to be done in that area.

[The Chair, Conservative, Rob Anders]

I'd like to follow up on something, if I may.

Say, for example, you have somebody who is clearly demonstrating all sorts of symptoms, and they obviously need help, but they're still in the process of trying to avoid recognizing that they have something. They're trying to ignore it, they're trying to pretend they don't have something, but to others around them it's very obvious. What are your suggestions for some of the best ways to get somebody who is obviously suffering symptoms to go and do something?

[Dr. Stéphane Guay]

I'm sure there are a lot of different answers to that question. However, I will give you one. I think peers need to be involved.

For example, the Correctional Service of Canada has developed a peer helper program which is primarily aimed at enhancing screening of mental health problems associated with critical events that have occurred as part of prison guard work, for example. The Operational Stress Injury Social Support Program can probably provide some assistance in that regard, if the program is connected to the Department of National Defence. I'm not sure whether it is limited to Veterans Affairs Canada or not. That could contribute.

This is how the Correctional Service of Canada's program works: the organization selects a certain number of workers or individuals within that organization who it believes have a natural ability or natural skills in terms of active listening, but who can also interact appropriately with their colleagues who have witnessed critical events. Let's take the example of a fight between two inmates: they have to come between the two to separate them, there is bleeding during the fight and one of the two fighters who was bleeding was HIV positive. That's the kind of event that the organization deems to be critical.

The procedure followed at that point involves a peer helper, to whom a certain number of people are assigned, going to talk to the prison guard involved in the incident, although not to ask him to talk about what happened, as you would in a debriefing. That is one of the aspects of this program that I find absolutely brilliant, as a matter of fact. He simply goes to see the guard and talks about some of the possible signs of post-traumatic stress; he tells him that if he ever requires assistance because he doesn't feel well or is constantly thinking back on what happened, he shouldn't hesitate to go and see him to get help or receive information about the kind of help that is available.

I believe a simple procedure such as that, which is non-intrusive and allows the individual to see for himself that support is available, if need be, is one example of the kind of process that could be applied to military contingents. That is a first suggestion.

[The Chair, Conservative, Rob Anders]

All right.

Monsieur Perron.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Stéphane, I'm not finished grilling you yet.

You just talked about the Operational Stress Injury Social Support Program. I was really surprised. That is not a criticism. I would like you to tell me what you think.

Last Tuesday, we were told that peer helpers receive three days of training at Sainte-Anne Hospital and go back into the field to organize meetings on a volunteer basis, a little like what Alcoholics Anonymous does. I think three days of training is an absolute minimum.

Is it possible to teach someone the basic tenets of psychology or psychiatry so that they are better able to manage these centres or organize these training sessions? I would be interested in hearing your opinion.

[Dr. Stéphane Guay]

Well, as I said earlier, I believe that peers and professionals have complementary roles. Are three days of training adequate for a peer helper to be able to provide the support he should be in a position to provide? In my opinion, we are talking mainly about support in the form of listening, but not necessarily extended listening. I think the idea is that this person becomes a kind of vector who may be able to encourage or bring the individual involved to seek the services that are available.

I think the role of a peer helper really should be to do the strict minimum and simply get the individual to avail himself of the professional services he or she needs. Otherwise, it continues to be a case of specific skills or aptitudes. If there is no serious problem, if the person is just sad or a little anxious, it is possible that active listening will be enough. On the other hand, if there are more serious and persistent problems, and notably PTSD, I believe the peer helper's role, which should be valued, is to get that person to actually make use of the appropriate resources.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

A door has been opened to provide assistance to veterans. I agree that it's a first step. However, I am a little uncomfortable with one aspect of this financial assistance.

There is talk of establishing five training centres all across Canada. There is already one in Sainte-Anne-de-Bellevue. However, we know that this particular centre only has five beds for veterans.

I have an idea and I would like to see whether it is achievable. I will be talking about Quebec, but I have no doubt the situation is the same in all the provinces.

