National Defence Committee on Feb. 25th, 2009

[Mary McFadyen]

That's hard to tell. We did our report in 2002, then we did an initial follow-up nine months later. They had made progress, but probably it was a little bit too soon. We waited six years to do this one, but we would have to see how things were going to see when it was appropriate.

[Steven Blaney, Conservative, Lévis—Bellechasse, QC]

Thank you very much.

[The Chair, Conservative, Rick Casson]

We just have a minute or two left. Over to the official opposition.

Mr. Coderre, just a minute or two.

[Denis Coderre, Liberal, Bourassa, QC]

It's a short question, and it's following up from my colleague Claude.

There's a way to protect quality of life and make sure that nothing falls through the cracks, and that's to provide status to the ombudsman.

Do you believe, as in some countries, in having an inspector general with some specific judicial power? We can talk about procurement, but there's also the angle of quality of life for the troops--like in the United States. I personally believe that we should appoint an inspector general. We can have all the recommendations we want, but when you don't even have the central data, recommendations are not sufficient. Do you believe that kind of position would add value to the system as a whole?

[Mary McFadyen]

I don't know if I've fully analyzed the inspector general model. I know that was looked at in 1998 when they created our office. It was decided that an ombudsman would be the appropriate model as civilian oversight for the Canadian Forces.

Despite this report that only half the recommendations were made, I think in 10 years we have done a lot of work. We've held the Canadian Forces' feet to the ground to make sure they improve treatment. I do believe the progress they've made in the last six years--the next panel may disagree with me--is partially because of our office pushing them on the issue.

Thank you.

[The Chair, Conservative, Rick Casson]

We want to thank you very much for appearing. We wish you well as you go on to your next life; I guess that's how we like to put it.

We appreciate the input and the way you answered the questions.

We'll suspend for a couple of minutes while we change panels.

[The Chair, Conservative, Rick Casson]

Order, please.

We'd like to get started. I know there's lots of interest in the next panel, so we'd like to have as much time as possible.

We have General Jaeger back with us. Welcome.

You have with you Colonel Darch, Colonel Grenier, and Colonel Ethell.

Good to have you all here.

We'll turn it over to you. You know the drill. We'll give you some time to do your presentation, and then we'll open it up for questions.

[Brigadier-General Hilary Jaeger, Commander of the Canadian Forces Health Services Group, Director General of Health Services, and Canadian Forces Surgeon General, Department of National Defence]

Thank you, Mr. Chairman.

I may have forgotten the drill, but—

[The Chair, Conservative, Rick Casson]

It'll come back quickly.

[BGen Hilary Jaeger]

—you will remind me.

Mr. Chair, members of the committee, good afternoon. I am happy to have the opportunity to appear once more before you to provide some information that I believe will be of interest and value to you. I have assumed that the major focus remains on mental health care. It has been many months since I last appeared before this committee, and there is quite a bit of new information to pass along. Due to the unavoidable absence of Major General Semianiw, I would present some information about initiatives outside the health services, as well as inside, to try to provide as complete a picture as possible.

The first thing I thought worth presenting is our most recent data about the size of the CF's mental health challenge. We have continued to collate the results of the enhanced post-deployment screening, which you will remember is done three to six months after return from deployment.

We now have results from over 8,200 completed screening questionnaires, which show 4% responding in a manner consistent with PTSD; 4.2% consistent with depression; a total of 5.8% consistent with either or both of these conditions; and 13% consistent with any mental health diagnosis.

We do see a correlation between the intensity of the operational stresses and the rate of positive screenings for PTSD. If the results were broken down by smaller groups, it would be expected that some platoons and companies would have higher rates. It is also true that some people experienced problems later on, even though they appeared well at the time of the screening. But it is worth emphasizing that 87% of those screened reported doing well.

It is also worth remembering that the overall mental health problem in the Canadian Forces is not limited to PTSD or OSI. We have some recent information about the overall number of mental health patients currently being seen. The eight largest Canadian Forces clinics tracked new patients over the 5-month period from August to December 2008. This data shows an average monthly total of 530 new patients, of whom roughly 250 were seen by the psychosocial programs—which deal with less complex, more transient issues—about 210 by the general mental health programs and an average of 76 by the OTSSC programs. If you assume these numbers carry on year-round, you can forecast that roughly 6,000 new cases will present to these eight clinics in a year—and most of these will be unrelated to deployment.

