Evidence of meeting #14 for Public Safety and National Security in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was treatment.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Zul Merali  President and Chief Executive Officer, The Royal’s Institute of Mental Health Research and the Canadian Depression Research and Intervention Network, As an Individual
Alice Aiken  Director, Canadian Institute for Military and Veteran Health Research
Paul Frewen  Professor, Psychologist, Department of Psychiatry, University of Western Ontario, As an Individual

11:50 a.m.

Director, Canadian Institute for Military and Veteran Health Research

Dr. Alice Aiken

The stats that Dr. Merali gave you are consistent for the military: about a third of the people who go into treatment for post-traumatic stress disorder are successfully treated, a third don't respond and will never respond, and a third stay in treatment.

Of the ones who are successfully treated, many do return to combat, if that is what is decided for them. The incidence of relapse is no greater than with any other mental health issue, if they have been successfully treated.

11:55 a.m.

Liberal

Sven Spengemann Liberal Mississauga—Lakeshore, ON

Would you speculate that the same is true on other sides of the spectrum of first responders, such as firefighters, EMS, and police? Do you know a reason to assume differently?

11:55 a.m.

Director, Canadian Institute for Military and Veteran Health Research

Dr. Alice Aiken

As Mr. Dubé mentioned, it is a different exposure, and from my knowledge I don't think we have enough data to tell us at all.

11:55 a.m.

Liberal

The Chair Liberal Rob Oliphant

I might ask, just on the concept of “successfully treated”, if a disease is diagnosed by a symptom as opposed to by objective testing, how do we know whether the treatment was the effective cause of the success or whether the success was a result of something else?

I come at this from asthma, where I just spent the last four years and where we have some objective lung function testing, not well used by respirologists or doctors. We have a symptom-based disease, and we are never exactly sure whether the treatment was really efficacious or if it was something else.

How do you prove “successfully treated” as opposed to functional or something? How do you measure that?

11:55 a.m.

President and Chief Executive Officer, The Royal’s Institute of Mental Health Research and the Canadian Depression Research and Intervention Network, As an Individual

Dr. Zul Merali

It is very hard. I think that to pin the success of a treatment to a specific intervention is hard, mainly because the people we treat will tell you that in life they might be doing yoga, doing exercise, or engaging in spirituality. Many of these interventions have an impact. It is very hard to dissociate them from the outcome.

What we typically do is double-randomized studies, where we divide the population into two. One gets a particular intervention, whereas the other one doesn't get that activity; otherwise, everything remains the same. Based on that, we derive our conclusions as to whether the treatment is effective or not. On an individual level, it is hard to tell, because something else altogether might have helped them.

11:55 a.m.

Liberal

The Chair Liberal Rob Oliphant

More work on double-blind randomized studies could be useful, as you keep telling us.

We are going to have to have money for this. We are always told not to ask for things, not to lead you guys to ask for money, but our report is going to have to ask for more research, although I am not predicting it yet.

11:55 a.m.

Di Iorio

We are going to have to start cutting down the meal budget.

11:55 a.m.

Liberal

The Chair Liberal Rob Oliphant

It can come out of the meal budget, yes, which is quite low....

Monsieur Rayes, go ahead.

11:55 a.m.

Conservative

Alain Rayes Conservative Richmond—Arthabaska, QC

Good morning. Thank you for your presentation.

My comments will follow on the question my colleague Mr. O'Toole asked. This is something that is of great personal interest.

Dr. Merali, you spoke about treatment after a PTSD diagnosis. You said that a third of people who go into treatment are successfully treated, that a third has limited success and that the remaining third has no success at all.

You also said that technology and research made it possible to better predict who would respond the best to a treatment, and it's important to note that this varies from person to person.

Are there pre-existing conditions, such as trauma, that exacerbate this disorder in certain individuals? It would be good if the research or the discoveries that have been made could be used to determine basically which individuals have such conditions. If that was the case, perhaps we could raise awareness about this.

Could you speak more about that?

My question is also for Dr. Aiken.

11:55 a.m.

