Veterans Affairs Committee on March 22nd, 2007

[Dr. Stéphane Guay]

Yes, certainly.

In fact, in terms of social support in general, there are a number of different types of social support that one can receive from one's immediate circle or environment. There is emotional support, there is more tangible support, and there is what is known as informational support, and so on. Every one of us needs different types of support at specific times—particularly when we are experiencing a stressful event.

Peer helpers are able to provide a different type of support from what is available from a professional. In that sense, they can be highly complementary. However, one cannot replace the other.

This is how I see peer helpers playing a useful role. They are particularly good at providing emotional support. They can also provide companionship by taking part in pleasant activities. Support does not only mean talking about difficult things; it also means having good times together. Peers can help them to experience that, to spend time in a group, and to have fun together. In that sense, their support is extremely helpful.

Professional support, however, is a more formal, specialized type of support, which may be closer to informational support, but also includes emotional support, to a certain extent. Indeed, when a psychologist listens to a soldier talking about what he's been through and all the distress he has experienced, he definitely has to demonstrate empathy and be an active listener. So, he also provides emotional support. In my opinion, it's very complementary.

At the same time, one cannot expect a psychologist to provide companionship, for example, or to take part in fun activities with the soldier. That is not the psychologist's role. Similarly, neither peer helpers nor family members should be asked to provide more formal or professional support.

In my opinion, we really need to separate out every person's role. That is the ideal situation, because peer helpers do not feel they have the necessary skills to provide counselling. And, as far as I am concerned, that is not what they should be doing; instead, they should be providing other types of support.

[Brent St. Denis, Liberal, Algoma—Manitoulin—Kapuskasing, ON]

In the case of a professional such as you, who is trying to determine or quantify as best you can the degree of the PTSD, is there such a thing as gradations or levels where you can say this is minor and you can prescribe a certain routine, a regimen of treatment, or this is serious? Can you determine that one on one, or is it too difficult to do that?

And with that, can you determine the balance between the peer counsellor and the professional? Could you say he just needs some time socializing as one extreme, and the other needs to be put in a hospital, if those are the two extremes?

[Dr. Stéphane Guay]

I think that depends on the needs of the individual. It is up to him or her to determine the kind of support that is needed. Peers should not force a particular type of support on these individuals. It has to be voluntary. When you impose the involvement of a support group, the impact can ultimately be a negative one.

So, there has to be a certain synchrony between the need for social support and what is offered in terms of support. In that sense, I think the best barometer is the individual concerned.

[Brent St. Denis, Liberal, Algoma—Manitoulin—Kapuskasing, ON]

Thank you.

[The Chair, Conservative, Rob Anders]

Thank you very much.

Now we go on to Monsieur Perron for five minutes.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Good morning, Dr. Guay.

Forgive me, but I may address you as Stéphane in the course of our discussion; but I want you to know that it is not out of a lack of respect on my part. I generally call everybody by their first name.

I was elected for the first time on June 2, 1997. In mid-July, I met my first constituent with PTSD. He was a young fellow the same age as my son. Since then, post-traumatic stress disorder has practically become an obsession with me. I've read the books written by Pascale Brillon, whom you most certainly know of, and I have become deeply involved.

Along the way, I have come to believe that there must be a way of predicting, when a young soldier is being recruited, the kind of psychological problems he might experience in the wake of a peacekeeping or war-related mission. It's too bad that Betty isn't here. I always tease her because she doesn't understand Quebeckers' black humour or people that speak in parables. I often say that if we can afford to buy C-17s, we can afford to invest in development and aid. I was really shocked when a witness we heard from last Tuesday, Maj Le Beau, a very nice lady, told us that before young soldiers are deployed, they are given a half-day of training to explain PTSD.

The written works of people like Pascale Brillon describe many different symptoms that make it possible to do a self-assessment and determine whether one has post-traumatic stress disorder. For example, people with PTSD suffer from insomnia, nervousness, have nightmares, and lose weight. We know that young soldiers are machos—we shouldn't shy away from using such terms—who say that they're tough.

In this country, we spend money. I'm not saying it's money that's poorly spent, but we do spend money to provide them with modern equipment. We spend money to train them physically for combat or to be in the army. On the other hand, we only give them a half-day of training to prepare them mentally for warlike conditions.