The second type of new information I want to present to you involves measuring results. How do we know whether the care we offer is of high quality?

I'll admit we have not yet progressed to where we want to be with performance measurement, so we cannot yet report on direct clinical outcomes. But to provide one indicator of quality, we have conducted periodic patient satisfaction surveys.

Our most recent data were gathered anonymously from our five OTSSCs between January 12 and 23 of this year. Every patient being seen was invited to complete a survey containing 19 questions, plus an opportunity for free-text comments. One hundred and seventeen responses were received.

In summary, we found that overall, 96% agreed or strongly agreed with the statement, “Overall I am satisfied with the support and care I receive”, while only one person disagreed or strongly disagreed. Eighty-eight per cent agreed or strongly agreed that “The amount of support and care I receive is sufficient for my needs”, while 2% disagreed or strongly disagreed.

In a separate assessment of patient satisfaction, the general mental health program in Halifax has also been collecting feedback. When it came to whether they felt they were making progress, 88% of the 288 patients who responded said “some progress”, 27%; “moderate progress”, 23%; or “considerable progress”, 38%; while 12 stated they had gotten worse--that was 3%--or they were not getting anywhere, the other 9%. A higher percentage felt that their counsellor was “somewhat helpful”, at 18%; “pretty helpful”, at 34%; or “very helpful”, at 45%.

We also have evidence that our efforts to combat stigma seem to be paying off. Indeed, the Global Business and Economic Round-table on Addiction and Mental Health recently cited the Canadian Forces as an example in this respect. While there is no task to directly measure stigma, we have been collecting survey data about certain beliefs linked to stigma from our returning personnel. Over 9,000 personnel have now responded to these questions and my analysts have been pleasantly surprised by the what they found.

Twenty-four percent admitted to being concerned that members of their unit might have less confidence in them if they were to develop a mental health disorder. This was the highest of any of the 10 questions asked. Only 14% admitted a concern that they might be seen as weak, 12% had concerns about harming their career, 10% expressed distrust of mental health professionals, and only 6% felt that mental health care doesn't work. Perhaps the most interesting result was the response to whether the respondent would think less of a colleague who was receiving counselling. Only 7% admitted they would do so.

In reality, the situation is probably not quite that rosy. But what this response tells us—and I want to emphasize that this was an anonymous survey of a large number of people—is that the vast majority of our personnel are unwilling to admit to this bias. It seems clear to me that the CF cultural norm is now to be supportive of those with mental health problems.

The third area I want to touch upon is what changes have been or are currently being put into place. The Rx 2000 mental health initiative has made substantial progress in hiring, and we now have a total of 361 mental health providers across the country. This is still short of our goal of 447, but represents a very real improvement on the 229 that existed at the outset. I know there has been particular interest in Petawawa, so I am happy to report that significant progress has been made there, and there's more to come.

In spring 2008 a senior CF social worker was posted to become the mental health manager and provide clear leadership. Additional clinical support has been and continues to be provided by Ottawa-based clinicians travelling to Petawawa at frequent intervals, and a tele-mental health connection is being installed that should become operational this spring. This coming summer we will post three additional CF social workers and a CF psychiatrist to Petawawa.

Thanks to the fact that Colonel Allan Darch—who is with us today—was appointed to be the Director of Mental Health of the Canadian armed forces, there will be a better coordination of efforts among all our mental health care providers. Since Colonel Darch's work will be entirely committed to mental health care, these services will be directed more attentively and there will be an improvement in the communication among the stakeholders. Lieutenant-Colonel Grenier, who is also at the table with us, is the Special Advisor regarding Operational Stress Injuries and he regularly and directly advises the Chief of Military Personnel about the non-clinical aspects of the care provided to members of our personnel who suffer from mental health disorders. Lieutenant-Colonel Grenier is focusing his efforts on education with the help of the DND Speakers Bureau, which reached out to 8,000 members of the Canadian Forces in 2008, and is intending to serve more than 12,000 this year. His upcoming project will deal with the social determinants of mental health. Together, Colonel Darch and Lieutenant-Colonel Grenier are actively trying to establish connections with their counterparts in the United States, especially with the Chief of the Centre of Excellence on Mental Health of the United States Defence Secretariat.

