National Defence Committee on May 1st, 2013

[The Chair, Conservative, James Bezan]

Good afternoon, everyone.

I call this meeting to order.

We're at meeting number 78, continuing with our study on the care of our ill and injured Canadian Forces members.

Joining us today for the first hour, from the Department of National Defence, we have Lieutenant-Colonel Alexandra Heber, who is the psychiatrist and manager of operational and trauma stress support centres. She is joined by Madame Huguette Gélinas, who is the Quebec coordinator of health services civilian-military cooperation, with the Canadian Forces.

I'll open it up for your comments. If you could each keep them under 10 minutes, I'd appreciate that.

Colonel, you have the floor.

[Lieutenant-Colonel Alexandra Heber, Psychiatrist and Manager, Operational and Trauma Stress Support Centres, Department of National Defence]

Thank you.

Thank you, ladies and gentlemen, for inviting me here today, and thank you for all the good work you're doing in studying the care of the ill and injured members of the Canadian Forces. As you may remember, I appeared before you last November with the surgeon general, and I'm delighted to be back.

To give you some of my background, I worked as a nurse in mental health for nine years before entering medical school. I worked as a civilian psychiatrist for about 10 years at Mount Sinai Hospital in Toronto before moving to Ottawa. I first took a position in the Canadian Forces health services centre mental health clinic in Ottawa in 2003 as a civilian psychiatrist. In 2006 I decided to join the CF.

Part of my motivation for joining was so that I could deploy to Afghanistan, which I did in 2009 to 2010. In many ways this deployment experience was the high point of my career, though when I think about it, the past 10 years I've spent serving our military members, both in and out of uniform, have really been the overall highlight of my psychiatric career.

Besides seeing patients, I've been the program manager of our operational trauma and stress support centre since 2003, and since joining in 2006 I've been the clinical leader for all mental health services in the Ottawa clinic, which is considered the flagship clinic in Canada. It is the largest with a staff of 35 mental health clinicians.

With my experience working in both the civilian and military health care systems, I must tell you that I'm impressed every day with the level of accessibility, quality of care, the cooperation, and facility of communication among the different parts of our health care system. For instance, in the civilian world I had never had the kind of access and close relationship with the family doctors of my patients that I now enjoy. The family docs live only one floor above us and it's not unusual for me to see one of my clinicians running upstairs to discuss a complex case that they share with one of our doctors or physician's assistants, or one of our nurse practitioners.

As well, in mental health we work on multidisciplinary teams where the care of each patient is shared by psychiatrists, psychologists, social workers, and mental health nurses, and where we have access to specialists in addictions. We have a chaplain on our team, a pharmacist, and when needed, we have case managers and peer-support workers.

I'd like to focus for a minute on the operational trauma and stress support centre, or OTSSC, in Ottawa. These centres were first stood up in 1999 as specialized clinics within mental health services to serve the needs of the members who suffered mental health problems following those difficult deployments of the early and mid-1990s to Rwanda, Somalia, and Bosnia.

The OTSSC is a multidisciplinary team of highly skilled, flexible, and creative clinicians who assess, diagnose, and treat members referred for mental health problems. But the OTSSC also responds to outreach requests from members, the chain of command, or at times, from outside agencies. For example, for two years, from 2007 to 2009, before an OTSSC was stood up in CFB Petawawa, members of my team did satellite clinics for three out of every four weeks of a month, so we could help meet the mental health needs of the people in Petawawa.

As well, for over a decade the Ottawa OTSSC has run a week-long care for the caregivers retreat for all CF chaplains who have returned from deployment in the previous year.

We've established partnerships with many organizations outside of the CF, including the Veterans Affairs OSI clinics across Canada, and most particularly with our clinic here at the Royal Ottawa Hospital, with which we have a close and collaborative working relationship. We're regularly approached by some other sister organizations, including provincial police, RCMP, and most recently, Ottawa Fire Services, to brief them on our approach to issues like critical incident stress, suicide, and managing mental health issues in the workplace.

