Veterans Affairs Committee on April 19th, 2007

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

I would like to call this Thursday, April 19, meeting of the Standing Committee on Veterans Affairs to order.

We're pleased to have with us today Raymond Lalonde and Bryson Guptill.

Mr. Guptill, are you from Ste. Anne's as well?

[Bryson Guptill, Director General, Program and Service Policy Division, Department of Veterans Affairs]

No, I'm from the Veterans Affairs office in Charlottetown.

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

Welcome to Ottawa. Thank you for helping us as we continue our study of the veterans independence program and health care review. The clerk has explained that you have up to 10 minutes each.

Who is going to go first?

[Bryson Guptill]

I'm going to start off by talking a bit about our mental health strategy.

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

Okay.

The drill is that after you've each had your turn we'll open it to questions from the members. So if you miss providing something in your presentation, you can import it into an answer to a question if you'd like.

Mr. Guptill, we'll start with you.

[Bryson Guptill]

We're very, very pleased to be here to speak before your committee. I'll tell you a little about who we are and why we're here today.

You've had some very impressive presentations from very knowledgeable people on the subject of post-traumatic stress disorder. We'd like to augment some of that information—or certainly try to—and tell you a bit about our mental health strategy.

My role in the department is the director general of program and service policy out of our headquarters in Charlottetown. I'm responsible for some of the policy aspects of the mental health strategy, and I have a director who works for me in that area. He's ill today, so he wasn't able to be with us.

Raymond is operational director for our mental health strategy, and he is responsible for the various clinics we have across the country. As you mentioned, Mr. Chair, Raymond is based out of our operational stress injury centre of expertise in Montreal. He has the knowledge of the day-to-day operational aspects around this issue.

You have a presentation from us. I won't go through all the detailed slides, but I will talk about our mental health strategy.

The department has made a commitment to improve the quality of life of its clients with mental health conditions, and their families, and that's what our mental health strategy is essentially all about. You will hear us talk about operational stress injuries. The term is used to describe a broad range of mental health problems, which include diagnosed medical conditions such as PTSD, but also anxiety disorders, depression, and other conditions that might be less severe but still interfere with daily functioning. PTSD, which you are more familiar with from the presentations that have been made to you, is a psychological response to an experience of intense traumatic events, those that threaten life, making one extremely afraid, helpless, or horrified.

I should point out, and I think other speakers have also pointed out, that although the term “PTSD” we're using now is a fairly new term, this is not unknown in terms of other conflicts. During the American Civil War it was referred to as “soldier's heart”. The First World War often referred to it as “shell shock”, and in the Second World War it was often referred to as “war neurosis”. It was referred to by our American colleagues during the Vietnam war as “combat stress reaction”.

The term “post-traumatic stress disorder” was coined in the 1980s. There's a substantial amount of research that has gone behind the establishment of this particular mental health condition. You've had some clinicians speak to you more specifically about the actual nature of the illness. Raymond and the colleagues he works with in Montreal are our departmental experts on the subject.

If you're following along, the next slide in our deck is number 5. I'm not terribly comfortable with putting this slide in next because it tends to focus your attention on pension conditions. Our approach has evolved in the last few years with the implementation of the new Veterans Charter, and we have many more tools in our tool kit other than simply a disability pension.

In the past, the department has focused on disability pension as a gateway to other benefits, especially benefits that relate to the treatment of things like post-traumatic stress. We no longer have to put people through that gateway process. We now have a suite of wellness programs that allows us to intervene when people have symptoms and deal directly with the medical treatment of their conditions without having to go through a long and complicated process associated with pension adjudication.

Certainly slide number 5 will show you that in spite of the perception perhaps, Veterans Affairs is a department with a reducing number of clients. The overall number of clients has gone up steadily over the late 1990s and into the 2000s, with the forecast numbers projected to drop off. But we haven't actually seen a decline in our work yet, and that's not likely to happen with the increased operational stress and tempo that is being experienced with Canadian troops abroad.

You will see from that slide that the proportion of clients who make up our veteran population has increasingly become Canadian Forces clients as our older veteran clients pass away. That trend is also expected to continue.