Director, Canadian Institute for Military and Veteran Health Research

Dr. Alice Aiken

You know, it's very interesting, because they did a very large-scale study in the U.K. on military people. They screened them for likelihood to develop post-traumatic stress disorder specifically. The people who they determined—based on childhood experiences of trauma and a bunch of different screening tools—were most likely to develop post-traumatic stress disorder were not allowed to deploy with their unit when their unit was going overseas, but the people who were not allowed to be deployed were more likely to develop post-traumatic stress disorder after the deployment, because of being separated from their unit, than they were had they gone into theatre.

As Zul said, it's a very loaded question to talk about screening. I think the more mediated response, as he suggested, is probably to identify if people are predisposed to developing a mental health issue and then help build resilience or help work on treatment programs, but don't take them out of their workplace and single them out. From speaking with people in corrections, I know that this is especially important for them. They know they're targeted, because they're taken off the floor if they're suffering from a mental health issue.

Noon

Conservative

Alain Rayes Conservative Richmond—Arthabaska, QC

Dr. Merali, I fully understand the distinction that could be made, especially with regard to these occupations. As a former mayor, I've worked with firefighters and police officers. It's an environment where they are all strong and where "weaknesses" aren't accepted.

You spoke about scanners and brain imaging. Do you think that investing in research would ultimately make it possible to detect this? We would see later what we would do, but at least we would have the indicators.

Noon

President and Chief Executive Officer, The Royal’s Institute of Mental Health Research and the Canadian Depression Research and Intervention Network, As an Individual

Dr. Zul Merali

You raise a very important question. There are no answers to it. I think the only way to answer that kind of a question is to have longitudinal studies that study people right from the get-go, from day one all the way through, for quite a few years, and have those biological, psychological, brain-imaging biomarkers collected over time to then see who develops PTSD versus who does not.

For example, if you look at people who develop PTSD, through brain-scanning we can tell that the area of the brain called the hippocampus is shrunk. It's smaller than normal. If we had longitudinal studies, we'd know whether the hippocampus was shrunk before the trauma and predisposed them, or whether it happened after the trauma. I think you need these longitudinal studies. There aren't many to be had in this area, and I think it's very important that they be done.

Noon

Director, Canadian Institute for Military and Veteran Health Research

Dr. Alice Aiken

They're mostly done on rats right now.

Noon

Conservative

Alain Rayes Conservative Richmond—Arthabaska, QC

This is very interesting. We need to make sure these people are treated.

You just gave the example of cholesterol, cancer and diabetes. With those diseases, we know that if we eat better and less, if we take care of our health and so on, our chances are better. There is prevention and public awareness.

My concern has to do with that. I know we shouldn't categorize people, but we could do sort of what they do in sports, where they work on an athlete's resilience. If human resources know the stress risks or the situations that may lead to professional burn-out, training can be given that includes scenarios and role playing, among other things. Ultimately, it would make it possible to determine who around us would be likely to be in a stressful situation.

Efforts shouldn't focus solely on treatment, especially when the results aren't always there. We need to work at the source, too.

I don't have any other questions.

Thank you.

Noon

Liberal

The Chair Liberal Rob Oliphant

Thank you.

We'll suspend for a minute or two as we bring Professor Frewen in on video conference.

Noon

Liberal

The Chair Liberal Rob Oliphant

We're going to resume the meeting.

Before we begin, I want to mention that Professor Frewen sent to the committee clerk a website that has been referred to by a previous witness, but since the website is in English only I would need to have unanimous consent to distribute it to members of the committee. If I don't have unanimous consent, we can't distribute it, but I want to check whether or not we have unanimous consent.

I see that we do not have unanimous consent. It may be referred to, and you can try to search for it on your own if you like.

Dr. Frewen, you have 10 minutes to present. Thank you very much.

12:10 p.m.

Paul Frewen Professor, Psychologist, Department of Psychiatry, University of Western Ontario, As an Individual

Thank you for having me. Indeed, I did share the website, and my presentation will pertain directly to it.

Thanks very much. I'm going to share my screen now. You can see it in a moment.

What I'm going to be describing to you is a therapy that we've developed that combines an Internet-based approach with making use of mindfulness meditation and other types of meditation that I feel would be a good intervention for post-traumatic stress in first responders as well as other populations.