I know a veteran from Matane, the region represented by my colleague. He believes he is suffering from post-traumatic stress. I told him to get in the car, to drive for eight hours to Sainte-Anne-de Bellevue, to spend a day or two there, and then go back home.

I'm wondering whether we could set up a group of psychologists in Quebec who would be trained and mandated by Veterans Affairs Canada to provide follow-up with veterans. There could be one psychologist in each of the different regions, such as in Rimouski, which is located right in the centre of the Lower St. Lawrence region, another one in Lac-Saint-Jean, and so on. There may be thousands of veterans in Quebec suffering from post-traumatic stress. We just don't know.

If it's a health problem—for example, if I cut my arm and I need to see a specialist in Montreal, I will have no hesitation about taking a plane from Rouyn-Noranda to go and see him. However, if I have a problem between the ears but I'm not totally convinced that is the case, I may postpone that consultation to the following week or a time when I have to go to Montreal for something else. I may not end up going at all.

A psychologist who practices general psychology in a regional clinic, however, could be given special training by people like you or Pascale Brillon so that they could also care for people with post-traumatic stress. If it costs $150 an hour, well, the bill would simply be sent to VAC. That would save the veteran money, who would otherwise have to pay to go to Montreal to consult a specialist.

What do you think of that plan?

[Dr. Stéphane Guay]

I fully agree with it. That is an excellent way of providing specialized and enhanced services to veterans. It would also help to develop a network of psychologists, which would mean they could work more effectively to treat this kind of problem.

That is one of my goals as Director of the Trauma Study Centre. Knowledge transfer is one of my objectives. We need as many competent people as possible to be available to provide treatment. Both in the general population and here, people have to wait several years before they are able to access the appropriate services. That is a long time. Their problems become chronic, and there is absolutely no doubt that there is a cost when people are unable to receive the right services at the right time.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

A man from Kirkland Lake, the city adjacent to my own hometown, had to go to Toronto or Ottawa to be treated. It would have been easier for him to go to North Bay, which is closer, or to Sudbury, had there been such a centre.

[Dr. Stéphane Guay]

These services could be provided to veterans, but also to the entire mental health network.

In England, because cognitive behaviour therapy is the preferred treatment for a great many types of mental health problems, the British government has decided to launch a training campaign. It will be training some 10,000 psychologists to use the cognitive behaviour approach, because it is the best treatment for depression and anxiety disorders. Those two categories of mental disorders are the most frequent in the general population. In my opinion, it is money well spent.

[The Chair, Conservative, Rob Anders]

Thank you, Monsieur Perron.

Now on to Mr. Shipley, for five minutes.

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

I have just one quick question.

You mentioned earlier that there are other disorders that may or may not be more prevalent than PTSD. What other operational stress injuries would be linked to this? If we were talking about other operational stress injuries—and correct me if I'm wrong—I believe PTSD is one of those.

[Dr. Stéphane Guay]

In fact, operational stress is the terminology used by the Canadian Forces and veterans. Rather than calling it post-traumatic stress disorder, they call it operational stress disorder. It's the same thing, but they describe it as being a disorder connected to work carried out as part of a military operation.

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

Are there other things encapsulated within operational stress injuries?

[Dr. Stéphane Guay]

Yes. I imagine there must also be physical injuries, but I believe they have just determined that what they call TSO is what is known in the military as post-traumatic stress. It is an operational stress disorder, but I imagine there must be physical injuries as well. As I was saying earlier, it's important to realize that post-traumatic stress disorder in soldiers is not only caused by events they are exposed to on deployments. They experience many other kinds of events: it could be during their training, or it could a sexual assault while they're at their base.

In fact, whether you consider lifelong prevalence, as opposed to prevalence in the last twelve months, it doesn't really matter, because between 50% and 75% of post-traumatic stress disorders are caused by an event experienced while on deployment. That means that between 25% and 50% of events which caused post-traumatic stress are experienced outside the context of a deployment. So, these things do not only occur while soldiers are carrying out their duties during a deployment; they also occur elsewhere.