We have re-oriented the OSISS advisory committee and broadened its mandate. It has become the DND/VAC/RCMP mental health advisory committee, and it had its inaugural meeting last week. The chairman of that committee, Colonel (Retired) Don Ethell, is also here today. You can see that there are open channels of communication and means for various points of view to be brought forward. As an aside, I know that Colonel Ethell has a direct line to the chief of military personnel, and they have a long history of working together.

To better reflect the range of people affected by tragedies, the CF members assistance plan, which is the confidential 1-800 service that provides access to up to eight counseling sessions, has been extended to parents and siblings of those killed or injured while in service. Of note, there has been no detectable growth in demand for this service over the past decade. Regular force members are the most frequent users, followed closely by family members. The most common reason for accessing this service remains marital problems, followed by psychological concerns.

All in all, I believe the CF now enjoys an excellent capability linked to overlapping proactive approaches to detecting members in need, but I'm willing to guess that what I've described to you today may not be in line with testimony you have heard from others. The natural conclusion might be that someone has been less than forthcoming. I do not believe this is the case, and in the last part of my remarks I'll try to explain why this apparent gap can exist, when everybody is speaking the truth as they know it and when everybody has the best of intentions.

The first point I will make, and I think I've made it before, is that no matter how much we care about the well-being of our patients or how well we are organized, staffed, and equipped to care for them, the unfortunate fact is that not all of them will get better. This is not the system's fault, it's not the provider's fault, and it's certainly not the patient's fault; it's because these are tough disorders to treat. The state of medical science at the moment just doesn't allow for mental health treatments that are perfect.

When someone being treated for coronary artery disease goes on to have a heart attack, the assumption is not made that their care was inadequate or their cardiologist negligent. Some people just have more serious cases than others. Mental health care and mental illness should be viewed in much the same way.

I suspect that you have spoken to patients or to families of patients who are in the unfortunate position of continuing to struggle. Remember that our own data shows about 12% of patients at one clinic did not feel they were making any progress. I don't mean to belittle their difficulties, but concluding that there's a systemic problem on the basis of extrapolating from a few anecdotes, no matter how compelling, is erroneous, and in fact may put at risk that which you seek to improve.

There is a phenomenon known as the “availability heuristic”, which produces a powerful cognitive bias. Basically, it states that our perception of the extent of a problem is strongly influenced by how readily an example can be brought to mind. If everyone knows of one or two examples of people who feel their care did not meet their expectations, that fact leads us to conclude there's a systemic problem.

Given the widespread media reporting about some cases, it's evident that interested observers can all think of at least one patient whose situation has not yet improved. Objective data, however, may reveal a very different picture. Individual problems should be addressed on a case-by-case basis while care is taken to preserve the system as a whole. Systemic problems obviously demand systemic solutions.

I'm spending quite a bit of time on this point because I firmly believe the CF is served by an excellent system of mental health care. But it requires two things in order to, most importantly, continue to function, and secondly, to make the local or incremental changes that may be warranted: we need to retain the trust and confidence of the members of the CF so that they will readily come forward to seek our care, and we need to retain the commitment of our health care professionals. Continuing to portray the glass as mostly empty when in reality it's over 90% full places both of these critical things at risk.

I ask that the members of the committee weigh all of the objective data presented before reaching any conclusions.

Thank you for your attention. I now look forward to addressing your questions.

[The Chair, Conservative, Rick Casson]

Thank you very much.

We'll start an opening round of seven minutes with Mr. Coderre.

[Denis Coderre, Liberal, Bourassa, QC]

Thank you very much.

General, colonel, thank you for coming.

It is important that the 10% be taken care of and that this does not turn into a chronicle gap.

We were talking to the ombudsman in the interim before this, as you noticed, and they were talking a lot about issues falling into the cracks. We're not dealing with statistics, of course; we're dealing with human beings, and that's important to note.

There are several issues I'd like to talk about. I know we don't want to go into personal issues, but the first one is an incident that happened in Valcartier a few weeks ago. The thing we have to realize is that because there was an important rotation that started on February 20, up to March, there was one case, and then another case, and then a third case in a row. Once is an incident. Twice, it might be a coincidence. But as for three times, I don't want to say it's a trend, but it's a bit scary.