I was able to hear some of the earlier presentations which had to do not only with treatment but also preparation for an individual who can be expected to witness and respond to traumatic life events. I heard the terms “preparation” and “self-training”. I feel this type of approach, which is Internet-based and very much an intervention in which people are training themselves, would fit very well with that interest. As such, it should be a feasible intervention to provide in a large capacity.

We should think about the treatment of trauma and stressor-related disorders as involving two primary objectives.

The first is to work through the trauma. This typically involves some dialogue with a therapist in which a person is reviewing what has happened to him or her in different formats, essentially trying to understand what happened to them. It could be verbally or through writing or art, etc. That reflection leads to an increased capacity to not become distressed, for example, by being reminded of what has happened to them.

The other component, which may be talked about less, is the component of self-regulation, which essentially is helping a person cope better with the difficult emotions that come with diagnoses such as PTSD. I think you've certainly heard of the current evidence-based treatments. We have some effective treatments, typically cognitive behavioural approaches to psychotherapy, but there are certainly limitations to the current approaches. Indeed, not so many participants get fully well. For example, only about half show a response rate that leads to a loss of the diagnosis of PTSD in randomized controlled trials, and there's also a lot of dropout.

The literature is starting to turn to both Internet-based treatments and alternative approaches to cognitive behavioural therapy, such as mindfulness-based therapy. Indeed, at the University of Western Ontario, we've been the first to essentially put these two together with an Internet-based approach to mindfulness-based therapy.

Very briefly, assessment of the web-based interventions have been published, especially in the areas of treatments for depression and anxiety disorders, and more recently PTSD as well, and the findings are quite striking. Relative to the same types of treatments administered in the typical way—in face-to-face psychotherapy, for example—the effect sizes, the outcomes for the Internet-based approach are often just as strong and just as good as those obtained in the face-to-face approach. That surprised many, but it has actually been documented extensively now.

This is also the case in PTSD trials, for example, in college student samples, community samples, and combat veteran samples. To my knowledge, we don't have a study yet on an Internet-based approach for first responder groups, but based on the literature, similar kinds of outcomes can be expected.

Mindfulness-based interventions so far have not been delivered in an Internet-based approach, but there are several reasons that we would think mindfulness-based practices should be helpful in the treatment of post-traumatic stress disorder and dissociative disorders.

For one, they tend to improve attention and concentration, can improve the ability to focus on the present and away from ruminations around past trauma as well as future-based anxiety, and can alter cognitive style and help a person become less judgmental and more compassionate towards themselves. They can directly reduce physiological arousal and associated emotions of anxiety, irritability, and anger. They can lower anhedonia—the emotional numbing, the inability to experience positive emotions such as joy—and so increase positive emotions, increase a person's experience of social connectedness, and restore existential concerns towards improved well-being.

There are good ideas. There have been several research projects that have also shown persons with post-traumatic stress disorder are lower on what are called mindfulness traits. For example, they are less likely to notice changes in the body, such as whether their breathing slows down or speeds up. They are less able to put feelings to words and less able to find words to describe their feelings. They are less able to stay in the present. Their minds wander. They are easily distracted. Further, they are less able to accept their feelings without judgment.

These are areas that a PTSD treatment should target, and a mindfulness-based treatment targets such things.

We have recently shown that the relationship between trauma exposure and PTSD symptoms is significantly mediated with these types of mindfulness-based personality traits. If we can affect these traits, then we can affect the PTSD symptoms.

Improvements in attention and improvements in emotion are expected outcomes for mindfulness-based therapy, and there have been several studies that have shown positive results for mindfulness-based therapy, including our own study.

If I have a moment, I'll be able to describe a bit more about the specific treatment using mindfulness and metta-based trauma therapy, which is an Internet-based approach. It involves teaching meditation as well as various mindfulness-based principles and ethics.

12:15 p.m.

Liberal

The Chair Liberal Rob Oliphant

You have about three more minutes.

12:15 p.m.

