Public Safety Committee on March 22nd, 2016

[The Chair, Liberal, Rob Oliphant]

I'm afraid I need to end this panel. We could go significantly longer, I think, but we have other witnesses.

Thank you very much for your time today. Stay tuned, because we may be back to you with some other questions very specifically when we get to some of the treatment or the things we may be wanting to recommend from further study.

We'll take a short break while we change our panel.

[The Chair, Liberal, Rob Oliphant]

We now have, by video conference from Toronto, Donna Ferguson, a psychologist at the Centre for Addiction and Mental Health, CAMH. In the room with us, we have Judith Pizarro Andersen, who is from the Faculty of Medicine at the University of Toronto.

Thank you to both of you. We tend to start with our video conference guest in case we have a problem and have to reconnect, so we'll start with you, Ms. Ferguson, for ten minutes, and then we'll go to you, Ms. Andersen.

Thank you.

[Dr. Donna Ferguson, Psychologist, Work, Stress and Health Program, Centre for Addiction and Mental Health]

Members of the House of Commons Standing Committee on Public Safety and National Security, thank you for the opportunity to appear before you today to share my perspective on this important topic.

My name is Donna Ferguson. I am a clinical psychologist and practice lead at the Centre for Addiction and Mental Health in Toronto. CAMH is one of Canada’s largest mental health and addictions academic health science centres. We combine clinical care, research, and education to transform the lives of people affected by mental illness or addiction.

Post-traumatic stress disorder or PTSD is an important area that we focus on at CAMH. PTSD occurs when an individual directly experiences or witnesses a traumatic event or has first-hand repeated or extreme exposure to aversive details of a traumatic event. PTSD causes a disturbance in social and occupational functioning and in other areas of life. Symptoms include avoidance of traumatic events; intrusive thoughts, flashbacks and nightmares; and increased arousal, including heightened irritability, sleep disturbances, and hypervigilance.

One in 10 Canadians develops PTSD, but the numbers are twice as high in first responders due to the risk of routine exposure to traumatic stressors. Suicide rates amongst first responders are also high. Between April 29 and December 31, 2014, 27 first responders died by suicide. As of March 2015, 40 first responders have died by suicide in Canada. This is a growing and urgent problem that we must address.

How do we make sure that first responders with PTSD get the help they need to become healthy and return to work? We do not have all of the answers, but today I will share with you three recommendations that I believe will help first responders with PTSD on their road to recovery.

First, all provinces need legislation that gives first responders faster access to workplace insurance benefits. Many first responders have had to prove that their work-related traumatic events directly contributed to their PTSD symptoms and diagnosis, which has made it difficult for them to access timely, appropriate care. In February 2016, Ontario introduced legislation that would create the presumption that PTSD diagnosed in first responders is work-related. Removing the need to prove a causal link between PTSD and the work-related event will expedite claims through insurance companies and lead to faster access to treatment and resources. If passed, this legislation would also require employers to implement PTSD prevention plans within the workplace. We need to ensure that all Canadian first responders are covered by similar legislation.

Second, first responders must be able to work in psychologically safe, stigma-free environments. Many first responders have undiagnosed PTSD. Some may be living with the symptoms on a daily basis and experiencing the distress of PTSD, but they are afraid to come forward to their friends, families, colleagues, or superiors for fear of reprisal. They worry that their colleagues will ostracize them and that their superiors will unfairly demote them.

Mental illness is a very difficult topic for people to discuss, particularly for first responders whose occupation requires them to be constantly stoic. First responders are part of a culture that frowns upon weakness. There is a belief that the job comes first and their lives, feelings, and families come second. The expectation comes with a great deal of pressure on individuals who see demise, destruction, death, and carnage on a regular basis. It is difficult enough to work this way every day, but even more so for those with PTSD who are dealing with symptoms of intrusive memories, traumatic events related to work, distressing dreams or nightmares, sleep disturbances, and hypervigilance. It is especially difficult when your colleagues or superiors think you should “suck it up” and get over it.

It is important to create a positive work environment for first responders that prioritizes mental health, addresses stigma, and provides psycho-education on PTSD. Such measures will prevent PTSD from becoming worse, possibly prevent suicides, promote a healthy recovery, and support a successful return to work or maintenance at work. Creating a positive work environment can include having each service work with, for example, the Mental Health Commission standards for a psychologically safe workplace, or even developing an employee mental health strategy that includes providing training in psycho-education with a focus on PTSD symptoms and the challenges related to PTSD.