I'd like to touch on another important issue as I conclude. I believe that in previous testimony you have asked the question, who helps the helpers? Well, that's a pretty important question and hopefully we'll have a chance to discuss that in the next hour. What I have learned from my 10 years with the CF is that one of the most important ingredients to preventing burnout in clinicians is to work in a team environment with the support of colleagues, a common focus, and an idealistic purpose.

In our clinic, I'm happy to report we have these ingredients in spades.

Thank you.

[The Chair, Conservative, James Bezan]

Thank you, Colonel.

Madame Gélinas.

[Huguette Gélinas, Quebec Coordinator, Health Services Civilian-Military Cooperation, Canadian Forces, Department of National Defence]

Mr. Chair, members of the committee, I would like to thank you for giving me the opportunity to speak to you about the alliances and the partnerships that the Health Services have established with the civilian community in the field of health.

First, the Canadian Forces Health Services Group is legally responsible for delivering care to Canada's military personnel at home and abroad. However, the closure of military hospitals in Canada has resulted in the Canadian Forces becoming increasingly reliant on a wide variety of civilian health care agencies to fulfil its mission in providing this health care. In fact, the group lacks a number of components, which makes it reliant on the civilian health care network, with which it must establish partnerships with regard to these components. Accordingly, partnerships and alliances with civilian organizations are core to the Canadian Forces Health Services Group's strategy, as it is often the only way to access some of the required resources and health-related services delivered in civilian settings.

In 2003, the Canadian Forces Health Services Group implemented the national Health Services Civilian-Military Cooperation, or the HS CIMIC: a unique capacity-providing expertise with no equivalent in the civilian sector. This section comprises one national manager — a position I have held for the past four years — who operates out of the Canadian Forces Health Services Group Headquarters in Ottawa, and regional coordinators operating in various regions of the country, each with an assigned geographic area of responsibility.

From 2004 to 2008, I worked as the HS CIMIC cooperation coordinator for the Quebec region, returning to this role three weeks ago. From 2008 until this past April, I was, as I mentioned earlier, the national manager for the team. Over these past several years I have gained solid experience in the development and maintenance of strong and efficient civilian-military alliance networks and at securing access to high quality care for ill or injured military personnel.

HS CIMIC ensures and facilitates access to care in the civilian sector either as a complement to day-to-day in-garrison care or urgent care in relation to operations or exercises. In 2006, as a complement to Canadian Forces Health Services Group's support to Operation Athena, HS CIMIC was formally mandated to develop and implement the strategy for securing the care of ill or wounded soldiers in Canadian health care environments, for example, acute or trauma care in Canadian civilian hospitals, rehabilitation services, mental health services and other specialized services such as home care. Particular efforts have been oriented to mental health related initiatives for ill or injured military personnel and their families.

HS CIMIC is also responsible for securing education and training opportunities in civilian francophone and anglophone settings for Canadian Forces Health Services Group personnel. As of today, 154 memorandums of understanding were negotiated and formalized in relation to a mandatory program held in hospitals or ambulance services. The objective of this program is to maintain clinical skills of Canadian Forces health care providers so that all can provide care to ill and injured CF members, at home or abroad.

The Department of National Defence and the Chief of the Defence Staff both consider care offered to injured or ill members of the Canadian Forces to be a priority. Furthermore, the Canadian Forces Health Services Group has a firm resolve to provide the highest quality health care services available to military personnel. In this respect, the continuous and fruitful relationships established with civilian health services in Canada, as well as with other departments with a health mandate at the federal and provincial levels through the section that I led, play a key role in following up on this priority.

Thank you.

[The Chair, Conservative, James Bezan]

Thank you very much, Ms. Gélinas.

I think we'll stick with five-minute rounds, since we only have an hour with these witnesses.

Mr. Harris, you have the floor.

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

Thank you, Chair, and thank you to both of you for coming and joining us.

Lieutenant-Colonel Heber, I was very impressed by your resumé and your journey from being a nurse to being a psychiatrist to and being a lieutenant colonel in the military, and your deployments.

I liked your description of what goes on here in Ottawa. I have no doubt that, with the 35 staff and the flagship operation, you can do very good work. One of the worries I have though is that if you have a flagship, of course, everybody wants to compare it other things.

