Public Safety Committee on March 22nd, 2016

[The Chair (Mr. Robert Oliphant (Don Valley West, Lib.)), Liberal, Rob Oliphant]

I call to order the eighth meeting in this session of Parliament of the Standing Committee on Public Safety and National Security.

Before we begin, I want to welcome our visitors at the back of the room, who are high school students from Montreal, Toronto, Ottawa, Winnipeg, and perhaps other places. They are here with CJPAC. We promise to be on our best behaviour as you are watching us. Thank you for being here.

We are continuing our study of the issue of operational stress injuries and post-traumatic stress disorder, particularly as they affect public safety officers and first responders. We're continuing with our study, gathering information, and really trying to lay a foundational understanding of PTSD/OSI as it affects public safety officers.

We've invited witnesses to come and share their understanding, from a theoretical or research point of view but also from their clinical experience. On our first panel, we have with us Nicholas Carleton, associate professor in the Department of Psychology at the University of Regina, and Mike Dadson, clinical director at the Veterans Transition Network, from Langley, B.C.

We'll begin with you, Dr. Carleton. If you could take about 10 minutes to give a presentation, we'll go immediately after that to Mr. Dadson. Then we'll open the committee to questions.

[Dr. Nicholas Carleton, Associate Professor, Department of Psychology, University of Regina, As an Individual]

Thank you very much for inviting me to speak with you today. I'm a registered doctoral clinical psychologist and professor at the University of Regina. I have expertise in anxiety, trauma, and pain, having worked with traumatic responses for the past 15 years.

My research is supported by the Canadian Institutes of Health Research and the Saskatchewan Health Research Foundation, among others. I maintain a small private practice, primarily treating RCMP officers and other public safety personnel who have PTSD and other operational stress injuries.

Canadians have recognized the need for ongoing dedicated efforts to support our military; our public safety personnel, which include a wide array of personnel, such as police, firefighters, and paramedics; and also corrections officers, 911 dispatch operators, veterans, and their families. As you heard from my colleague, Dr. Sareen, we've come a particularly long way in supporting military mental health, but we have a similarly long way to go in supporting the mental health of our public safety communities.

Our public safety personnel have unique workplace environments, where trauma exposure is the rule rather than the exception. That exposure is different for public safety personnel than for military personnel, not better, not worse, but different. Our public safety personnel are deployed at home in an environment of ongoing uncertainty, often for decades. They have complex roles, such as providing protection, law enforcement, and community development. Accordingly, they require dedicated and specialized resources to ensure their mental health.

I have seen, recently and consistently, exceptional mental health leadership from our first responder communities. Indeed, we are seeing increasing demands from all public safety personnel to provide ready access to evidence-based solutions, interventions, and preventive strategies for improving mental health. The rationale is clear: they are reaching a tipping point. The dramatic increase in reported operational stress injuries is starting to overwhelm the stigma that has silenced so many of these citizens for so long. However, these same citizens have also underscored the need for evidence-based solutions informed by expert research.

Our government has set a mandate to develop a coordinated national action plan on PTSD and other operational stress injuries for our public safety personnel. That mandate was followed by the January 29 national round table on PTSD hosted by our Minister of Public Safety at the University of Regina.

The round table brought together leading researchers with leaders from government and public safety, all of whom supported the urgent development of a coordinated national action plan with a heavy focus on research.

Canadians have an established national mechanism for supporting, coordinating, and communicating health research. The Canadian Institute for Military and Veteran Health Research, CIMVHR, represents a 40-university network and facilitates the development of new research, capacity, and effective knowledge translation.

For the past 18 months, the University of Regina, a founding member of CIMVHR, has been working closely with research leaders from other member universities, international academic leaders, and our public safety leaders to develop a dedicated Canadian institute for public safety research and treatment, to support evidence-based policies, practices, and programming for public safety mental health.

The rapidly developing institute includes a host of academically diverse leaders from universities across Canada. The institute's leadership also includes key representatives from the Mental Health Commission of Canada, CIMVHR, the RCMP, the RCMP Veterans' Association, the Canadian Association of Chiefs of Police, the Canadian Police Association, the Paramedic Chiefs of Canada, the Paramedic Association of Canada, the Canadian Association of Fire Chiefs, and the International Association of Firefighters, to name only a few.

