Veterans Affairs Committee on March 22nd, 2007

[The Vice-Chair, Liberal, Brent St. Denis]

Bonjour, tout le monde. Good morning, everyone. I'm pleased to call to order this Thursday, March 22, 2007, meeting of the Standing Committee on Veterans Affairs.

We're very pleased to have with us today Dr. Stéphane Guay, who will no doubt enlighten us considerably on a very important subject when it comes to the health of our returning soldiers and our veterans.

We'll get started, and then I'll hand it over to Rob.

Dr. Guay, I think the clerk or the chair has talked to you about spending 10 minutes, give or take, on your presentation, allowing members a good chance to ask questions afterwards. And you'll have a chance to bring up whatever issue you would like.

With that, we ask you to start. Thank you for being here.

[Dr. Stéphane Guay, Psychologist and Director, Centre d'étude sur le trauma, As an Individual]

My name is Stéphane Guay, and I am a researcher and Director of the Trauma Study Centre at Louis-H. Lafontaine Hospital in Montreal. I am also an associate researcher for Veterans Affairs Canada, at the Sainte-Anne Centre located at Sainte-Anne Hospital. I am affiliated with the Department of Psychiatry at the University of Montreal. I am a psychologist by training. I received my PhD in 2001 and subsequently did post-doctoral studies on treatment of post-traumatic stress in civilians. This was a study aimed at determining whether the involvement of a relative could increase the effectiveness of treatment. At the present time, my main activities involve assessment of various methods of psychological treatment of post-traumatic stress in different types of sufferers, mainly civilians, but also some military personnel.

Since 2003, I have been conducting research projects that are supported by a variety of Canadian funding organizations, such as the Canada and Quebec Health Research Institutes, and the Quebec Health Research Fund. In recent years, much of my writing on the subject has been published in both Canada and abroad, and I have also presented papers at a number of different conventions. Recently, a book I wrote on post-traumatic stress with my colleague, André Marchand, entitled Les troubles liés aux événements traumatiques : Dépistage, évaluation et traitement was published by the Presses de l'Université de Montréal.

As regards my appearance before the Committee this morning, I believe that the fact I worked on two major studies involving Canadian Forces members is of particular interest to you. One of them consisted of analyses based on the Canadian Community Health Survey and the Supplement involving members of the Canadian Forces. That survey was conducted using a representative sample of the military population. There was a sample of 8 441 participants. I also conducted a study with military personnel at the Valcartier Base in Quebec City which was intended to assess the quality of life and social support provided to soldiers suffering from post-traumatic stress. We completed that study some time ago.

I believe I will be in a position to provide information and clarification with respect to the results of those studies based on the questions you have for me this morning. I am here today in my capacity as a researcher. I am also a psychologist and clinician, but I believe I have been invited to speak to you primarily as a researcher, and I will attempt to clarify data found in literature on the subject, as it relates to veterans, to the best of my abilities.

[The Chair, Conservative, Rob Anders]

All right. That was fast. Well, there will be room for more questions, I guess. Are you sure you don't have anything else? Are you done? Okay, fair enough.

Now we'll go on to Mr. Valley, for seven minutes.

[Roger Valley, Liberal, Kenora, ON]

Thank you, Mr. Chairman. I don't even have my water poured yet.

Thank you for the presentation. It was very interesting.

I'm going to ask a couple of questions that I didn't get a chance to ask the other day. Maybe you can help me with them.

You mentioned families. We know that's important, but we need you to explain just how important. We know that's a bit of a change, but things change. That's about the only thing around this place that's constant. Everything is changing all the time.

We've seen dramatic change in the things our forces are having to deal with right now. We're dealing with issues in Afghanistan that we didn't deal with before: suicide bombers, child bombers, all those kinds of things.

What new tools do we need to deal with some of these issues? What aren't we doing that we could be doing?

