National Defence Committee on Nov. 6th, 2012

[BGen Jean-Robert Bernier]

After deployment, everyone undergoes medical screening that's fairly thorough at the three- to six-month point, and then they carry on being followed up on with a periodic health assessment every four or two years, depending on their age group. At the time of release, there's a final evaluation.

There are multiple measures to try to identify and screen for mental health conditions along the way. As far as third location decompression goes, there was no data that justified its establishment before we established it. It was based on a common-sense review of what had happened in the past when colleagues had the opportunity to take advantage of social support after wars such as the Second World War and the Korean War, in which they had a long time together before complete demobilization back in Canada, as well as on the experience of the Americans in Afghanistan, who sent individual patients and demobilized soldiers from the theatre of operations directly back into North American society without that kind of opportunity.

I'll just ask Colonel Heber if she has any additional comment to make on third-location decompression.

[LCol Alexandra Heber]

I think the general was referring to Vietnam when he mentioned the Americans. That really did not work well, so we developed this idea of doing a third location decompression. Anecdotally, people talk about it having helped, about having that space with their buddies, with their colleagues, prior to coming back home to their families and to Canadian society, to everything that is here that wasn't over there. It's like a little safety time for people.

This is totally anecdotal, but I always remember a spouse from Petawawa telling me that her husband had deployed to Afghanistan both before we had third location decompression and after. She said TLD was wonderful. Her way of measuring this was that beforehand it would take six months before she could take him to Tim Hortons when he came home, and after he had gone on his second deployment and had had third location decompression, it took only about a month and a half. That was her measure for the difference: he was able to be around people and not be hypervigilant and not be triggered.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

For the people at home, what is third location like? Is it a specific geographic area or a social atmosphere or both?

[LCol Alexandra Heber]

It's the geographic area of being not in the war zone anymore, but not home, so yes, that's the first thing, and it's both social and educational. People are there with the troops they deployed with.

We also have quite robust mental health teaching that goes on there, reminding people of what they learned pre-deployment about what kinds of things they may feel and helping them in how to deal with it. There are also mental health folks available there 24-7 for people to talk to at any time. We would sometimes get referrals right from the third location before people hit the ground at home.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. Strahl.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Thank you, Mr. Chair.

Thank you to the witnesses.

You spoke about the great work of our medical teams in Afghanistan. I've read two books this fall by Dr. Ray Wiss, reserves doctor: Fob Doc and A Line in the Sand. Thanks to John for bringing those to committee members. I think any Canadian who wants to learn more about what our forces did in Afghanistan, and certainly what the atmosphere was like for front-line medical services personnel, would do themselves a great service by reading those two books.

I asked a previous witness if she could compare the mental health services or the medical services that CF members receive in Canada to those of other jurisdictions. She called our services the Cadillac of the health care system, I think for some of the reasons you have outlined, such as the ability to move quickly to respond to different situations. That's what she said it was like in Canada.

How do our military injury support centres measure up against the services that our allies have in place for their injured forces members? Have we looked into that? You mentioned some awards, but for our near peers, how are we doing in treating our men and women in uniform compared to how our allies are?

[BGen Jean-Robert Bernier]

On the administrative support side, the integrated personal support centres were partly modelled on the U.S. model. They were well ahead because of their years in Iraq and the number of casualties they've had. They have been doing very well in terms of administrative and casualty support to families and all taht kind of thing, but objectively, when it comes to things like suicide, there are so many variable differences in the way we operate, in the duration of our deployments, in the way we treat and consider mental health conditions, and in our levels of stigma. That may account for the differences. For example, among Canadian Forces members, we have a significantly lower rate of suicide compared to our American colleagues.

For example, some governments don't have a ministry of veterans affairs—like the U.K.—so the follow-up and the services provided to their veterans are quite different and are primarily taken on by private charities. On the other hand, they have a far, far higher number of private foundations and charities focused on the welfare of former armed forces members than we do in Canada.

Other than that, I can't comment much on the differences on the casualty support element. As far as the clinical support is concerned, there are significant differences, but it is widely recognized by NATO and by our allies that the standard of care we provide to Canadian Forces members is very, very high.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

We also heard a little bit about the efforts that the CF makes to educate families who have loved ones in the forces or specifically deployed overseas in Afghanistan, for example. What resources are available to military families? Is that part of your oversight? Is that under your structure?

Again, I just want some comparison as to whether we have learned lessons from our allies there as well. How does our family support structure stack up against our near peers?

[BGen Jean-Robert Bernier]

Thank you.

Family support is not part of my mandate. There's a separate organization that provides the family support that the Constitution and our legal framework permit us to provide. Also, health care, under the BNA Act and the Constitution Act, is a provincial jurisdiction and responsibility, so there are limits to how much we can provide there.

But certainly on the mental health side, because it's influenced by many things that are not purely clinical, there are significant services that are provided to families. The Road to Mental Readiness program, which assists with resiliency skills development and the identification of symptoms related to mental health conditions, how to deal with them, and how to get people into care, includes a family module. Family members are included in elements of that.