Institute members are already assessing the impact of implementing the road to mental readiness program with Regina Police Service and others, researching formally integrated mental health into policies, education, practices, and support, concluding the first of several program evaluation reports after assessing the evidence base for and the deployment of crisis intervention and peer support programs for Canadian first responders.

Right now the institute is poised to, first, conduct a coordinated national mental health prevalence survey to refine the widely varying estimates associated with public safety personnel.

Second is to conduct a Statistics Canada feasibility study supporting a gold standard epidemiology survey for public safety mental health.

Third is to conduct a pilot study exploring high-fidelity simulated traumas and training scenarios, so that we can empirically and experimentally better understand risk and resiliency variables for operational stress injuries, therein informing traumatic stress procedures.

Fourth is to implement a comprehensive and ongoing biopsychosocial assessment of RCMP cadets and officers using state-of-the-art technologies to evaluate the impact of integrating evidence-based interventions throughout their initial training, during their service, and as part of lifelong learning. The research will be globally and historically unprecedented, providing crucial information about risk and resiliency variables to inform mental health physicians for the RCMP, other public safety personnel, all of their families, and eventually all Canadians.

The institute can also build solutions to help address new challenges in meeting demands for mental health services, such as those recently underscored by the military ombudsman. The solution requires that we do three things: first, ensure patients can and do access appropriate specialists who are correctly using evidence-based treatments; second, support the training and accreditation of more specialists; and third, support research that improves evidence-based care and innovates models for care delivery.

To that end, the institute is also poised to extend work done at the University of Regina on Internet-delivered cognitive behavioural therapy, ICBT, which can increase our access to highly effective, private, popular, and broadly deployable evidence-based treatment as part of a national stepped care system for all public safety personnel. Pending resources, pilot testing for that system in Saskatchewan and Quebec can begin as early as 2017 with pan-Canadian access for our public safety personnel as early as 2018.

The institute can also help to emphasize evidence-based practice. Indeed many public safety personnel appear to be receiving care that is not empirically supported and that is not good enough. Accordingly, members of the institute have worked with the Alberta Paramedic Association to develop new standards for mental health provision for their members. We have also seen efforts to improve mental health care quality and access through the Canadian Association of Cognitive and Behavioural Therapies, which is working to certify practitioners and ensure access to evidence-based care. These are only a couple of examples of people working hard to ensure that our evidence-based practices are made available to those who need them most.

Solutions for public safety personnel inform solutions for all of us. Moreover, they are our community leaders and role models who can facilitate transformations in attitudes and actions towards mental health at a grassroots level in communities across Canada. We have leaders, including all of you, who want to build on the initiatives I've highlighted today.

I suggest that a full and proper response to the Prime Minister's mandate requires that we do the following: First, invest in the Canadian institute for public safety research and treatment; second, ensure the institute remains at arm's length while engaging federal and provincial governments, academics, policy-makers, and key stakeholders; and third, support ICBT treatments and stepped care clinics that are funded through partnerships between federal and provincial agencies with workers' compensation boards.

The institute can then do four things: first, use evidence to guide a national action plan for research and treatment dedicated to public safety personnel that incorporates leadership from our public safety personnel; second, facilitate cross-sectional and longitudinal interdisciplinary research projects so we can speak with authority about variables associated with risk, resiliency, and recovery; third, develop nationally recognized online evidence-based resources for operational stress injuries to support our clients, their families, and their providers; and fourth, work collaboratively to facilitate pan-Canadian access for public safety personnel to minimum standards of evidence-based prevention, early interventions, and programs for treatment.

We can do better and we must do better. These solutions are no longer aspirational; they are achievable. Working with our public safety personnel as role models in all of our communities, we can develop and proliferate better assessments and better interventions, and engage in preventative strategies that reduce risks, increase resiliency, and improve mental health, first for these critical members of our communities and then for all Canadians.

We look forward to your support. Thank you.

[The Chair, Liberal, Rob Oliphant]

Thank you, Dr. Carleton.

Mr. Dadson, go ahead.

[Dr. Mike Dadson, Executive and Clinical Director, Veterans Transition Network]

Thank you.

I'm Dr. Dadson. I'm the adjunct professor at the University of British Columbia on the advisory committee for the centre of group therapy and trauma. I'm also the clinical director and the national director of the veterans transition program. As well, I'm a board member of the International Society for the Study of Trauma and Dissociation. I'm an ordained chaplain and I operate a trauma treatment centre and training centre here in Langley, British Columbia, that services about 200 folks a week.