[Dr. Stéphane Guay]

I am not sure I understood your question. You're talking about the events that soldiers are exposed to on a mission and the children who commit these acts. I guess you are asking whether these events can affect the quality of life of military personnel when they return. Is that correct?

[Roger Valley, Liberal, Kenora, ON]

Yes. When they come home, they're going to have to deal with some of these things that we haven't seen in past wars or past operations, so how do they deal with that? How do you deal with it when somebody comes back suffering from PTSD? How do you deal with it when they're dealing with an issue that's fairly new to the armed forces?

[Dr. Stéphane Guay]

Well, it's difficult to prepare soldiers for these kinds of horrific situations. There is no doubt that if a soldier who has children witnesses events involving children, whether they are victims or whether they're carrying weapons, while on a mission, his conception of life could be turned upside down by what he has witnessed. How can this problem be managed when they come home? Well, it depends on how much trouble he has coping. Whether or not he is suffering from post-traumatic stress, he can receive psychological support that will help him come to terms with those events and find meaning in them. The important thing is to avoid that having a negative impact on the ability of the family to function normally.

In fact, I believe that illustrates why it is important not only to act on soldiers' individual symptoms, but also consider the broader impact—in others words, the systemic effect or effect on the family.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

We've heard, and I think you've alluded to the idea, that quick action or action at the very start is a very important part of your job. It's not your job personally, because you deal with the problems afterward, but we bring our soldiers out of the difficult situations they're in and we know now that they head off to Cyprus or some kind of decompression. From what you know of it, how important is it for that to be immediate? We understand it's immediate right now; it's the first thing they face. How important is that, and do you actually look to see if there's more we can do in the decompression part of this, or do you not really deal with the issues afterward?

[Dr. Stéphane Guay]

Yes, absolutely. With any type of event that could have a negative impact on the effectiveness of a soldier's role when on a mission, I think you need to try to address the problem in order to avoid things getting worse. In terms of research, there is very little data to suggest that such interventions or strategies are effective, even on site. I believe we have to go further than that and assess the impact of this type of intervention, even though that is relatively difficult to do. Perhaps some resources should be set aside to that end.

In terms of what is called early or preventive intervention, reference is often made to debriefing, which can occur after what is called diffusing. That is probably what you are referring to. Diffusing involves giving an account of the events that occurred. Debriefing is intended to prevent problems from developing subsequently.

Research dealing specifically with the impact of debriefing on the prevention of PTSD clearly shows that it is not effective. It is possible not enough research has been done yet on this particular subject. In fact, there has been little research dealing with military personnel. However, a dozen or so studies have been conducted based on the normal practice and according to scientific methods. There are a number of literature reviews that deal with that. There really is an international consensus to the effect that universal early intervention—in other words, treatment of all the victims of a traumatic event, although we do not yet know of any cases involving soldiers—does not prevent the development of post-traumatic stress.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

I'm a bit confused, because I believe you just said that most countries, or all countries, believe in the debriefing, the decompression, whatever you want to call it. But you're saying the studies we have now don't prove that that's going to avert PTSD. So what do we do at this point? If we're not sure it's working, yet everybody's doing it—help me here—where do we go from here? Do we need a more in-depth study? I would have thought if everybody in the world was doing it, there would be some value to it. Are you saying the studies that have happened up to this point don't bear that out, don't show that?

[Dr. Stéphane Guay]

Yes, it is paradoxical. This is a common type of intervention, particularly in the workplace. It can involve soldiers, but it can also involve civilians—police officers, for example. I think it really flows out of a need to do something to help people who have been involved in potentially traumatic events.

Just to summarize my answer with respect to what you were asking earlier, I would that say although many people use it, according to many studies that have been conducted, it is not effective. You asked me what exactly we should be doing. Well, obviously, there is no simple answer to that question. From an ethical standpoint, the question is whether we should just let things go without any kind of intervention, and simply wait for problems to develop in some people, at which time we provide treatment or do whatever we can to help them.