The following is a case example. A 48-year-old woman was employed as a police officer for approximately 21 years. She was suffering from undiagnosed PTSD symptoms for the first five years of her career. She continued to work with these symptoms, constantly experiencing one traumatic event after another until the final straw. She was faced with a traumatic event after which she felt she could no longer cope and went off work. She saw her family physician who prescribed her medication for her PTSD symptoms and was formally diagnosed with PTSD.

Within a few months her claim was accepted by WSIB, the insurance company, and she was referred to a psychologist in her community for treatment. After one year she returned to modified work on a full-time basis. She was assigned to desk duty and was not allowed to work on the road in her front-line capacity for at least two years. She had a difficult time returning to modified work as she was teased by her colleagues who would constantly play pranks on her. She was also mocked by her superiors and was constantly accused of shirking her duties. They inundated her with most of the paperwork and said it was now her job to do the extra paperwork. This was a very difficult time for her as she lacked the support she needed to get well and maintain work successfully. She was receiving treatment from a psychologist and had been recovering prior to return to work, but now experienced a setback. She was demoralized and her symptoms deteriorated due to lack of support at work.

My third recommendation is that all first responders have access to evidence-based treatment for PTSD. It is important that first responders with PTSD be able to access not only support and treatment but that they be able to access the right treatment to enable them to recover.

Evidence-based treatment for PTSD includes cognitive behavioural therapy, CBT. This treatment is also called prolonged exposure, which involves imaginal exposure, having the client process the traumatic event to assist with reducing the intensity and frequency of intrusive thoughts, flashbacks, and distressing dreams.

The other CBT and intervention is in vivo exposure or what we call real-life exposure. This involves having the therapist help the client to develop a step-by-step ladder or hierarchy of the distressing traumatic situations that the client is actually avoiding while rating the distress levels for each situation and working to reduce the distress level over time.

When a first responder diagnosed with PTSD is able to access these treatments, their chances for successful return to work and productive life are good.

A U.S. study that looked at CBT and long-term outcomes for PTSD indicated that patients who received CBT reported less intense PTSD symptoms and particularly less frequent avoidance symptoms than did those who received supportive counselling.

This is another case example. A 40-year-old male police officer employed for approximately eight years was suffering from undiagnosed PTSD from a traumatic event in which he and his family were threatened by a suspect he had arrested. The threat and alleged stalking by the suspect went on for many months before he began to experience many of the PTSD symptoms mentioned. Finally, after a year, he visited his family doctor and was formally diagnosed with PTSD and prescribed medication for his symptoms. After a few months, his WSIB claim was approved; he was signed off work; and he was referred to me for psychological assessment and treatment. I have been seeing him in treatment, using CBT interventions, in addition to some anger management and social skills training techniques to decrease his heightened irritability, which was one of the main problems for him. After almost a year of treatment, he was ready to begin the return-to-work process, a step-by-step gradual return to modified work initially, followed by a return to his pre-incident role as a full-time police officer.

Since his return to full-time employment, his quality of life has improved. He now has a better relationship with his family. He is socializing again with his friends. His anger is under control, and he's fully functional at work again, even handling some of the issues related to stigma in the work environment. He has been receiving praise from his superiors for his work performance, and he has also told me that the CBT I provided him has saved his life. He is very grateful to me for helping him to resume his life with his family and friends, and to return to an occupation he's very proud of and successful at.

Committee members, thank you again for the opportunity to speak with you today. We are grateful that you are developing a national framework or action plan for first responders suffering from PTSD. I hope that the information and recommendations I have provided will assist you as you move forward with your work.

I would be happy to take any questions.

[The Chair, Liberal, Rob Oliphant]

Thank you very much.

We trust you to stay there, because we'll have questions for you in a moment.

Now we'll hear from Dr. Andersen.

[Dr. Judith Pizarro Andersen, Assistant Professor, Department of Psychology and Affiliated Faculty of Medicine; Director, Health Adaptation Research on Trauma Lab, University of Toronto, As an Individual]

Thank you for inviting me here today.