I'm here to speak to the committee primarily as a clinician and through my experience in the veterans transition program. The veterans transition program is a group-based experiential program that's been operating for 18 years. It was researched and developed through the University of British Columbia. In our experience, we have seen the struggles for veterans and first responders in accessing mental health treatment. We see that there are several barriers that prevent them from accessing treatment. We actually would take the view that there are a lot of effective, empirically based, research supported treatments available but that many first responders are unable to access these treatments because the job that they do requires them to operate at such a high level of competency and high pressure that if they begin to crack, show weakness, or ask for help, they're perceived as failing or being weak and unable to continue in their work. Seeking help may pose a risk to their careers. We've seen this regularly with veterans where, even though they are suffering clear occupational stress injuries or even post-traumatic stress, they'll continue to work in their field and they will resist seeking treatments early because they believe that it could threaten their career, where early treatment may actually prolong their career.

They deal with situations that are far outside the norm. They are not only experiencing a single incident or event but they are exposed to multiple traumatic or high-impact stress situations. They often express that, even in speaking to therapists, they fear that they will damage their counsellors because of the horrors that they've seen. The way that these traumatic experiences, or these occupational stress injuries, intersect with the masculine gender role or the masculine expectations of their position, because they're very highly.... The expectations are that they are to behave in accordance with masculine norms, which is that they are strong, hard-chargers, capable, independent, and don't seek help. They're not the lambs, they're the ones who go and actually provide the help. When they need help it's very difficult for them to actually seek help because that contradicts the very culture in which they are working.

The way that the veterans transition program has addressed this is, first, it was developed in accordance with first responders. We met with first responders, we worked with first responders, and we asked them what would help them to be able to address these concerns. We offer a multidisciplinary program that focuses on a strength-based and peer-helping approach. We work in groups and we don't just help or provide therapy for individuals, we show them some very basic techniques and very basic communication skills that can help them support each other. This, in itself, normalizes the experience, which is really important for those first responders because it helps them to recognize that they can still be the warriors that they see themselves to be but they can incorporate the possibility that they also may need help.

They also find it easy to communicate to one another the experiences, the horrors that they've seen, because they know that they've each seen them. They're not saying anything new when they speak in a group to one another. That normalizes their experiences and it makes them available to receive help. We buffer them from the experiences by providing a very caring and supportive environment, which actually reduces the anxiety and the avoidance so they are able to go deeply into their experiences with one another in a shared way. This actually helps them normalize the experience and then do the work that they need to do.

In effect, they challenge one another to do the work because they see that as part of their new battle, or their new career or their new job.

We use de-stigmatizing language. Instead of using language such as “seeking therapy”, we use language such as “trying to drop the baggage” or “just trying to move through a situation”. Instead of talking about emotional experiences, we'll talk about sensory experiences. We'll begin with the body and their physical reactions, and normalize those reactions.

We believe that one of the reasons our program is so successful is that 50% of the folks who are recommended to our program are actually recommended by other veterans or first responders. That means they come in already expecting that they're going to receive some help that's a bit different from what they've seen in the past. In other words, they won't experience the barriers they've experienced.

Here's an example of a barrier for a veteran. For veterans to apply to be treated for PTSD, they need to demonstrate that they have PTSD, which means they need to retell the story several times, again and again, to a variety of folks who have a pretty clinical mindset. They're not there to actually do therapy; they're there to assess whether the people actually qualify, whether they meet the standard for PTSD. Telling the story in this context again and again actually is unhelpful. It creates avoidance, and they actually avoid even applying for help.

We see many veterans who aren't even a part of VAC services, because they can't go through the process. Their injury is a barrier to their going through the process. That means they don't get treatment.

So 50% of our participants have not accessed services from Veterans Affairs Canada. We have a 90% retention rate, which means that, of the people who have gone through our program, very few have dropped out. When they do, it's usually because of family or because of medical concerns. I'm aware of only one person who's dropped out of the program because they decided not to continue on; it wasn't right for them.

We screen participants, so we don't take everyone. If someone is highly suicidal or psychotic, then we're not going to see them in our program. They need to first get some of those things in check. But our program has a high success rate. Not one participant, of over 600 participants who have gone through our program, has committed suicide.