Many people perhaps lose sight of the average age on release. This is something that the new Veterans Charter was about. The average age of a CF member on release is 36. That's quite a young age to be thinking about a disability pension and being disabled for life. I think it's quite appropriate that we have done a lot more than issue pensions to these younger veterans who are suffering from conditions such as PTSD.

Having said that, the interventions are still there. We now have 10,000 clients who have been pensioned or who are receiving disability awards for a psychiatric condition. There are 63% of them who have conditions labelled post-traumatic stress disorder. That number has increased quite dramatically over the last five years. Slide number 7 illustrates the number of people who have been pensioned for psychiatric conditions in the last number of years.

The next slide highlights those people who have been specifically pensioned with post-traumatic stress disorder. I say pensioned, but I should say that since last year, younger CF members are now able to get a disability award, which is a lump sum payment, treatment, and monthly benefits by virtue of rehabilitation that they undertake as part of their case management.

As I mentioned, we now have a much more comprehensive approach to case manage members. We provide a very broad suite of wellness programs to help them back into civilian life and to recover as quickly as possible.

The next slide, committee members, focuses on where the favourable decisions for PTSD are located in our offices across the country. I should tell you that the five offices where we have the most clients are in Edmonton, Quebec, Montreal, Halifax, and Calgary. We have clinics, and our colleagues in the Department of National Defence have clinics, for the treatment of post-traumatic stress disorder and other occupational stress injuries in these areas. Part of the budget measure is to expand our number of clinics across the country. We are putting even more focus on this issue in the next few months and years.

If you look at slide number 10, the deployments the military is facing result in serious and dramatic human suffering. This human suffering is the type you see in the newspapers and on television almost every day, but it is also a much more subtle form of disablement that comes from mental health conditions such as PTSD.

The other thing that's quite evident from the research and the work we are doing is that in general there is a lack of capacity in Canada to deal with mental health issues. That is why we focus a lot of our efforts in two areas. One is to establish a legislative and regulatory framework that gives us the tools, as I mentioned, to actually intervene and provide the treatment that is necessary for these folks. The second thing is to provide facilities where they can be treated. That is what these occupational stress injury clinics are all about.

I'm now on slide 12, if you're following, and I'm talking a bit about our response. Veterans Affairs Canada has launched an aggressive approach to try to deal with people suffering from these operational stress injuries. We've established a mental health strategy. This strategy was developed and launched a number of years ago, but we have put a lot more resources into it in the last couple of years, and we envisage, as I mentioned, putting substantially more resources into it in the years ahead.

The components of the strategy, on slide 13, are providing a comprehensive continuum of mental health services and policies, to build our capacity in the department to deal with these issues, and to provide leadership, not just leadership in Canada but leadership outside the country. We've sponsored a number of international symposia on this subject, and we're working in collaboration with many of our colleagues in the health care field in Canada and also internationally.

In terms of a comprehensive continuum of mental health services, we are focusing on more health promotion, assessment, and treatment for people who are suffering from these conditions, and we have a very comprehensive case management scheme under our new Veterans Charter that allows us to deal very actively with cases.

I'll move quickly through the next few slides and then conclude and answer your questions.

I mentioned the capacity-building we're doing. We're focusing on establishing these new clinics, five that we've already established and five more that were announced in the recent budget. We're providing leadership in terms of research in this area, and we'd be happy at some future date, if you have interest, to talk to you more about some of our research, the research that's taking place at Ste. Anne's and also across the country with some of our research capacities. And my research colleague who works with me, Dr. David Pedlar—we can talk to you more, if you have interest, about the collaborative partnerships we have.

That summarizes the major issues we wanted to highlight for you this morning. I'd be happy to answer any questions you have on the policy aspects, and I'll direct questions on some of the operational issues to my colleague, Raymond.

Thanks very much.

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

Thank you. Is it “Dr.” Guptill?

[Bryson Guptill]

No. There are a number of doctors in my family, but I am not one of them.

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

I just wanted to address you correctly. Thank you, Mr. Guptill.

Monsieur Lalonde, please.

[Raymond Lalonde, Director, National Centre for Operational Stress Injuries, Ste. Anne's Hospital, Department of Veterans Affairs]

Good morning. I'm pleased to be here today to testify before your committee. I had the opportunity of meeting some of you during your visit to St. Anne's Hospital, last year in November.