I'm here to speak about evidence-based interventions to prevent OSI and PTSD among first responders. My background includes more than a decade of working with first responders, combat veterans, and police, both as a research scientist in two U.S. veterans hospitals and most recently as an academic at the University of Toronto. My research is focused on the health and performance costs of severe and chronic stress experienced by trauma-exposed first responders. I will cover a number of key points and then provide recommendations.

First, operational stress injury and post-traumatic stress disorder are associated with significant health costs, physical disease, and early mortality. My colleagues and I have demonstrated that officers are two and three times more likely to develop chronic health conditions, such as cardiovascular disease, diabetes, and even cancer, when compared to the general population. The U.S. Department of Veterans Affairs data says that the cost of health care for treating a first responder with PTSD is almost five times higher than it is for treating a first responder without PTSD, due to the costs of comorbid physical and mental health treatment.

Second, research clearly indicates that first responders are most likely to develop OSI and PTSD following highly stressful critical incidents in which they are exposed to traumatic material, such as a severely abused child, or when they are forced to use lethal use-of-force options. Yet, during use-of-force training, first responders do not receive adequate training in managing the severe psychological and biological stress responses that do put them at risk for OSI and PTSD.

My colleagues and I have witnessed this first-hand. We've collected thousands of hours of biological and psychological data with first responders, both during their training and in active duty emergency calls. We've collected data on things such as heart rate, breathing, body movements, sensory distortion, fear responses, and stress hormones. Our research indicates that these extreme stress responses actually negatively affect their performance, raising the risk that during a lethal use-of-force encounter they may not use the de-escalation techniques that are available to them and may make a lethal use-of-force mistake. These are directly the types of incidents that are related to getting OSI and PTSD.

Third, scientifically validated resilience interventions for addressing the stress associated with critical incidents in use of force are essential in preventing OSI and PTSD. Science-based methods are the only way we can test that an intervention is working and achieving the intended outcome and worth the financial investment.

Canada is at a critical juncture in deciding the best course of action to address OSI and PTSD among first responders. This committee will be considering the available and proposed interventions with limited training dollars, so it's critical to clarify what we mean by an evidence-based resilience intervention. Large-scale resilience-building programs, originally developed for military personnel, such as the road to mental readiness, have been rolled out in some police organizations. However, there are no randomized, control trial, evidence-based studies showing the efficacy of this for preventing OSI and PTSD among first responders.

An issue is that classroom-based material, as research has shown, is not easily transferred when you're trying to learn motor movement skills in such things as use-of-force training and so forth, so it may be misleading to assume that resilience programs delivered in classroom environments would generalize the use of force and behavioural outcomes in the real world. In fact, our biological objective data show that if we want to reduce the maladaptive stress physiology that is associated with OSI and PTSD, we must intervene directly in the training for these high-stress critical incidents, and this entails use-of-force training.

There are few researchers globally working on evidence-based—meaning randomized, control trial evidence—OSI and PTSD prevention programs. I know of one group in the United States. As far as I know, our group is one of the only ones in Canada doing this type of work. I'll present for you the basics of our program.

First, our science-based method, based on all the objective data we've collected, has shown that use-of-force training and de-escalation techniques are best delivered by use-of-force trainers, not in classroom settings by health professionals or so forth. You get the best buy-in from the actual officers in this very tough environment if it's taught by use-of-force trainers. The topics should be helping officers consider their full range of options, including verbal de-escalation and less lethal use-of-force options, so that encounters do not escalate unnecessarily, leading to potential OSI and PTSD.

Second, we use strategies that maximize how humans form brain pathways to learn new information and retain it. This is critical, because in high-stress encounters, responses result from the most automatic, instinctual reactions. Applying some of our techniques for physiological control during critical incidents can override these natural human responses that block an officer's ability to consider all their use-of-force and de-escalation appropriate options.

Third, training should be personalized and individualized, tailored to the individual officer. In our program, devices for officers were taking advantage of new developments in technology, which can analyze an officer's sensory nervous system readings during highly realistic police training scenarios—events like hostage-taking, school shootings, and calls to distressed persons. It's very important that they are exposed, in training, to these highly realistic scenarios.