Our concern primarily is that, at this moment, for us, in our program, we have waiting lists across Canada that can mean some veterans can wait a year and two years, depending on their region, to go through our program. Yet if they go through our program, we're confident that the possibility of suicide will be significantly reduced, to the extent that now we.... Our research demonstrates depression has dropped and their suicidality is minimized.

My concern is that, as these folks wait to get through our program, if any commit suicide while waiting to get into our program.... It troubles me to know we could have helped them significantly, and they're waiting to access our services.

We're kind of boots on the ground. We're here to communicate to the committee some of the challenges we see veterans facing as we're working with them therapeutically.

I think that's where I'll conclude.

[The Chair, Liberal, Rob Oliphant]

Thank you very much, Dr. Dadson.

We're going to begin our seven-minute rounds with Ms. Damoff.

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

Thank you both for being available to our committee for this very important study.

Dr. Carleton, you had mentioned that first responders face challenges beyond those faced in the military. I wonder if you could explain that a little bit more, why you think that is, and also whether it makes first responders harder—or different, perhaps—to treat than those who have served in the military.

[Dr. Nicholas Carleton]

Sure. I should make sure that I'm very clear about that. I don't think they are experiencing traumas that are beyond what's happening in the military; I think that they're experiencing things very differently.

When we deploy our military to Afghanistan, for example, we're taking them from a safe zone and we are deploying them to an unsafe zone, and then we are bringing them back to a safe zone. There's an important distinction between that framing and what we do with our public safety personnel or our first responders; we deploy them, effectively, to an unsafe zone for 25 or 30 years. They're in a constant state of uncertainty. On day one they might be out for a coffee with someone, and on day two they might be responsible for arresting that person, resuscitating that person, or rehabilitating that person. We're really deploying them to their own communities, which makes for a very different form of exposure.

We're also asking them, as Dr. Dadson said, to experience trauma on a very regular basis. Paramedics, for example, are called out to manage a current and urgent traumatic event, and they're asked to do that day in, day out, sometimes several times in a day. When we consider how that's impacting our first responders and our other public safety personnel, we need to understand that there's a dose-response that's going on there that's much higher than something we would see in most other cases.

With our military, you might see a very extreme, very intense dose-response, for example, during a specific period; but they're brought back to a safe zone that they can believe is safe and is kept safe by our public safety personnel; whereas for our public safety personnel, they're the ones keeping it safe.

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

On operational stress injuries versus PTSD, I understand that PTSD has a fairly specific definition. Is there a connection between those two? Are we doing enough to treat people before they get PTSD or if they're suffering from depression, anxiety, or addiction issues?

[Dr. Nicholas Carleton]

“Operational stress injuries” would be best defined as a really broad umbrella term that includes a variety of things: post-traumatic stress disorder, certainly, but also depression, substance use, and panic disorder, just to name a few. There are a lot of potential sequelae following traumatic exposure, the most common sequelae actually being recovery. The vast majority of people, even our public safety personnel, actually recover.

That said, I don't think we're doing anywhere nearly enough with respect to what we could be doing, and certainly not nearly enough with imminent treatment provision and ensuring that we have effective treatment provisions. I agree with Dr. Dadson that one of our biggest challenges is the huge delay between when the person actually experiences the injury and when we begin effective treatment. That's something we need to address, because, as with any form of health care, the sooner you address the injury or the health care concern, the more likely you are to experience a positive overall prognostic outcome.

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

Have either of you done any work with our correctional services officers? That's one area that we don't seem to talk about very much. We talk about our first responders and our veterans, but we don't talk about people who are working in corrections services. I'm wondering if either of you have had any experience with that.

[Dr. Mike Dadson]

I have had some experience with corrections. In our programs, we invite first responders to join, so there may be one or two first responders, and sometimes a corrections officer joins us.

A corrections officer is just like responders in the police or ambulance or fire. Their context is different, so the way the trauma affects them depends on the context they're in.

As my colleague stated for veterans, they're like a blunt instrument. They'll go into a situation and experience something that's horrific and traumatic. They'll do it with buddies, and they'll leave with buddies. That often is a buffer to their experience, because they're a part of a strong community or a pack, where they have strength.