Why can't a member of Parliament like Gilles Perron dare to tell the Canadian government, whatever his political stripes, that every time it spends a billion dollars to buy equipment, it should consider investing 1% of that amount in veterans, in order to educate our young people and provide them with the proper care later on?

What do you think of my investment plan? Stéphane, I am certain that, like everybody else, you say you haven't got enough money.

[Dr. Stéphane Guay]

Prevention is probably the best remedy. I think there is probably much to be explored in that regard, including trying to increase soldiers' resistance to the events they will be exposed to on their mission or deployment. I am very much in favour of that. I think we should be investing a lot of money in research in that area, to try and see what works and what can really help them.

My first impression is that a proper self-screening procedure such as the one you described is probably the best solution. However, soldiers being the way they are, they may be reluctant to acknowledge they have a mental health problem.

I would just like to make two or three additional comments. To my knowledge, we are not currently able to identify soldiers who could suffer post-traumatic stress if they were exposed to a potentially traumatic event during their deployment. I don't think we have yet reached that stage.

In terms of our study of risk and protection factors in relation to our soldiers, we are still finding our way. We have identified three types of protection or risk factors. First of all, there are what are known as pretrauma factors—age, gender, past psychiatric problems or a family history of such problems, a history of physical or sexual abuse in childhood, or first-hand experience with other types of trauma. Then, there are peritraumatic factors—in other words, all the factors related to the seriousness and duration of the event, dissociation during the event, and so on. Finally, there are post-traumatic factors, particularly social or organizational support received after the event, and the number of stressors experienced subsequently, which may not necessarily result in trauma. For example, an individual may have difficulty sleeping. There are certainly factors at other levels as well, but I am just summarizing here.

Based on the current state of knowledge as to the extent to which these three types of factors can be good predictors, it is clear that pretrauma factors are not the best predictors of who will suffer from post-traumatic stress. The best ones are really the peritraumatic factors—in other words, the intensity and duration of the event, and how horrifying it was.

Having said that, such things cannot be predicted in advance. Every event is unique. There are events that one cannot even conceive of and for which no one could ever be prepared. Any soldier who came before you to give testimony could give you examples of horrifying events that he or she had experienced and that we could never have imagined.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

I have heard a lot about such events, Stéphane. More than 500 soldiers who have since left the Canadian Forces told me stories about atrocities. Just listening to them practically stresses me to the same extent. I have also met with young soldiers at the Valcartier base. Because they were afraid of losing their jobs, there was a curtain between them and me when I met with them. They did not want to be recognized. I think we need to invest in that area.

In closing, I would ask you to comment briefly on this. When we met with the last witness, I compared the Operational Stress Injury Social Support Program, or OSISS, to Alcoholics Anonymous. I don't want to denigrate Alcoholics Anonymous, because they do good work, but based on what I've read, the debriefing has to occur within a month or several weeks of the event. You cannot wait. That means that psychologists have to be in the battlefield.

[Dr. Stéphane Guay]

The ability to identify mental health problems as early as possible would certainly be beneficial but, in my opinion, that would lead to organizational problems. It is not easy to do. As a psychologist, I might end up being traumatized by my experience in the battlefield. However, there may be other options, particularly in terms of the processes and destigmatization. In this morning's National Post, it talked about the fact that Senator Kirby has been given a budget to establish a National Health Commission. I think that budget will be spent simply destigmatizing mental health problems. Just imagine, he is doing that in the general population, but it is even more necessary to do that in the military population, particularly because of what you just mentioned. There is a great deal of work to be done at the level. I could say a lot more about what I think should be done with respect to armed forces personnel and PTSD, but I will stop there.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

But that is exactly why you're here, Dr. Guay.

[The Chair, Conservative, Rob Anders]

I'd like to ask a couple of questions, if I might.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

No way. I'm leaving, in that case.

[The Chair, Conservative, Rob Anders]

I thought so. I guess there's a smoke involved as well.

You mentioned behavioural cognitive therapy. I don't know exactly what that is, but I'm going to take a stab at it, and you tell me how right or wrong I am.

I'm guessing that is where somebody suffering post-traumatic stress disorder exhibits symptoms. Maybe they don't want to be around things that trigger a memory of the events, or they have difficulty sleeping, etc. What you do—this is my guess—with behavioural cognitive therapy is educate them to the fact that those symptoms are related to PTSD, making them aware of it. That's my guess. I would like to get your sense of what it is and get an explanation.