You mentioned a special program in Petawawa from 2007 to 2009. I'm sure you're aware of the report that was done by civilian clinicians in April 2012, only a year ago, which outlined what was being done in 2007 and 2009, and we assume it was top of the line. There were serious problems at this point with complaints that the OTSSC program was under-resourced; that they didn't have a medical addictions specialist, although 60% of the caseload were addictions related; that the wait times were unreasonable if you had a psychiatric diagnosis and needed somebody else; that the salaries weren't competitive with similar positions outside; and that there was no incentive for people to come live there. You're probably aware of the litany of what happened.

We've been told that improvements have been made. We don't have all the chapter and verse on that. But what I want to know is, how can this happen? If you did set this up—I'm not doubting that—and if you have a capability like we have here in Ottawa, how can that happen in Petawawa where we have so many soldiers, so many returning soldiers, and a huge complement of people? Why not have the kind of services available to this group of soldiers as are available here in Ottawa at the same standard?

[LCol Alexandra Heber]

I'm going back in my mind and trying to think of the series of events. In fact, they do have an OTSSC in Petawawa now. It was set up, in fact, in 2010 and had, as most of these kinds of specialized clinics do, some growing pains in terms of trying to, first of all, attract clinicians to the Petawawa-Pembroke area to work.

What we had done for those two years was.... At that time Petawawa fell under us in terms of operational stress injuries. We actually have a huge catchment area for our OTSSC. At that time it also included Petawawa. Now it includes all of Ontario except for Petawawa. For those two years, we decided that we needed to have at least some kind of a solution, a temporary solution, until further action could be taken in terms of things like setting up a separate OTSSC.

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

But this was 2012, two years later. They're saying, for example, that they're setting up assessments—that was April 25—in July, just an assessment. That seems to be very unreasonable if you have somebody coming forward who needs an assessment and they can't get an assessment for almost three months.

[LCol Alexandra Heber]

Well, here's what I can tell you. You're right, we worry about a 12-week wait time. Although, in Petawawa now they do not have a 12-week wait time. They probably have a two-week wait time. Our wait time in Ottawa is about 12 weeks now. We work on that.

By comparison, my friend and colleague, Dr. Raj Bhatla, who is the head psychiatrist at the Royal Ottawa Mental Health Centre, was quoted last summer in the Ottawa Citizen as saying that to get an assessment in their mood disorders clinic at the Royal Ottawa, people were waiting 12 months. Not to say that makes 12 weeks an okay wait time, but I think if you look at the comparison to the civilian sector, you can see that we actually work hard and we do quite well.

The second thing—

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

Do you think that's a valid comparison though, because we're talking about soldiers who have presumably received their stress injuries as a result of being in the forces? Why would we compare those to civilian wait times when we have a medical service designed to treat and care for our ill and injured soldiers?

People don't wait if they have physical trauma. Let's face it, that's just the nature of the beast. Why would they have to wait if it's psychological trauma?

[LCol Alexandra Heber]

It has to do with our resources first of all. The second thing I want to say is that we have a system of support within mental health services so that if somebody needs care immediately, they get it. It's very much like you would see in an emergency department, where physical trauma cases are staged and some people are given priority over other people in much the same way.

We also have a team where we have two clinicians dedicated to seeing people without appointment on a crisis basis. Now, that's not the full diagnostic assessment, but they are seen quickly. They can be seen the same day they come in and they are assessed. Then we look at how to prioritize people.

[The Chair, Conservative, James Bezan]

Thank you very much. Mr. Harris's time has expired.

Mr. Norlock, you have the floor.

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

Thank you very much, Mr. Chair, and through you to the witnesses, Doctor, why haven't you found the cure for the common cold? There are two of us here suffering, and we don't have a cure.

[LCol Alexandra Heber]

I'm a psychiatrist. I can empathize with you, but I cannot cure you.

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

You sound like my wife telling me I have to think the cold away.