Police officers, though, are a bit different, because they're walking the streets every day and using social engagement as a means of crowd control. They're constantly scanning their environment and looking for a perceived threat, and when they see it, they're actually withholding a blunt instrument response. They're going for something more nuanced. They're using their social skills to try to play down an incident or to keep an incident from erupting into something violent. When it goes violent, it goes violent very quickly, and they then need to jump into a fight-or-flight or an active role of aggression to be able to match the aggression and to be able to restrain or to control the situation.

For firefighters, the context is different. In the same way, for the folks who work in our prison systems, their context is different, whereby that becomes, really, the place where they're living. They can experience things such as inmates who are self-mutilating, slowly trying to take their lives, and trying to torment the guards as they do it. They have to experience that daily and try to provide a measure of care for those individuals as they deliberately try to psychologically injure them.

[Dr. Nicholas Carleton]

I agree.

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

I have a slightly different question. A gentleman in Oakville was suffering from depression following a heart attack, and he credits physical activity with bringing him out of depression. Do you see physical activity playing a role in dealing with some of these issues, with the operational stress injuries and PTSD?

[Dr. Nicholas Carleton]

I think so. I have a colleague, Dr. Gordon Asmundson, who is currently running a study on exercise therapy as a component intervention for PTSD specifically. Exercise, generally speaking, is a really good thing, full stop, especially if it's being done appropriately.

That said, I think we need to be very careful to understand that exercise alone is not a panacea. It's not going to resolve everything but, full stop, is it a good idea to engage in exercise, and will it help with depression, mood in general, and mental health and anxiety? All of the evidence seems to suggest yes.

[Dr. Mike Dadson]

I agree with that as well. Exercise is great, but sometimes when someone is so depressed that they can't get out of bed, exercise is not an option for treatment. Or if because of their occupational stress injury they also face physical injuries, and they can't operate physically in the way they once did, exercise in itself can be a trigger for the loss of what they were able to do once and are no longer able to do. It's contextual.

[The Chair, Liberal, Rob Oliphant]

Thank you very much.

Mr. Rayes.

[Alain Rayes, Conservative, Richmond—Arthabaska, QC]

Thank you, Mr. Chair.

I want to thank the witnesses for joining us today to share their experience in this area.

We often talk about what happens after the event and the treatment. You also mentioned it. However, I would like to hear you talk about what happens before. When it comes to the culture of organizations, first responders, our soldiers, the army and the RCMP, is everything being done to prepare for the potential risks?

I will make a very simple analogy with an athlete participating in a competition. They will be psychologically and physically prepared for unfortunate situations that could happen during a competition. Is anything being done before the problem even occurs? Is awareness being raised among employees and stakeholders of all sectors? Can you tell us about any relevant studies or research?

[Dr. Nicholas Carleton]

I can speak to some of that and to one of the biggest challenges we have right now.

First of all, yes, I think we could be doing more. Second, I think there are some organizations that are working towards those preventative measures.

One of our biggest challenges has been and continues to be that if I can only afford to do a handful of things, and you ask me which things I can do to buy us the best possible prevention, to build the most resiliency, and to reduce the risk, we don't have those empirically supported answers in as robust a fashion as we need for any of us to make those statements.

We can make some general statements for you, but one of the challenges we've seen is that it has been very difficult to engage in prospective longitudinal research, so that we can measure people before they're injured, identify what things are associated with each individual in large groups, and then track them over years and years. Then we could say to you, “This variable was associated with resilience and this one was associated with risk.” This requires a tremendous commitment on behalf of researchers, clinicians, government, and public safety agencies. It's a team effort. It's one of the things that we're excited about being able to begin shortly with our RCMP, because those are critical answers.

That doesn't mean we can't give you generalities. But specifics, so that we can then provide really good information, require investment in long-term research, and that requires big collaborations. That's what we're trying to do and trying to start, beginning this year, so that we can give you a smarter answer, hopefully very soon.

[Dr. Mike Dadson]

If I could add to that, as my colleague said, it's difficult to achieve and to get the research. One of the reasons that I see for this is that for the organizations—the military, the RCMP, firefighting—their mandate is to serve and protect. For the military, it's “mission, team, self”, with the self coming last. That's embedded in the culture. That's a part of that hypermasculine culture that is necessary in order for them to do their jobs. That is part of the buffer, but unfortunately it also prevents us from being able to go in and gather the research, because it can produce a culture where the focus is not on prevention and recovery. The focus is on getting the mission done or protecting the public.