[Dr. Stéphane Guay]

In fact, that is part of the therapy. Generally speaking, we are talking about cognitive behaviour therapy that includes three or four components. The first is psychoeducation with the person, treating the symptoms and what he or she is experiencing. Very often, particularly among military personnel, people are not aware of the fact that others may have the same type of symptoms. Where soldiers are concerned, if the symptoms only appear in one of the ten people who were exposed to the same event, that individual will obviously not easily be able to recognize them. As a result, the psychoeducation phase is extremely important, simply as a way of beginning the therapeutic process.

Following that, they are taught ways of reducing the physiological manifestations of anxiety—muscular tension, quick breathing, and so on. We use a method of relaxation or teach them a new way of breathing from the diaphragm.

After that, we usually move on to the main ingredient, which is exposure, in their mind's eye, to the scenario of the event, and then exposure to situations which are to be avoided. The first part is the most important one, obviously, where soldiers are concerned. We help them to gradually relive the scene associated with the event, recount what occurred and, in so doing, recall images and their thoughts. However, all of this takes place in a therapeutic context which allows the individual to come to terms with the images and memories in such a way that they no longer evoke strong negative emotions or cause as much distress. The idea is to gradually bring the person to recount the event to us, find some meaning in that event, and see it as forming part of the past.

The main problem for people with PTSD is that they are haunted by their memories on a daily basis. We try to help them to no longer be haunted. Of course, you cannot wipe out someone's memory of the event, but if you can bring them to talk about it and think about it without feeling distress, that is a major step forward.

After that, we can move on to exposure to situations or stimuli associated with the event. When psychological trauma occurs, associations are made between certain things and the trauma. It can be images, smells, or sounds. The idea is to generalize the learning that occurred during exposure to the scenario of the event and other stimuli that prompt the individual to recall the event subsequently, or on a day-to-day basis.

As a general rule, the final step is to try to prevent relapses. The idea is to consider the risk factors, which situations involve risks, and also to teach strategies that will allow the individual to manage those problems, if they re-emerge.

So, we are essentially talking about multiple components. Of course, to that can be added all kinds of very relevant modules, especially for veterans. I know that at the Sainte-Anne Centre, for example, we do a lot of work with respect to nightmares. Often, nightmares are part of the symptoms. In fact, the dreams are what cause distress. And the dream may not necessarily be an exact representation of the event to which they were exposed. There are intervention methods and strategies that allow people to stop having these nightmares, and that can be very helpful. We can also help with anger management, and with respect to other emotions which are not necessarily fear-related and are therefore not a result of anxiety—for example, guilt or shame—feelings that are often very prevalent in veterans and which must be addressed as part of the therapy.

[The Chair, Conservative, Rob Anders]

You made a mention in one of the responses here to hyperarousal. I'm guessing, and once again I'm just clarifying, that this would be where they are extra-sensitive to their environment. In a military scenario, you hear about somebody who is very sensitive when they are sleeping, for example. My father talked about that with Vietnam veterans. They were particularly sensitive, as if they were in a field of operations or what not. I'm wondering if you can go into hyperarousal a bit and explain that a little further.

[Dr. Stéphane Guay]

I am not sure I understand. All sorts of things can be associated with sleeping—for example, being in the dark and going over the events in one's mind and the distress that they cause. As far as I know, the simple act of sleeping—other than the fact that an individual may think back to the painful events or have nightmares—is not associated with that.

[The Chair, Conservative, Rob Anders]

I was trying to give you an example, but could you just give a more thorough description of what hyperarousal is as a symptom of PTSD?

[Dr. Stéphane Guay]

Hyperarousal is what is known in French as “l'hyperactivité neurovegetative”. It is one of the groups of symptoms that are part of the diagnosis. These symptoms include sleep disorder, problems concentrating, hypervigilance, irritability, and so on. Obviously, this kind of hyperactivation can mean that the person is constantly on the lookout. The simple fact of finding oneself in complete silence at bedtime or when in bed—silence in itself—can recall certain aspects of the trauma. It may cause a person to relive the trauma he experienced, to feel anxiety and to have depressogenic thoughts.