You spoke not only about the patient, but also about the sake of the family, and rightfully so. We have to take a look at that. How do you explain that? Is it from the stress? Is it because we might have forgotten some of the prevention tools? We can never know when it will blow up, of course. We already spoke about that the first time you came here. I think it may be important for the benefit of our colleagues here to address that question specifically regarding rotation and the impact on our troops.

[BGen Hilary Jaeger]

I'll start off and then perhaps people who have more specific information can jump in.

I admit that I am only aware of these cases through the media reporting, and I take everything I see in the media with a relatively large grain of salt. I'm pretty certain there were these police incidents and members were barricaded inside their homes, but I don't know anything specific about what was going on in their lives at the time, other than that they were on the list for rotation. There's a whole lot of unknown information in the background.

[Denis Coderre, Liberal, Bourassa, QC]

With your answer, are you just proving that it's falling into the cracks?

[BGen Hilary Jaeger]

I don't think so, because the reason we're organized the way we are is that there are local resources in place. Obviously, it's terrible that this happened, and everybody would rather prevent it, but it's not always possible, so you have to react to the situation when it occurs.

The first line of reacting to this kind of thing would be the police, but at the conclusion, after being taken into custody by the police, the next step would be to have a mental health assessment. Depending on the results of that, you would go from there.

A mental health expert would tell you that this constitutes a crisis. It's an easy word to say, but there's a threshold you have to reach in order to be in one. But that would be treated as an in-patient--

[Denis Coderre, Liberal, Bourassa, QC]

You and I agree that it's a serious matter.

[BGen Hilary Jaeger]

It's a serious matter.

[Denis Coderre, Liberal, Bourassa, QC]

So what's the chain of command? They were soldiers. It was a serious issue. Of course, I saw it on the media, too, but some of the entourage spoke about it, too, so it was serious.

Just for the benefit of our understanding, what are the steps? Is it under the Valcartier unit? How do you manage that? Since you were aware, you know what's happened since then, I guess.

[BGen Hilary Jaeger]

They would be assessed at a civilian facility, one that had a mental health in-patient capability. Depending on how disorganized they were or what their state was, you may need one of the locked facilities, and there are not many of those. The attending civilian psychiatrist would institute immediate treatment. At the point where they had settled down somewhat, then care would be transferred to the mental health clinic in Valcartier.

Now, as to the chain of command's role, they of course are keeping track of what's happening, and they are thinking about what adjustments they have to make to the immediate pre-deployment training plans. It's not a tough decision to say this person shouldn't go on the rotation. That's the easy part. And then what?

[Denis Coderre, Liberal, Bourassa, QC]

The problem as I see it in general, is that we are about to perform a rotation, if it has not already begun. Right from the start, you say that an event can bring about a certain amount of stress. They are leaving for Afghanistan for a second or a third turn, and just at that time, they could reach a breaking point.

I do not want to discuss these people specifically, but I want to understand what is going on. If there are problems with the follow-up of a file, if the left hand does not know what the right hand is doing... We must have adequate communication in order to improve the system and to help the people. We are dealing with individuals.

Colonel Grenier, have any preventive measures been taken? The cases that occur may be due to the fact that the measures are inadequate. What do you do when you face this kind of situation?

[Lieutenant-Colonel S. Grenier, Special Advisor, Operational Stress Injuries, Post-Traumatic Stress Disorder, Department of National Defence]

These situations are not isolated cases. In fact, in 2000-2001, we launched a social support program among peers. More communication was established since Colonel Darch and Lieutenant-Colonel Jetly, a psychiatrist, arrived. At my level, we now have very close communication between the non-clinical support program and the clinical mental health care programs. I would be lying if I told you that over the past 10 years there has been total harmony between our perception of the experiences we lived through as soldiers and peers and, on the other hand, the solutions proposed by the clinical workers.

Nevertheless, I think that the events, especially the fact that the right people were appointed to the right place at the right time, have led to closer communication. Personally, I am envisaging closer coordination between the non-clinical interventions for which I am responsible and the clinical interventions. This might offer a systemic solution.

