Evidence of meeting #8 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 evidence-based.
A recording is available from Parliament.
11:50 a.m.
Associate Professor, Department of Psychology, University of Regina, As an Individual
I'm not sure there are protocols for protecting against rapport erosion. I think part of that comes down to clinical experience in clinical practice, and having good supervision when you were being trained. At this point, the top two protocols for providing evidence-based treatment overall, though, for post-traumatic stress disorder would be prolonged exposure and cognitive processing therapy.
11:50 a.m.
Liberal
11:50 a.m.
Associate Professor, Department of Psychology, University of Regina, As an Individual
It would depend on who you asked, but prolonged exposure would certainly be your top one. Cognitive processing therapy would probably come in at number two. Possibly EMDR would come up somewhere in there as well.
11:50 a.m.
Liberal
Marco Mendicino Liberal Eglinton—Lawrence, ON
Okay.
Could you talk to me a little bit about the use of CBT to prevent the onset of chronic PTSD? Is there a way to provide CBT in a prophylactic and pre-emptive manner as part of the training of individuals who will either be first responders or responding to other natural disasters?
11:50 a.m.
Associate Professor, Department of Psychology, University of Regina, As an Individual
I believe there is.
I don't know of any evidence whereby we have explicitly tested it over the long term yet. That's one of the things we want to do with the up-and-coming research study, but there's no good reason at all to believe that appropriately integrating some of the core what we call “psycho-educational” components as a part of training would be anything other than beneficial.
11:50 a.m.
Liberal
Marco Mendicino Liberal Eglinton—Lawrence, ON
This is an experimental area that hasn't really been explored or studied or validated.
11:50 a.m.
Associate Professor, Department of Psychology, University of Regina, As an Individual
I don't think it has yet. We have seen some evidence from expert Canadian researchers like Dr. Keith Dobson, for example, with the road to mental readiness program, and including that as part of some initial training work that's done. I think we would want to see a far more pervasive integration of some of the CBT protocols into training earlier and more often.
11:50 a.m.
Liberal
Marco Mendicino Liberal Eglinton—Lawrence, ON
We don't have time to get into the details, but I would be interested in receiving a few additional written comments on the very specific subject I just asked you about, namely CBT and prevention. If you could just make a note of that, I think my committee colleagues and I would be very grateful.
Finally, are there any characteristics that make a person more prone to PTSD or OSI?
11:50 a.m.
Associate Professor, Department of Psychology, University of Regina, As an Individual
I don't think that we have a set of individual characteristics that make someone more or less prone to developing PTSD.
Very quickly, consider the following two possibilities. An officer approaches a scene after a week where they've been well rested well supported by their team, when no one has been off sick, and they've had lots of resources available to them. If they come upon a car accident, they're going to have a very different interaction with that traumatic exposure than they would if they've had a week that was really hard, in which they hadn't slept much, and they'd been having trouble at home and had been working too much because somebody had been off sick. Now instead of the car looking unfamiliar, the car is the same colour as their spouse's car; the kids looks very much like their kids, and everything becomes familiar, but it's not them.
You have the same human encountering two different traumatic exposures and they're going to have two very different responses, as I'm assuming you can intuit. This situation makes identifying specific individual variables very difficult to do. We can give you broad strokes, and we hope to be able to do that fairly soon, in the next few years, but saying this person is always more vulnerable or this person is always less vulnerable is not something I think we're ever going to do.
11:55 a.m.
Conservative
Cheryl Gallant Conservative Renfrew—Nipissing—Pembroke, ON
Thank you, Mr. Chairman.
We're told that the sooner an individual is treated for PTSD, the greater the chances of successfully overcoming it are, and therefore early detection is key.
With some first responders, for example the fire departments, after a fire or some incident, they all gather together at the fire hall and talk about what just happened. Before leaving, they're all handed a brochure to take home to their spouse so that they have a list of symptoms or behaviours to watch out for, and if they get four or more check marks, they're told through their commander or chief that they need to get some help.
The Canadian Forces don't have access to that when they have a situation in theatre, but it would seem to me that the RCMP does. Are you aware of whether or not it is a practice in the RCMP to have an after-incident sit-down with everyone who was involved?
11:55 a.m.
Associate Professor, Department of Psychology, University of Regina, As an Individual
I think what you're talking about is referred to broadly as critical incident stress management and more specifically as critical incident stress debriefing. There's a lot of discourse going on about those areas right now.
I know that the RCMP does engage in some debriefing. It doesn't happen for the RCMP or for any other organization after every single event that might be considered traumatic; doing that would be logistically impossible.
As for the efficacy of doing that, we just finished a fairly large review of critical incident stress management and critical incident stress debriefing and peer support models and implementation across the country for public safety personnel, specifically our first responders. The evidence in support of or against any specific model or even broadly speaking is actually extraordinarily limited at this point.
We're not saying that it doesn't work and we're not saying that it does work; we're saying that when people ask us whether they should do these things and which ones work, the best answer we have is that the research is limited and we don't know yet.
11:55 a.m.
Conservative
Cheryl Gallant Conservative Renfrew—Nipissing—Pembroke, ON
Personal experiences, including traumas occurring prior to joining the forces, can have an impact on whether or not someone will develop PTSD after an incident.
I can't speak for your province, but in Ontario we have a shortage in general of medical doctors, specialists, and even psychologists, and in fact in order to see a psychiatrist or one of these practitioners or in order to have your insurance company—if you're lucky enough to have insurance—cover it, you need to have a referral from a family physician.
Could part of the problem be, at least in the background, the fact that the basic medical services just aren't available in some provinces?
11:55 a.m.