If, on average, they waited seven or eight years before receiving services and the post-traumatic stress has become chronic, there is a good chance they will have developed comorbid major depression. According to the Statistics Canada survey, more than half of Canadian Forces personnel experience major depression, and it is the same thing in the civilian population. People present with secondary depression and, very often, they will take antidepressants. It is also important not to overlook the effects of depression on mental health or on soldiers' general quality of life.

[The Chair, Conservative, Rob Anders]

Now we'll go over to Mr. Valley for five minutes.

[Roger Valley, Liberal, Kenora, ON]

Thank you, Mr. Chair. I just have one quick question and then I'll hand it over to Mr. St. Denis.

When we were talking earlier, you were talking about different methods of—I don't know if I'd call it treatment, and I'm not sure if I got the translation right, but what I got from it is that you used a term called “watchful waiting”. I'm wondering if that's self-explanatory. Is it the professionals who do this when somebody has actually been identified as having PTSD? Is it the professionals, the family? Can you tell us what kind of treatment watchful waiting is? Does it mean we're just keeping an eye on these individuals?

[Dr. Stéphane Guay]

It doesn't only concern people suffering from PTSD, but the term basically applies to them.

Having said that, it is important to identify mental health problems in the family, in spouses and in children, because such problems can have repercussions for them and manifest themselves in different ways.

As far as I know, soldiers do not easily talk to their spouses about what they are experiencing, or the events they were exposed to, often out of fear of contaminating or traumatizing them. If they don't talk about these things, their spouse will not understand why they are in that state or the magnitude of the problems they seem to be experiencing. Often they suffer from the isolation and emotional detachment of their spouse, because they have trouble talking about their problems. As well, post-traumatic stress means they also have trouble feeling positive emotions. That means, for example, receiving and giving affection, having sexual relations, and so on. There are a number of components.

Soldiers or people coping with PTSD often report that they are more irritable with their children. They are less tolerant of bad behaviour, which has a fairly important impact on the family. We obviously have to look after them.

It can even go further than that. Studies conducted on Vietnam war veterans show that there is more domestic violence and domestic dissatisfaction among members of this group. Is this domestic violence the result of symptoms of post-traumatic stress disorder? It most probably is, at least in part, and perhaps completely.

So, we have to deal with this problem. Spousal separation is not always disastrous. Some of you are most certainly separated or divorced, given the general trend in today's society. When our spouse ends up leaving us or wanting to separate because of our mental health problems, that is even more difficult to accept. The impact of a possible separation on a veteran must also be taken into consideration.

It would also be a good idea to screen close family members for mental health problems, and to look at family or spousal health.

[The Chair, Conservative, Rob Anders]

Thank you.

[Brent St. Denis, Liberal, Algoma—Manitoulin—Kapuskasing, ON]

I'll just take the last few moments of my colleague's time, if I may.

In relation to predicting in a given person's case the potential for a bad reaction to a difficult situation in the military universe, how much do we know in the area of prediction? Presumably funding agencies, governments, and so on, if they have $100, want to spend some of that $100 on the upfront aspect, the prediction and the preparation, but clearly the bulk of the dollars is on the follow-up, because you can't predict very well. Let's say it's $10 before and $90 after, just to make it simple.

Could you talk about the prediction and predictors a little bit, please?

[Dr. Stéphane Guay]

I'm glad you asked that question. If I had $100 to invest, I would spend half of it on developing treatments that could be used following development of PTSD, and the other half on research aimed at identifying individuals at risk and developing effective prevention strategies. Unfortunately, we have very limited knowledge in those areas.

I believe soldiers are a group with whom we could really do some very good work. They are what we call in our research jargon “captive individuals”. In other words, we can assess all of them before they are exposed to traumatic events. It would be very difficult to do that in the general population. You would have to assess several hundred thousand people in order to obtain a sample of individuals who would be exposed in the following months to traumatic events. With soldiers, we are dealing with a cohort of people who we know will most certainly be exposed to such events.

Of course, the ability to conduct research, to assess risk and protection factors before they leave, and to ascertain which of these factors enable us to predict the individuals who will develop PTSD could open up some very interesting avenues in terms of applying preventive and therapeutic strategies when they return. I would also invest money in the care to be provided people returning home. In my opinion, the current state of our knowledge is not adequate and we therefore cannot afford not to invest in prevention.

[Brent St. Denis, Liberal, Algoma—Manitoulin—Kapuskasing, ON]

Thank you.