The Strengthening the Forces health promotion programs that deal with education on addictions, various elements of social wellness, stress management, anger management, and things like that—various factors that contribute to mental illness—are available to families in addition to Canadian Forces members. There is a specific couples counselling program that can include families. Our chaplains and our social workers—if it's relevant to the health of the Canadian Forces member—can include family members in their services.

There are military family resource centres everywhere, many of which include social workers or other mental health folks to assist them. Finally, the Canadian Forces member assistance program, which permits confidential access to counselling services, is available to family members.

Do you have anything to add, Dr. Heber?

[LCol Alexandra Heber]

I have just one thing. In the OTSSCs, as part of our assessment when we do our diagnostic assessment of the military member, we routinely ask the member to bring in his or her spouse. We will also interview the spouse. For many reasons, that's very helpful.

First of all, we get collateral information. We often find that military members are stoic and will under-report their symptoms. The spouse usually will tell us the real story about how difficult things are getting and how much the person is suffering. It also gives us a chance to see how the spouse and family are doing. We can then provide some support in terms of education. If the couple needs some help, we can always do couples therapy with them.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Thank you.

[The Chair, Conservative, James Bezan]

The time has expired.

Before we go on to the third round, I want to ask one question myself.

Mr. Strahl brought up the books by Captain Ray Wiss. I have read both of his books and was quite interested in his pioneering use of ultrasound in the FOBs to do diagnostics.

Earlier in this session, our committee travelled to DRDC—Defence Research and Development Canada—and met with some of the scientists there. They are working at how we increase survivability of CF members, especially from blood loss, and how we do those transfusions.

I'm just wondering what new technologies are coming online that the Canadian Forces Medical Service is looking at to increase survivability and to reduce the trauma that is inflicted upon our members in the line of combat. Also, what might we be able to expect as outcomes from this new research and from new adaptations of these technologies and medical techniques?

[BGen Jean-Robert Bernier]

Thank you for the question.

Research is critical for us, because we need to stay ahead of the enemy. We need to stay ahead of operational threats from hostile action, and ahead of naturally occurring industrial threats as well, because we deploy to places where there are threats that Canadians generally don't face.

Chemical, biological, and radiological defence is a big aspect. We have a quadripartite memorandum of understanding to work on a wide variety of medical countermeasures. There's a specific medical countermeasures coordinating committee to integrate our research to achieve economies of scale. We have a $160-million program that has been going on for several years now, in concert with the British and the Americans, to develop biological warfare defence vaccines.

We have an internal Surgeon General's health research program, through which a lot of our clinicians are embedded in university trauma centres or academic medical centres. In collaboration with either DRDC or their civilian academic partners, or both, they conduct specific health research related to military-specific health issues in critical care, trauma management, and a variety of other things. This is a very large program. We leverage elements of our contribution with that of the Americans and civilian academia. The Americans are paying about 40 times the amount we're paying.

In many cases, by virtue of having embedded our people in civilian facilities, we can leverage the research grants they receive from the Canadian Institutes of Health Research or their own university funding to address military-specific issues.

We are working on various diagnostics. Telemedicine is a key focus as well. There's quite a wide variety.

We publish elements of the research in the Journal of Trauma and Acute Care Surgery, the world's top trauma journal. A couple of years ago, we had a whole Canadian Forces supplement on operational medicine. We were invited to prepare it for that world-renowned journal and for the Canadian Journal of Surgery.

We've also helped establish the Canadian Institute for Military and Veteran Health Research, a collaboration of 26 universities led by Queen's University and the Royal Military College, to specifically address health issues relevant to military populations, their families, and veterans.

We have quite a wide variety of approaches and means by which we're focusing on research in too many areas to list in the time available.

[The Chair, Conservative, James Bezan]

I appreciate that.

We're going to go to our last round. Each party gets another five minutes.

Go ahead, Mr. Harris.

[Jack Harris, NDP, St. John's East, NL]

Thank you, Chair.

This is a most interesting presentation.

I want to follow up on something Colonel Heber spoke about, but first of all, I will say that I'm extremely impressed by the level of change that has taken place, particularly at the senior level of the military. It is exemplified by the former CDS and the attempts to de-stigmatize mental health issues in the military and to have a regime that seeks to have a strong understanding of that throughout. I know that there are the efforts to talk about this as an injury as opposed to a mental illness, to treat it the same as an injury. These are all very positive.

I wonder if I could ask Dr. Heber, or you, Dr. Bernier, to talk about this aspect of whether you're dealing with treatment or with discipline. I want to bring it back to your comments about the soldier who was in a traumatic circumstance. He comes back, and the commanding officer or the leader says, “Okay, you're off for a couple of days, but I expect you to get back on deck”. I'm not saying that this is a bad thing. It's helpful.

How is that different, then, from the “buck up, soldier” attitude? I know it is, but can you tell me how that distinction is made from the medical perspective, from the point of view of setting medical policy and dealing with that at the operational level?

You talked about the symptoms of PTSD. It's suggested that 90% of individuals diagnosed with PTSD have at least one psychiatric disorder, including drug abuse, depression, and suicidal thoughts. Sometimes there's a lot of overlay. How do you make that distinction? How do you do that from a medical perspective, as medical officers, and how do you see that operating at the pointy end, I guess?