When they receive their own information about their own body and their stress responses, the expert use-of-force trainers then can create an individualized use-of-force instruction for them so that they can learn what their triggers are and how to overcome those in the use-of-force situations. Currently training for use-of-force situations is in blanket form. Everybody gets the same. Clearly some officers' needs are not being met in this form. We found this even with the most highly trained tactical teams on the federal level. They still benefited from personalized training. They were less likely to shoot the wrong person, such as a person holding a phone and not a gun. Those are directly the events that lead to OSI and PTSD.

We have recommendations based on this data. We need greater support for scientific evidence-based research and intervention. We need more just-in-time funds allocated for researchers. Currently, grant cycles of eight or nine months are too long. We are missing opportunities to work with organizations that are trying to answer the public's outcry for more police training and end up adopting non-evidence-based training programs. We don't have funding in to actually provide them with evidence-based training.

Second, we need to develop minimum standards for assessing performance outcomes of police training programs in terms of the quality of the training program offered and the value returned for the officers and the public they serve. There are programs available, as I mentioned, but they are not evidence-based. Standards regarding program quality need to be established. Things like evidence, scientific studies, and randomized control trials are critical, as are data from pilot studies. We need funding for large-scale longitudinal follow-up to understand how often and how intensely we need to be training these officers before they have OSI and PTSD, in order to avoid it. There are ever-changing threats in society for police officer safety and wellness. We need to take advantage of the most current technological devices and neurobiology of learning in order to meet these changing demands in society.

Three, we really need to establish a centre for excellence in evidence-based police training. Surprisingly, currently there's no global centre for excellence in police training. By establishing a national centre, Canada is poised to take an international lead in developing the highest quality police use-of-force training and critical incident stress management. Canada can create and export new police training programs, further benefiting the field of law enforcement internationally and building Canada's reputation and goodwill.

Finally, we need to require certification for police trainers and facilities based on high quality standards and best practices.

We recommend that police trainers be required to be certified regularly and to maintain a high degree of current knowledge through continuing education programs much like what is required of health professionals and physicians. There is a cost benefit to doing interventions for OSI and PTSD. A U.S. program, though not as comprehensive as our program currently, did find a 14% reduction in annual health care costs among first responders, so as you can imagine, if it's over $1,000 per year per employee, in an organization of 500 officers, that would be a cost savings of over half a million dollars that could be redirected to police training.

Thank you.

[The Chair, Liberal, Rob Oliphant]

Thank you very much, Dr. Andersen.

For our questions we'll begin with Ms. Damoff for a seven-minute round. I should just let people know that I think we're going to have to end at about three minutes to one, as I have a budget we have to approve as a committee.

[Pam Damoff, Liberal, Oakville North—Burlington, ON]

Thank you very much.

Dr. Andersen, you spoke a lot about police training.

Have you done any research with other first responders and, in particular, with our corrections officers? You mentioned how you have to treat veterans differently from how you treat first responders. Is there a difference as well with our corrections officers?

[Dr. Judith Pizarro Andersen]

Just to clarify, there is a difference between prevention training, that is, before someone has OSI and PTSD, and post-therapeutic training. I know Ms. Ferguson can speak about the “post” and the “pre”. Since we're looking at the biology of stress responses and intervening at that level, I would imagine everybody's stress response physiology is similar. I've worked with veterans with PTSD in the U.S., and they have shown that they have the high risks of the physical health disorders, but I haven't done actual prevention interventions with them. The interventions I did were with police, special forces, tactical teams, police recruits, and first-line officers.

[Pam Damoff, Liberal, Oakville North—Burlington, ON]

We heard previously about the use of online resources for treatment. Are there similar opportunities to use online resources to help with prevention?

[Dr. Judith Pizarro Andersen]

Again, I would caution the committee on this, because there's no evidence base that shows that. Online, PowerPoint, and web-based training can bring awareness about PTSD and OSI, but we know from the neurobiology of learning that if you want to link rational thought—how you should do something, or what you know you should do—with the motor movements and how you should do those in high-stress incidents, you have to practise them together, and that means actively. Again, in high-stress critical incidents, you start relying on your automatic fight-or-flight response, so if you haven't trained that automatic fight-or-flight response to be doing the correct thing, then it's going to go back to instinctual behaviour, which often puts you at risk for OSI and PTSD and mistakes. Really, a wise use of money, at least for prevention in the use of force, is to do these two things together rather than to sit and listen to something.