Associate Professor, Department of Psychology, University of Regina, As an Individual
I would suggest that it's certainly part of the challenge. I think it was Pierre Daigle, the military ombudsman, who said that they can't hire enough psychologists fast enough in order to meet the demand. I have no reason to believe that it would be any different for anywhere else in Canada. You're looking for people with some fairly high levels of specialization, so there are a lot of barriers there.
If the person has met up with their physician—assuming that they made it there, keeping in mind everything that was mentioned before—they now have a referral, and now they have a wait list. Now they're going to go into that, and you get some programs, like the one in Langley, that are highly integrated and really well set up programs, but they have massive wait lists, and they exist very geographically. I can't ship everybody from one part of the country to Langley or to anywhere else.
I think we're seeing a basic shortage, I think we're seeing a specialist shortage, and I think we need to very seriously consider how we're going to innovate solutions for that if we're going to provide evidence-based support for public safety personnel. There are available options. There are options that we've seen around the world for how other countries have managed this. I think we need to take some lessons from them and consider whether we want to use those same kinds of solutions here at home.
11:55 a.m.
Conservative
Cheryl Gallant Conservative Renfrew—Nipissing—Pembroke, ON
The same would hold true, then, for that transition period, that long gap between the person leaving the forces and perhaps having treatment and then going through Veterans Affairs and having to find a civilian doctor.
The Canadian Armed Forces have made giant strides. What I'm wondering is why you aren't—or they aren't, in general—taking the Canadian Armed Forces models of treatment and applying them to the RCMP when there have been so many studies and people in these various programs. For example, we have the war horse project, the Courageous Companions program, and CAREN, which is here in Ottawa, and there are the studies. MSAR is coming out with one in Manitoba on Monday or Tuesday of next week that will be describing the different types of PTSD.
Noon
Associate Professor, Department of Psychology, University of Regina, As an Individual
I think we are taking the evidence-based.... Certainly, I work with the researchers who work with the military and study these kinds of questions, and I can tell you that, where it's applicable and appropriate, we are certainly sharing information. We are doing that in part because of the relationship we have with the Canadian Institute for Military and Veteran Health Research. Dr. Jitender Sareen, among others, works with me and the broad Canadian team.
We are doing it, but just because it works for the military doesn't mean that it's going to work the exact same way for our public safety personnel. We need more longer-term studies in order to make sure that we are providing those evidence-based pieces of information to support our policies, broadly speaking, because we want to move carefully.
Noon
Liberal
The Chair Liberal Rob Oliphant
Thank you, Dr. Carleton.
We were about six minutes late in starting, Mr. Di Iorio, so we have maybe two or three minutes if you have a couple of quick questions.
Noon
Liberal
Nicola Di Iorio Liberal Saint-Léonard—Saint-Michel, QC
Thank you, Mr. Chair.
Dr. Carleton and Mr. Dadson, thank you for being here and for your invaluable contribution.
Dr. Carleton, at the outset of your presentation, you referred to “evidence-based solutions” for PTSD. Could you share some of those solutions with us?
Noon
Associate Professor, Department of Psychology, University of Regina, As an Individual
For the treatment-based solutions, we have a variety. There are a lot of evidence-based treatments, including prolonged exposure and CPT. As for evidence-based protocols of long standing, as I said, there's a paucity of research to suggest what will and will not work as prevention strategies. There are also the integrated treatments like those being offered in Langley. There's a variety of those evidence-based treatment protocols that can be put into place.
Noon
Liberal
Nicola Di Iorio Liberal Saint-Léonard—Saint-Michel, QC
I'd like you to share some of those with us, please, those that you've observed, or found, or read about that were most effective.
Noon
Associate Professor, Department of Psychology, University of Regina, As an Individual
Prolonged exposure, delivered by somebody who is experienced in doing so and has been supervised in doing so, tends to be probably the most robustly supported treatment for post-traumatic stress disorder. There are also cognitive processing therapy and EMDR. There can be dialectical behaviour therapy. Those are the ones that are the therapies after the fact, so when they are appropriately implemented by someone who has the appropriate skill set, those are evidence-based solutions that are supported by the research evidence to provide reductions in PTSD symptoms.
Noon
Liberal
Nicola Di Iorio Liberal Saint-Léonard—Saint-Michel, QC
What about “prolonged exposure”? Could you expand on that and give us more insight as to how that is being applied and why it is effective?
Noon
Associate Professor, Department of Psychology, University of Regina, As an Individual
Prolonged exposure typically is applied at an individual level, one on one with a psychotherapist who has the appropriate training. You begin with a series of sessions on psycho-education. You might include progressive muscle relaxation. You might include interoceptive exposure depending on the patient-specific symptom set. Thereafter, you would go about a series of what we call exposures, usually imaginal exposures, so the patient begins re-engaging with the trauma.
One of the key things that we know supports ongoing maintenance in post-traumatic disorder symptoms is avoidance. It makes perfect, reasonable sense that if you had a traumatic experience, you are not interested in thinking about that traumatic experience again and again. Unfortunately, that avoidance behaviour can often also cause the symptoms that we see associated with post-traumatic stress disorder.
So it becomes a facilitating mechanism. You engage with that trauma in an appropriate way, and in an appropriate environment, by having the patient retell the trauma, having the patient imagine the trauma, and work with the psychotherapist in order to take some of the sting or the edge off, if you will. It doesn't remove the memory, but instead of having it be debilitating to consider what had happened, we can make it distressing. Eventually, hopefully, we can make it an unfortunate memory as opposed to something that the patient is having to re-engage with daily.
That is prolonged exposure in a nutshell.