In England, clinicians from various parts of the world got together and drafted a paper that sets out guidelines to be followed for interventions with people who have been exposed to trauma or have developed post-traumatic stress. They suggest not conducting universal debriefing—meaning, in every single case—but rather, treating only those who demonstrate a risk for developing problems in the short term, or in the two weeks following the event.

Having said that, it isn't always easy to use such a process for military personnel on a mission who have been exposed to that kind of event. I understand that particular context is complex. I simply want to mention that watchful waiting is what is suggested. This is a non-intrusive screening procedure used to repeatedly and regularly assess people's state of mind and provide more forceful or intensive treatment through cognitive behaviour therapy. That approach is based on research conducted over the last five or ten years with victims of sexual assault or road accidents who subsequently developed what is called acute stress response.

Acute stress response is a temporary diagnosis that can be made during the first month following a traumatic event. This diagnosis is made when people have developed a series of symptoms that closely resemble those of post-traumatic stress, the difference being that it occurs in the four weeks following the event.

So, it would be a good idea to implement a process for screening and treating only those who have the potential to develop post-traumatic stress. Indeed, they are at greater risk of developing post-traumatic stress because they already have symptoms that are closely related to PTSD. However, acute stress response is not a perfect predictor. Indeed, only 60% of people who meet the criteria for acute stress response actually develop post-traumatic stress subsequently. It is also important to continue to screen people who are not experiencing post-traumatic stress.

[The Chair, Conservative, Rob Anders]

Thank you very much, Mr. Valley and Mr. Guay.

Now on to Monsieur Roy, for seven minutes.

[Jean-Yves Roy, Bloc, Haute-Gaspésie—La Mitis—Matane—Matapédia, QC]

Thank you, Mr. Chairman.

You just talked about acute post-traumatic stress. You gave a percentage. How many people did you say actually develop PTSD?

[Dr. Stéphane Guay]

In people presenting with symptoms of acute stress response, between 50% and 60% subsequently show symptoms of post-traumatic stress. When we only consider people with post-traumatic stress, as opposed to the number who experienced acute stress response prior to that, we see that the percentages are quite similar: between 40% and 50%. So, they do not equate perfectly.

[Jean-Yves Roy, Bloc, Haute-Gaspésie—La Mitis—Matane—Matapédia, QC]

That was the purpose of my question. I have been listening to you, and I am thinking that any normal human being who finds himself in a situation like that is automatically going to demonstrate obvious signs of stress. I cannot imagine that you could witness someone being blown apart before your very eyes without experiencing some kind of stress. It may not be acute stress response, but there is no doubt that any normal human being would feel stress in such a circumstance.

[Dr. Stéphane Guay]

I fully agree with you. There is no doubt that the vast majority of people who witness an event such as the one you describe—body parts strewn about that they have to pick up—will experience stress. However, acute stress response is not just stress. It includes symptoms such as flashbacks and nightmares. You also have to have experienced dissociation when the event occurred, have problems concentrating, have symptoms such as hypervigilance, and so on. Not everyone presents with these symptoms. It's more serious than the simple stress response that most people have. It's a little different.

[Jean-Yves Roy, Bloc, Haute-Gaspésie—La Mitis—Matane—Matapédia, QC]

I'd like to talk about the study you conducted on the health status of Canadian Forces personnel in their community. One is left with the impression that very few soldiers who experience post-traumatic stress actually seek help. These individuals are sent back to their communities—that was basically the purpose of your study, from what I understand—when, in fact, they are having problems that have not necessarily been identified. I would like you to tell us more about the results of that study.

[Dr. Stéphane Guay]

That was a study that Statistics Canada was commissioned to do by National Defence. The Canadian Community Health Survey is a Canada-wide survey on mental health. National Defence asked Statistics Canada to survey a representative sample of Canadian Forces members.

As part of that study, the lifelong prevalence of post-traumatic stress was examined, and it was observed that 6.8% of military personnel have apparently experienced post-traumatic stress at some point in their life.

