Public Safety Committee on March 22nd, 2016

[Matthew Dubé, NDP, Beloeil—Chambly, QC]

I'm sorry to interrupt you, but my time is limited.

Perhaps I didn't pose the question correctly. The gap I'm referring to is about the data that's available concerning PTSD, among other things, for veterans, versus the data that's available for correctional officers or first responders. The point I was making is that we heard in the last meeting that there is more and more data available for our veterans, but there is not very much data—if any at all—available for first responders, correctional officers, and parole officers.

That's the gap I'm referring to, with all due respect to the great points you've made. Does that gap exist between those folks? What can we do to resolve that issue?

[Dr. Nicholas Carleton]

The quote is from Dr. Jitender Sareen, a colleague of mine, and I believe the quote is accurate.

If you want to close that gap, and I believe we absolutely must, one of the critical things the government needs to do is invest in an institute like the Canadian institute for public safety research and treatment so that we can have a pan-Canadian, interdisciplinary, interuniversity expert team that collaborates with public safety leaders and public safety members to give you the best data possible, as fast as possible, so that we can close that gap, build better treatment options for you, and resolve some of even the basic questions, such as giving you an epidemiological set of stats that you can rely on to know how large the operational stress injury problems are. We can't even give you that basic data, at this point, in a robust fashion.

So yes, I would say 15 years is probably accurate. I would say the best thing you can do at this point is invest in a team research response. That's what will get you the fastest, best data at this point. If you invest in individual silos, you'll get the data, absolutely. But we can do better when the government helps us to work together across Canada as a team.

[Matthew Dubé, NDP, Beloeil—Chambly, QC]

Thank you very much.

I would like to come back to the question my colleague, Ms. Damoff, asked, as I found it interesting.

I'm talking about the issue of safe zones versus unsafe zones. I find that to be an interesting element. You talked about it briefly, but I would like to hear more about it.

In what way should the approach differ for first responders and correctional officers compared with Canadian Armed Forces members? Does the peer-to-peer relationship become more important? It has to be something that is constant and routine, while that happens in the case of veterans when they return home.

[Dr. Nicholas Carleton]

Yes, I think the peer support and the ongoing peer interactions are pretty critical. Again, I think we need to do some additional research to provide you with some data to answer those questions, because the kinds of traumatic exposure are different—not better or worse, but different because it's prolonged.

They need to be better able to manage uncertainty. They need to be better able to manage ongoing states of low-level stress. There's been long-standing research showing that daily hassles, for example, in the general community cause more and more distress than big and significant issues. Big and significant issues certainly are important, but those daily hassles that sort of edge on us, day in, day out, also have a significant impact.

For our public safety personnel who live that—and for them, the daily hassles are in some cases traumatic stress injuries—we need to come up with better solutions. They need to be different. We're really talking about building better teams. I think peer support will be important, but we don't have a lot of research to know what kinds, in what doses, and in what ways.

So yes to peer support, but we also need a broader, different set of solutions to deal with these kinds of ongoing exposures.

[Matthew Dubé, NDP, Beloeil—Chambly, QC]

Thank you.

Mr. Dadson, you spoke about changing the language to take into account the existing culture that makes it more difficult to talk about these issues. I'm just wondering if there is something we can do to maybe change that culture so that we don't even have to get to the point where we have to speak about it in those terms, and we can actually make it so that folks do feel comfortable speaking about it in the appropriate terms. Is there something we can do to change that culture?

[Dr. Mike Dadson]

It's probably outside my knowledge base to discuss how to go about changing the culture of the institutions. I can more accurately address changing the culture around the treatments.

In terms of therapists, research shows that sometimes the way we approach therapy is much more feminine, because women access therapy several times more than men. The agencies we're talking about are largely populated by men, and they don't necessarily address men the way men need to be addressed in treatment. Take, for example, an hour of treatment for a guy who is an RCMP or who is a first responder. By 40 or 50 minutes they're just starting to get into what they've been talking about. They're used to working really hard. In our program, we will work with them for four days straight in therapy, with each other, so they can work hard together.

So that's what I could speak to more, the way therapy is delivered and how cultures are shaped. I actually think the military needs to shape culture the way they do in order to give these guys and gals the best shot at survival when they're in those battle situations. It's getting them out that the military doesn't know how to do. They know how to get them in. When they're in there, they know how to help them survive. They're excellent at it. They just don't know how to help them get out. I wouldn't ask the institutions to be the ones that can allow them to do that, because that isn't their expertise.

[The Chair, Liberal, Rob Oliphant]

Thank you, Dr. Dadson.

Mr. Mendicino.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

Dr. Carleton, I have a series of focused questions I'd like to ask you about cognitive behavioural therapy and the prevention of PTSD. I think there is broad agreement that people who suffer from PTSD need to be able to access the correct support and treatment. Is that right?

[Dr. Nicholas Carleton]

Yes.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

One of the recommendations I heard you refer to during your oral presentation just a few moments ago was that part of the suite of treatments needs to include evidence-based treatment and CBT. Yes?

[Dr. Nicholas Carleton]

Absolutely.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

CBT has been proven to be effective?

[Dr. Nicholas Carleton]

Yes. There have been multiple studies, hundreds now, probably thousands, that suggest that it is efficacious, although nothing is perfect, and that it can in fact improve symptoms quite substantially.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

Implied in all of what you've just said is that it's been validated. Is that right?

[Dr. Nicholas Carleton]

Many, many times.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

It's been used across many cultures and work sectors?

[Dr. Nicholas Carleton]

Yes—across the planet, actually. It's probably one of the most robustly delivered and empirically assessed treatment protocols we have for mental health. It's actually a broad suite of treatment protocols. It's not a single treatment. To refer to it as a single treatment would be erroneous. It's a suite of protocols.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

Would you tell me what some of the factors are that contribute to the retention in cognitive behavioural therapy of people who suffer from PTSD? Afterwards, could you say a few words about the factors that contribute to premature dropping out of those who undertake CBT?

[Dr. Nicholas Carleton]

I don't know that I have time to give you all of it, so I'll pick some highlights.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

You're best to give me a nutshell within the next 60 seconds, because I have some additional questions.

[Dr. Nicholas Carleton]

Okay.

Rapport, the capacity to actually engage with an individual, is probably the most critical component for maintaining anyone in a treatment protocol. It doesn't matter what it is, the person has to feel like they have a relationship with that person. Whether you're offering CBT or whether you're offering any of the other protocols that could be available, it doesn't matter; you have to be able to build a relationship. The person has to believe you have a relationship. For the most part, as long as that relationship is supportive and maintained, I think you'll see good retention. I think a failure of retention occurs when you have a failure of that relationship.

Broadly speaking, I'd say it's about that relationship. Most success and failure of therapy, I believe, does still require that relationship. It's just what you're doing after you have that relationship that I think differentiates between really effective treatments and treatments that could be more effective.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

Does revisiting some of the trauma experienced erode the confidence and the trust in the relationship?

[Dr. Nicholas Carleton]

Not if done correctly, no. In fact all of the evidence we have so far suggests that when it is done appropriately, when it is done within the correct context and with someone with the correct experience, revisiting the trauma is actually a critical component to engaging in successful long-term treatment. I think one of the key elements is that you have to begin with a relationship with that person. Then you build trust, and then you can engage in the evidence-based treatment protocols that are necessary to help them with symptom reduction.

[Marco Mendicino, Liberal, Eglinton—Lawrence, ON]

What are the top two protocols that help insulate against the potential for an erosion of that relationship?

[Dr. Nicholas Carleton]

Protocols that help to protect against the relationship eroding?