But if I may, getting down to serious matters, I'm also on the public safety and national security committee. We have seen in all areas of federal government, all government services, where the government provides—to the taxpayer—services to the ill and injured. In particular in this case, it's people who suffer from mental illness or stress-caused injuries, as we see in the armed forces. We see that there is, and please do correct me if I'm wrong, a chronic shortage of psychiatrists, psychologists, and people in that field right across society, and in some cases especially in government services, because some professionals like a broad base of injury type, whereas in the prison system they're all pretty much the same thing, and with AIDS it's all pretty well the same types of illnesses or people are suffering along the same lines.

If we could use that societal comparison—and you have the experience in both fields—could you compare wait times, the availability of professionals both in the civilian field and the military field, and in particular, could you transition—if we have time—into the differences between the experiences you've seen from Bosnia and Herzegovina right down through to today from Afghanistan?

[LCol Alexandra Heber]

Thank you for the question.

There are two parts to that. First of all, the wait times, and then the difference I've seen in how people suffer from the days when I first started working in this field until now.

I gave the example from the Royal Ottawa hospital, of the difference, at times, being 12 weeks in our system to 12 months in the provincial health care system. One of the problems for a lot of the organizations that you're talking about is that they fall under medicare. They fall under the provincial health care system, and they don't have their own internal health care and mental care like we do in the military, so it becomes much more difficult.

We've instituted programs where, for example, we will see the RCMP members who have deployed with us. We will prioritize them and see them for assessment. We will then give back recommendations to their physicians so that they can start getting treatment. It's because it was taking so long for them to get services in the civilian world, and of course, they had deployed with us and had put themselves in harm's way, the same as CF members had.

In terms of the difference, that's a really good question. One of the things that I remember from when I first started working in the OTSSC, was that when members came in and I took their history, it wasn't uncommon for them to tell me that they had not slept through a single night in 10 years since returning from Rwanda or from Somalia, and that they had nightmares for almost all of those nights.

I have to tell you, as a civilian psychiatrist first starting to see people, I was taken aback. It was a bit hard for me to believe. But, of course, I had so many people who came in over and over again telling me that same story that I realized it was, in fact, true. These people had suffered in silence for years and years, had continued to work, and were stoic. I often needed to get their spouses in to get the real story of how much they were suffering because they didn't want to say very much.

Now it's much more the case that people come in six months to a year after returning from tour if they find that they are still having nightmares or still having an exaggerated startle response. I think they are much more willing to come in. There seems to be less stigma associated with this. I think part of it is that often their partners are much better educated now. They won't let them stay in the basement and drink for 10 years anymore. They say, "Hey, you're going to go and get some help.”

[The Chair, Conservative, James Bezan]

Thank you.

Time has expired.

Mr. McKay, go ahead.

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

Thank you, Chair.

Thank you to you both for coming.

We had Lieutenant-Colonel Grenier here a few weeks ago, and what added particular poignancy and credibility to his testimony were his own experiences with mental health issues. If this is an inappropriate question, tell me that it's an inappropriate question, and we'll move on. It's sometimes true that, looking at it from the other side of the gurney, the belief about your clinic, etc., is different, maybe not even quite as good. If appropriate, have either of you received treatment for issues relating to mental health?

[An hon. member]

That's inappropriate.

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

I gave them the option. If in fact it's inappropriate, say so, and I'm happy to move on, but it is quite relevant, because you speak about the burnout of clinicians, and it's true.

What we've been getting in a lot of this testimony has been people who are the providers of the service, or they are responsible for the providers of the service. We haven't been hearing so much from the people who are the recipients of the service. If it's inappropriate, just tell me so, and I'll go on to another question.

[The Chair, Conservative, James Bezan]

I'll leave it up to the discretion of the witnesses whether or not they wish to reply to that.

[LCol Alexandra Heber]

I have not had treatment for an operational stress injury, if that's your question.

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

Okay, that's fair.

Tell me about the profile of the individual who's going into the clinic.

A 35-person staff is a fairly substantial clinic. What is the protocol and the frequency with respect to the issuance of opiate narcotic prescriptions?

[LCol Alexandra Heber]

First of all, those would not be given out in mental health. If somebody has chronic pain disorder, they would be seen by their family doctor, their general duty medical officer. They may be referred to a pain specialist and some of these people may be prescribed opiates for their pain. But that's not generally in our purview.

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

So that doesn't happen within your clinic, then.