[Jean-Yves Roy, Bloc, Haute-Gaspésie—La Mitis—Matane—Matapédia, QC]

But without necessarily seeking help.

[Dr. Stéphane Guay]

Over the last 12 months, the percentage was 2.3%. When we wanted to know how many Canadian Forces members had consulted someone, we did some research with a colleague by the name of Deniz Fikretoglu. Those studies were published.

Basically, the proportion of people who seek help for mental health problems is between 40% and 50%. That is not only for post-traumatic stress, but for all mental health issues. So, as a general rule, within the military community, between 40% and 50% of people will seek help if they have a mental health problem.

But what is even more important, in my view, is the amount of time they wait before seeing someone. According to our study, people who had experienced post-traumatic stress during their lifetime waited seven or eight years, on average, before receiving treatment. That doesn't mean the treatment was not available; it may mean that they simply did not seek treatment earlier. Seven or eight years is a long period of time and, unfortunately, post-traumatic stress disorder can become chronic during those years.

Among civilians, it also takes quite a long time. At the Trauma Study Centre, we have treated more than 150 people who have experienced traumatic events in recent years. On average, those individuals had been experiencing post-traumatic stress for four years. So, it's exactly the same situation in the civilian population. Screening doesn't occur quickly enough and doing it sooner would be beneficial. Of course, we would need to encourage people to seek treatment earlier or, at the very least, remove the barriers currently preventing people from availing themselves of the services that are available.

We know that at National Defence, for example, there have been clinics in place for almost ten years now, if I'm not mistaken. So, services are available, but there are also barriers. As part of another study she conducted, my colleague, Deniz Fikretoglu, looked at what the main barriers are and the predictors of recourse to existing services.

The two most significant findings of her study are, first of all, that it is the soldier's own perception of his state of mental health that will prompt him to seek help or not. The greater his sense that his mental health problem is having a detrimental effect on his ability to function, whether we're talking about functioning in a professional, family or other environment, the greater the tendency will be for him or her to seek help. In other words, people who have a tendency to minimize their symptoms or to avoid thinking about them will not be as likely to avail themselves of services, even if they are available.

The other most significant finding of this study has to do with barriers that prevent people from seeking help. Variables taken from the results of the Statistics Canada study show that a lack of confidence in the Canadian Forces was the main reason why people decided not to seek help.

[Jean-Yves Roy, Bloc, Haute-Gaspésie—La Mitis—Matane—Matapédia, QC]

What do you mean by a lack of confidence in the Canadian Forces?

[Dr. Stéphane Guay]

I really can't give you any details in that regard, but I can certainly speculate. This is not very precise, but I assume that the fear of revealing the fact that one is experiencing post-traumatic stress, of being expelled from the Canadian Forces, of losing one's job or of being stigmatized by others, are some of the underlying elements.

[Jean-Yves Roy, Bloc, Haute-Gaspésie—La Mitis—Matane—Matapédia, QC]

As you know, it was recently reported in the newspapers—I believe it was last week or the week before—that soldiers with mental health problems were being sent back to Afghanistan. That means that people with very serious problems are being returned to theatre. That could exacerbate the issues, not only for the individual concerned, but also for the Canadian Forces, could it not?

[Dr. Stéphane Guay]

Yes, you're right. It is inevitable that some will return, but not necessarily. It is possible to identify more of them. As you know, people will sometimes pretend to have PTSD in order to receive a pension. On the other hand, some will hide it in order not to lose their jobs, because they want to remain in the Armed Forces. This latter phenomenon is much more widespread. And the fact that it is happening is not necessarily the fault of the Canadian Forces. There is no doubt that some people with mental health issues are going back to theatre. Will that exacerbate their problems? Well, it probably will, of course.

[The Chair, Conservative, Rob Anders]

Mr. Stoffer is next, for the NDP.