Professor, Psychologist, Department of Psychiatry, University of Western Ontario, As an Individual

Paul Frewen

We teach six therapeutic principles. The first is about how a person can stay present. The second increases awareness of both mind and body. The third helps a person understand how to let go of difficult forms of distress. The fourth refers to metta, which has to do with loving kindness and self-compassion. The fifth has to do with recentring and decentring, and the sixth with acceptance and change.

I have a couple of slides to show you how we do this. In general, we try to teach a person greater control. PTSD and trauma lead to a sense of inability to control the controls beyond oneself. We're trying to put the control back into a person's hands. We use the acronym PALM to refer to the first four principles of presence, awareness, letting go, and metta.

Presence is the first. This has to do with helping people understand they are in the present and not the past. This has to do with the flashbacks and the re-experiencing and recognizing the influence of the past traumas on their responses in the present.

To assist with the awareness, we're trying to teach people to become more aware of their senses, their body, and their emotions, and to try to label and understand their experiences.

With the letting go, we're trying to help them to be able to let go of the distress as well as teach non-attachment to harmful impulses and desires that can develop from a significant trauma history, such as substance abuse or alcoholism.

We also help with the capacity for metta, for being kind and compassionate to oneself and others.

With the the recentring, people can desire a feeling, but they are feeling too far from it. We're trying to reverse that and bring people back to their sense of self and bring them back to their emotions. At other times we're teaching that if a person is feeling something too much, then the person needs to get outside of that. We're trying to teach a person to be able to develop that experiential distance so as to have the capacity to reflect, decentre, and then wait it out, as the distress will eventually subside.

I'm not sure about my timing, but what I would like to suggest in comparison with—

12:15 p.m.

Liberal

The Chair Liberal Rob Oliphant

You have about one minute left.

12:20 p.m.

Professor, Psychologist, Department of Psychiatry, University of Western Ontario, As an Individual

Paul Frewen

Thanks very much.

In comparison with the decentring, we want to contrast that with avoidance. We'll be rejecting the present. With dissociation, we leave the present.

Finally, that last principle is acceptance and change. It really is a sort of balance that typically the trauma survivor is trying to avoid. We talk about this as if it's like a blanket. We try to sweep it under the rug, for example, but it's really a see-through blanket, so we can't do so. Really, the only way to move forward following a trauma is this right balance between acceptance and change.

How are we doing these? Essentially, the website involves a journaling activity as well as various guided meditations.

What I'd also like to suggest, beyond just the website, are various technologies that are being researched, including here at the University of Western Ontario. Persons may have heard of the terms “neurofeedback” and other forms of biofeedback, such as heart-rate variability. The practice of meditation is going to have an effect on the brain and the body, and that's essentially indirect; the practice of biofeedback and neurofeedback is to learn what's actually happening in the body through physiological signals such as heart-rate variability and through the EEG. We can teach a person to directly modulate brain rhythms, cardiac rhythms, respiration, etc., as they're going to be doing naturally in meditation, but the biofeedback can be an additional aid to the person.

12:20 p.m.

Liberal

The Chair Liberal Rob Oliphant

I'm afraid I need to have you wind up.

12:20 p.m.

Professor, Psychologist, Department of Psychiatry, University of Western Ontario, As an Individual

Paul Frewen

Thank you.

For example, we can combine the biofeedback approaches with the mindfulness practices to achieve an even better benefit.

Thanks very much.

12:20 p.m.

Liberal

The Chair Liberal Rob Oliphant

Thank you.

We're on to questions. Ms. Damoff is first.

12:20 p.m.

Liberal

Pam Damoff Liberal Oakville North—Burlington, ON

Thank you so much for your presentation. We heard of your work when Dr. Lanius was here, so it's wonderful you're able to be with us.

One of the other witnesses, Dr. Andersen, talked about the use of much of what you're doing as a preventative strategy as opposed to only for treatment. I'd like your comment on that. There was also a comment she made about terminology, which was that in the macho environment, you find within first responders and corrections officers that sometimes the terminology—and much of it you've used today—about meditation and mindfulness doesn't necessarily play well. Doing the same techniques but using different terminology to describe it is sometimes more effective. Could you comment on that?