[LCol Alexandra Heber]

Thank you for that question.

First of all, when I was talking about combat stress reaction, this was something we were doing in Afghanistan. The idea was about trying to keep people near their colleagues, to not separate them, because there's always a lot of shame involved. It was interesting. If somebody was in a FOB, a forward operating base, it was better if there was something that we could do there. Sometimes we would send our nurse or social worker out there, actually, if we felt it was necessary, rather than bringing them back even to Kandahar airfield.That was very much something we developed in Afghanistan.

In terms of what we do back home, you're right, in that there's always a tension between the confidentiality around patient care versus the chain of command wanting to have some information so they can help their members. One of things that we do now is a lot of education of the chain of command—the Road to Mental Readiness. People get this at every level of their career courses.

Last week I was in Kingston presenting to the army officers' course. These are people in the army at the level of captain who are being promoted. This is the thing we talked about. We talked about how we work together. We've set up, of course, a system of medical employment limitations that are recommended by the GDMO, the family doctor, not by mental health. The medical employment limitations state that “these are the things the person can't do” for x period of time, but it doesn't name what the conditions are.

[Jack Harris, NDP, St. John's East, NL]

Okay. So how do we get into situations, like when you're sent back home...? We've heard a case of it recently. A soldier is complaining that he's put on so-called light duties, where basically he's sweeping up the area in the presence of people who he was superior to and obviously being treated in a different way while supposedly being treated for PTSD. That's very wrong. I think you would agree. How does stuff like that happen?

[LCol Alexandra Heber]

First of all, I can't speak to individual cases—

[Jack Harris, NDP, St. John's East, NL]

I don't ask you to speak about that particular case, but that scenario doesn't sound right to me.

[LCol Alexandra Heber]

Right.

Certainly, we would never recommend something like that. People who are given medical employment limitations...sometimes they work part time. Of course, there are also times when people are taken out of the workplace because their symptoms, at that time, are so severe that they aren't able to function in the workplace.

The whole system of the JPSUs, the joint personnel support units, was set up for this purpose: so people can come out of their workplace, get the help they need for the period they need it, and then, hopefully, reintegrate back into the military. In the JPSUs, they have their own chain of command. The JPSU is there to assist people and help them with their recovery. As well, for the people who, for whatever reason, aren't able to recover and will end up leaving the forces, the JPSUs work with us around helping those people transition into civilian life.

[The Chair, Conservative, James Bezan]

Thank you. The time has expired.

Mr. McKay, for the Liberals.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Thank you, Chair.

I wanted to change tack a bit and get your observations with respect to the use—and maybe abuse—of drugs by forces personnel. Frankly, I don't know whether the use of illicit drugs is greater or lesser than in the civilian population, but it certainly does exist.

Clearly, from an operational standpoint, the consequences are far more significant for a member of the forces than for a member of the civilian population, possibly, in terms of deployability, I suppose, and in terms of danger to self and others. There is some self-medication going on and all that sort of stuff, so I'd be interested in your thoughts with respect to how illicit drugs affect you, as medical practitioners—i.e. you want to help—and also how it affects deployability and how much masking is going on, because soldiers are particularly clever at making sure their superior officers don't know about what they're doing. I'd also be interested in your observations with respect to psychotic breaks, which, in the case of a military person, particularly on a battlefield, are extremely serious.

I'd be interested in hearing your general observations and about your unique challenges.

[BGen Jean-Robert Bernier]

Thanks, Mr. McKay.

The illicit drug use is a concern. It's a disciplinary concern. Even though the health system will screen at enrolment for illicit drug use, it's not enforced by the medical system in any way. It's completely separate. We don't want to be seen as potentially.... It would harm those individuals who may want to be treated for an addiction if they suspect in any way or perceive that the health system is involved in the disciplinary enforcement of the rules related.

We'll treat people with addictions to the maximum extent and we'll do it confidentially. We have a series of in-patient addiction referral centres and one of own residential referral centres, in Halifax, to treat people with addictions and maximize, as the whole institution wants to maximize, their recovery and their ability to remain productive and stay in the armed forces.

With respect to the other elements, to psychotic breaks, Dr. Heber...?

[LCol Alexandra Heber]

As to psychotic breaks, I have to say, again, that this isn't something we have researched in terms of how many people have had psychotic breaks, but from my experience, it's pretty rare. If we look at people with serious and persistent mental illnesses like schizophrenia or bipolar disorder, where people will have psychotic episodes, we'll see that generally those people are not in the Canadian Forces.

Part of it is, again, the medical history that's taken when people come into the forces. Quite frankly, I think that some of the rigours of being in the forces.... Also, there's the fact that the community is small, so somebody is having those serious kinds of problems where they're becoming psychotic, it's usually picked up, and often fairly soon after recruitment. Those are the cases that we tend to see of people—

[John McKay, Liberal, Scarborough—Guildwood, ON]

So your argument is that they're screened out at the beginning, in effect.