When veterans, RCMP, or firefighters are unable to achieve or to live up to the same standard, they start to be on the outside of that culture, and that really begins their descent. They've already become injured before they've been identified, but when they can no longer hide the injury, they start to move out of that culture. They start to become alienated from the group that once helped buffer their symptoms. As they move out, you then start to see the effects of the occupational stress injury or the PTSD.

It's difficult for an organization such as DND to research and to protect people from getting occupational stress injuries when their focus and their mandate is on the mission, not on the protection. Obviously, there's life protection, but it's not keeping people from getting occupational stress injuries, because they're constantly under stress: their mandate is to achieve the mission.

What we see for veterans, particularly when they start to move out and often can no longer operate at the same high level of functioning, is that they're given roles or jobs that are far less than what they're accustomed to, and they already see themselves as “out”. Now they're the injured ones, and they're perceived—and seen in the culture—as the injured ones, which actually exacerbates their symptoms. They really need to begin to be treated right at that point, before they can actually leave the military and even apply for VAC assistance. I don't yet see these organizations and agencies being highly invested in helping their people identify their injuries and treating them before they've actually become problematic.

[Dr. Nicholas Carleton]

If I can, I'll build off what Dr. Dadson said for a moment—

I'm sorry. Go ahead.

[Alain Rayes, Conservative, Richmond—Arthabaska, QC]

If I may, I would like to say something about this. I will then let you continue.

If I have understood correctly, there are no studies or research on the topic. There isn't really any basic training to prepare those employees, soldiers and first responders for the potential risks. Do you know whether—before research is even conducted—some work is done at the outset with those people during their basic training and in various educational institutions, including universities and vocational schools?

[Dr. Nicholas Carleton]

I should make sure that I'm clear here. Yes, there is some research. It's just that there's not enough, and it's not enough prospective longitudinal research, which is pretty critical. There is research we've engaged in that is being started by team members across the country to try to get some of those answers.

Just to underscore this, the RCMP leadership, since we brought this to their attention and brought the prospect of the research study to their attention, has been extraordinarily supportive, in part because they also recognize, I believe, that these types of data will allow us to recognize injuries much, much earlier and to turn what might have been a debilitating and excluding injury into something that we can help the person recover from. It's just as important for those organizations as it is for the individuals—and as it is for all of us—to make sure that we can keep them active and healthy.

[The Chair, Liberal, Rob Oliphant]

Thank you, Dr. Carleton.

Monsieur Dubé.

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

Thank you, Mr. Chair.

I want to thank the witnesses for participating in today's meeting.

Before I ask my questions, I would like to specify that I am asking them in the all-important context of recommendations we will make to the government. In that spirit, we clearly want to improve the situation. I will briefly continue talking about research, more specifically about the available data.

If I remember correctly, at our last meeting, we heard a former psychiatrist say that Veterans Affairs Canada and the Canadian Armed Forces were 15 years behind when it came to first responders compared with correctional officers or parole officers. Do you find there to be a large gap between what is available to people affected by our study and what is available to the members and former members of the Canadian Armed Forces, veterans? If so, what do you think we can do to remedy the situation?

[Dr. Mike Dadson]

I think there is a significant gap, particularly for veterans, between when they know that because of occupational stress or PTSD they're going to be transitioning out of military life, and when they're actually out. Sometimes it can take two years before they're actually out of the military. They know they're on their way out and, to them, their job becomes less and less significant or meaningful, because they know they're not going to be doing the thing they love to do. They can't do it anymore.

It takes two years for them to get out, and then sometimes it has been six months to a year before they could access VAC services. This is far too long. This is a three-year gap in treatment for some of these folks, who are sometimes in critical condition psychologically, and also physically, because there are difficulties that can go along with it. That affects their family lives, their confidence, and their ability to engage in their career. It supports substance abuse, depression, and anxiety.

I've worked with veterans who have been home from Afghanistan for six years. One fellow was unable to take his children for a walk because of what he had seen; he had been seeing his psychologist for six years, but had yet to tell the psychologist about the injuries he had faced in Afghanistan that were preventing him from doing so.

To me, this becomes a critical issue. How do we help these folks get help immediately rather than having them wait the three years or the six years before they can actually begin the process of recovery? There are treatments out there that can help them. We know that we can help them if we can get them into services—