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.