Regarding the patients, we have been saying for many years that soldiers have private lives between their assignments. We do not want the doctors to infringe on the private lives of their patients. Besides, we favour an approach that takes the individual's life more into account. Benchmarks and supportive measures have been implemented to make sure that once a patient has left the clinic, he continues to follow the treatments and therapies properly.

The treatment compliance, I think, is a huge issue.

I do not mean to say that this closer communication is the solution. As you know, during these past years, I saw that as a glass that is half empty. Today, I see this more like a glass that is half full, not only by reason of the improved functioning of my therapy, but also due to this closer communication. We no longer seem to belong to adversarial camps, and I am proud of it. Finally, our coordinators on the ground can rely on somewhat more solid support. That will repair a big hole in this net that is, after all, rather broad. I am not saying that that is the solution, but from my point of view, it is a positive factor.

[The Chair, Conservative, Rick Casson]

Thank you. That's very good.

We'll go to Mr. Bachand.

[Claude Bachand, Bloc, Saint-Jean, QC]

Thank you, Mr. Chairman.

I want to welcome the General and his aids.

On February 5, 2002, the ombudsman published a report entitled Systemic Treatment of CF Members with PTSD. Several months later, in December 2002, the Department of National Defence responded to each of the 31 recommendations. I have the document with me. This is a profile of the response to the recommendations. Amendments were suggested for only 3 of the 31 recommendations. As for the 28 remaining ones they received support, even full or entire support.

How do you explain the fact that seven years later, only 13 of the recommendations have been implemented? Moreover, 7 have been partially implemented and 11 have not been implemented at all.

It is important for me to say this right after your presentation. I do not think that this is a superficial problem. Instead, I think that it is a fundamental problem. I want to know what it can be attributed to. For example, could this be conceivably a cultural problem, with a predominating stereotype of the resilient man? I tried very hard to find a dictionary here. It says that resilience was at the outset a term that referred to the resistance of material to shock. It was first published in the field of psychology in 1939-1945, and Boris Cyrulnik developed the concept of psychological resilience based on his observations of concentration camp survivors. Thus, resilience could be the result of many processes that disrupt the negative trends.

At the Canadian Defence staff, they are so intent on developing resilience that they end up denying the real problem, which is present everywhere. Many witnesses have confirmed to us that these are not nearly small exceptions. What we heard is the contrary to what you are saying. It is false to say that 98% of the witnesses said that they had received adequate treatment. It was more like the contrary. Perhaps you were taking a preventive measure when you yourself said that this could sometimes seem to contradict what we have heard.

At the Canadian Defence staff there is so much emphasis on the resilience of the armed forces that there is an attempt to minimize the fundamental process and the reality of post-traumatic stress disorder. Do you agree with me?

[BGen Hilary Jaeger]

Sir, let me answer you in English, because it is important that I choose my words carefully.

I do not agree that the senior staff of the Canadian Forces, the leadership of the Canadian Forces, are focused on resilience or on the concept you're describing, for the reasons you attributed. The leadership of the Canadian Forces is very interested in having a Canadian Forces that's fundamentally ready to undertake operations in every sense of that word, and that means they have to be confident in what they're doing. They have to have a certain esprit de corps. They have to have confidence in their training, in their leadership, and yes, that could be construed as perhaps leading them into a bit of a sense of denial about what they might be facing. But I don't believe it goes that far, and it's certainly not because they want to deny the extent of problems when they occur.

You mention resilience. It's a wonderful concept. We would all like to prevent post-traumatic stress disorder. Unfortunately, if you read the scientific literature carefully, there is not even an accepted definition of resilience, much less anything you could measure in order to conduct a scientific study to say which interventions might promote resilience and which might not. As far as we know right now, the best we can do is to encourage tough realistic training with the same group of people they're going over with, to build confidence in the team.

I'm a bit sensitive to your point about not necessarily believing the rosy picture I've painted for you about the state of care in our clinics. You might be interested to know that Accreditation Canada, which is the national body that looks at the quality of care in hospitals and clinics across Canada, visited the Ottawa clinic over the past two and a half days. I was present at their debriefing this afternoon at which they praised the mental health clinic for outstanding work—one of the best mental health clinics they had ever visited.

[Claude Bachand, Bloc, Saint-Jean, QC]

I'll continue by—