[Pam Damoff, Liberal, Oakville North—Burlington, ON]

I have a question for both of you.

It has to do with something we have in the federal government called gender-based analysis plus, or GBA+. I'm curious, with regard to treatment and prevention, to know if there have been any studies or work looking at how men and women are different in terms of the prevention and also the treatment. Is there any relation to age or any other social circumstances versus coming up with a one-size-fits-all treatment?

Dr. Andersen, maybe you could go first.

[Dr. Judith Pizarro Andersen]

I'll just speak to the prevention side.

We've studied both women officers and men officers. We've hooked them up with the biological data. We find that when they're starting to encounter training or real-world critical incidents, all of their physiological responses and stress hormones—cortisol and adrenaline—as well as heart rate and breathing, can skyrocket similarly. They're very intense depending on the complexity of the situation. So those are similar. I would recommend that any intervention before they get OSI and PTSD and use-of-force training would be similar, but I think it may be different for treatment afterwards.

[Dr. Donna Ferguson]

In terms of treatment, I know I've seen some research. For example, I believe Ruth Lanius has looked at some neurobiological differences in the brains of men and women in terms of how they experience PTSD. There's some evidence showing that men experience an increased level of arousal in different parts of their brain, whereas responses by women's brains are more dampened down. From my perspective, in terms of treating and targeting PTSD, it's very much an individual thing and not a one-size-fits-all thing for sure. Whether we're talking about gender differences or even just individual differences between different first responders who come into my office, whether they are firefighters or police or correctional officers or paramedics, I think you really have to look at the symptoms they're presenting with. If, for example, there is somebody presenting with fewer re-experiencing symptoms like nightmares, flashbacks, or intrusive memories and they're experiencing more avoidance and heightened irritability, then I would really be looking at focusing on that hierarchy for avoidance of situations and helping them through that as well as at anger management and social skills training techniques to really help to dampen the heightened irritability.

[Pam Damoff, Liberal, Oakville North—Burlington, ON]

You had talked about the crisis with suicide and about how many there have been, which is really quite tragic. What programs do you believe are most effective in preventing these mental health issues from getting to the crisis level?

[Dr. Donna Ferguson]

I think it starts with assessing the culture of the workplace. I really think the stigma in the workplace is a major problem for people. I think the lack of support that first responders feel they experience in the workplace is a really big issue, and even before they admit they have PTSD or go for treatment, it really starts with that piece. A lot of people won't come forward and actually admit they have PTSD, and they will go on for a long period of time and they sometimes feel as though suicide is the way out because they have nowhere else to go. They feel that if they do come forward, there's going to be some bullying or reprisals, and they are really just not able to deal with or handle what could come with saying they're dealing with PTSD.

[Pam Damoff, Liberal, Oakville North—Burlington, ON]

You keep referring to just PTSD. Is that the only cause of the suicides or is it also depression or some of these other operational stress injuries? Are you using that as a broad umbrella?

[Dr. Donna Ferguson]

That's a good question. You know, when we're looking at PTSD, we often see comorbidity. So, we often see co-occurring depression, other anxiety disorders, panic disorder, or concurrent issues like alcohol or substance use as well. There are a number of other issues that come with PTSD or OSI, so we're looking at all of those together. I say PTSD because that's primarily who we see in our program, but we are dealing with a lot of co-occurring or concurrent issues as well. Those all definitely contribute to suicidality as well as to deterioration of symptoms overall and recovery.

[The Chair, Liberal, Rob Oliphant]

Thank you.

Mr. O'Toole.

[Erin O'Toole, Conservative, Durham, ON]

Thanks to both of you for your testimony here today. I'm going to pick up on the subject Ms. Damoff left off on.

Dr. Ferguson, I want to say a personal thank you. When I was Veterans Affairs minister, we often consulted many of the resources CAMH produces, particularly with respect to suicide and, in fact, we consulted CAMH a few times on how we publicly presented reporting of suicide and that sort of thing. Your world-class reputation and the tools you provide are very much appreciated.

On that specific subject, we've run into terrible instances—and we saw this just last week—of someone feeling that their only option is suicide. Of course, we're all trying to break down the stigma so that it is not the only option and so that they will seek other treatment. With regard to media reporting of these instances, particularly, as we found a few years ago with several veterans or service members, the Canadian Psychiatric Association and the suicide prevention network have media reporting guidelines. What does CAMH recommend on how to properly report on this issue but to do it in a way that reflects that there's treatment available and also doesn't glorify or lead people who are struggling towards that outcome?

[Dr. Donna Ferguson]

It's a good question. I am involved in some media work with public affairs, and from what I understand from my personal experience, they're very good, first of all, at vetting interviews that they think we should do and interviews that we should stay away from, ones that might lead to glorify the issue more and not really put the issue in the right perspective. That's one thing I know they're very good at doing.

The other thing is that when we do prepare for these media interviews, we really think carefully about how we do want to promote, understand, and educate on the issue of PTSD, or mental illness and suicides. Obviously we don't know the individual cases. We really need to be careful with that. We really just explain some of the relationship between mental illness and suicides. We also talk about areas in which we can improve and prevent, and really focus on evidence-based treatment for people who really need help to access appropriate care.

[Erin O'Toole, Conservative, Durham, ON]

Yes, I'm always concerned when I read reports on it. It's important to not hide these statistics or anything like that, but sometimes the same reports then don't detail treatment options, such as the Veterans Transition Network and some programs you run. The reports provide just the sad end of someone, not the treatments that we should have been promoting.

I may share my time with Ms. Gallant. In my next few minutes, I'd like to discuss one thing I struggled with when I was minister. That was the concept that some families, first responders or military, would like to see a monument to people who served but who died via suicide. I struggled with that personally. To some families who want to know their member is remembered, they see this as a way to do that. But my fear, and I told them this, was that this could lead to more families going through the turmoil they were facing, because a monument like that could be something that pushes someone who's struggling over the end, thinking if they take this route, they'll be remembered through this monument.

Could you comment on that?

[Dr. Donna Ferguson]

You know, I guess I'd be torn as well. I think I can see that side of it, where people might think they would be revered, almost, if this is the route they would go. On the other hand, I've actually had first responders say to me that just seeing that somebody goes through suicide, even if they were kind of put on a pedestal, actually reminded them that there was a reason for them to live, and that was not the way they wanted to go.

I think people have different perspectives on how that would look for them. I do think we have to be very careful about how we do promote that, so we don't give people ideas that this is the right way to go and that this is what will happen if you do complete your suicide.

I'm torn on that as well, because you do also want people to be remembered.

[Erin O'Toole, Conservative, Durham, ON]

Dr. Andersen, I'm intrigued by your experience in the U.S. I wish we had time to compare the veterans hospital experience in the U.S. with our integrated public health system here.

Specifically, you seem very evidence-based and randomized control study-based, which I love, by the way. In the last session, we had a psychiatrist from Winnipeg speak about medicinal marijuana and how, while there are a lot of anecdotal reports on its impact for symptom relief and things like this, there's virtually no clinical support for its benefit in treating PTSD. In fact there is some evidence that it can be harmful for people with PTSD.

Have you studied this at all? Would you care to comment?

[Dr. Judith Pizarro Andersen]

Actually, one of my advisers at one of the veterans hospitals I worked with was studying substance use and PTSD. To summarize her research, not mine, she found that sometimes when you take something like that, or alcohol, it can calm the symptoms in the moment, but then there can be bounceback anxiety. That's all I'll say on that.

What I will say is that in moving forward with any intervention, I really believe in collecting objective biological data. If we want to know if marijuana treats the symptoms, we can't just rely on self-reports. In the data I've collected, I've always asked the officers to self-report: how stressed they were, how confident they were about the situation, how well they were going to perform. Often those self-reports were opposite to what I saw going on in their bodies and in the mistakes they made.

It's the same with a program like road to mental readiness. I know there have been surveys about how beneficial it is for transferring to use of force by self-reports, but my concern is that they're saying these things because they want to appear well in the organization. When I've actually spoken with the use-of-force first responders, with the very macho attitude among them, it's not taken as well as their surveys indicate.

[The Chair, Liberal, Rob Oliphant]

Thank you.

Monsieur Dubé.