Today, you'll have an opportunity to get a better understanding of what the department does when it comes to mental health and issues surrounding operational stress injuries. I won't rehash the presentation, because a number of points have to do with our role at St. Anne's Hospital. I would however like to talk a little about the Department of Veterans Affairs' National Centre for Operational Stress Injuries, what we do, and the plans we have to improve our services.

In 2002, we announced the official opening of the trauma clinic at St. Anne's Hospital, where we have now begun to treat young members of the Forces suffering from post-traumatic stress disorder, or PTSD. The department then broadened St. Anne's Hospital's mandate, and that of the clinic, to make it a national centre responsible not only for providing services, but also for developing programs, promoting clinical practices for the treatment of mental health problems, for research and enhanced access to services nation-wide, including health care and treatment services for our clients. That gives you an idea of the broad mandate of the National Centre for Operational Stress Injuries.

In order to carry out this mandate, one of our roles is to enhance access to clinical care. So the clinics we developed and which will be set up following the budget announcement, will become part of a pan-Canadian network of clinics available to veterans, and members of the Canadian forces and of the RCMP. These clinics will work hand-in-hand with similar Canadian Forces' clinics called OSI centres. These are ultra specialized clinics that assess and treat people with complex mental health problems related to operational stress, including PTSD.

These clinics should be able to treat about 1,200 to 1,300 patients across Canada. Clinics will be set up in every region of Canada. The overall network may include up to 15 clinics. The Department of Veterans Affairs currently has five operational clinics, and the Department of National Defence also has five in military bases throughout Canada. So, we'd like to increase the total number of clinics with the addition of five more. These are ultra specialized clinics, meaning that they don't provide all the health care services our clients may need.

When our clients suffer from mental health problems, they have access, just like every Canadian, to the public health care service. They also have access to clinical services, therapeutic services provided by psychologists, and specialized community social workers. These are services that we pay for. With the network of clinics, they'll enjoy access to a network of specialists working in multidisciplinary teams, including psychologists, psychiatrists, social workers and nurses. In addition to these health care professionals, the team may also include general practitioners, occupational therapists, and substance abuse counsellors. Our clinics rely therefore on a multidisciplinary team which works across the spectrum of disciplines. In other words, the whole team of professionals contributes to the assessment, treatment plan and care provided, based on the particular needs of the client.

These clinics specialize in assessment and treatment, but they're also mandated to work with community service providers, both public and private, in order to refer people to the appropriate professionals in the community—as I said earlier, not every client is treated in our clinics—broadening the knowledge-base of community health care workers, teaching best practices in the care of the people suffering from mental health disorders related to operational stress, and providing expert opinions to facilitate a collaborative approach with people in the community when it comes to treatment plans and the provision of services.

Our vision is to ensure that all our clients needing an initial assessment, or ongoing assessment due to the complexity of their problems or in absence of positive outcomes, have access to such. We offer clinical care at St. Anne's Hospital, but there's a whole array of complementary services provided by peer helpers. Bryson referred to these earlier.

The Operational Stress Injury Social Support Program, called OSISS in English, whose representatives you've met, I believe, provides services to people who have had mental health disorders and post-traumatic stress, and who offer support. We also provide the services of clinical care co-ordinators. These are people in the community who are available, and who are there to work more closely with the client in the community to ensure that there is no interruption in the services they receive. When a client suffering from an acute disorder out of hospital, after spending time in emergency and two or three weeks in a psychiatric wing, we want to ensure that there is some sort of follow-up to the health care that has already been provided. So these people are available to work with clients at Veterans Affairs' district offices, and also to work with the various community service providers, peer helpers, and with our specialized clinics to ensure these various levels of service are coordinated, that clients go to their appointments, that there is some sort of follow-up, sometimes daily, so that clients take their medication and know that the next step will be treatment in the community.

When you came to St. Anne's Hospital, one of the questions raised was about the beds we have for veterans. This question is often raised by the media, and you asked about it also when you came to visit. I'd like to point out that the beds we have at St. Anne's Hospital are not the only beds available to veterans suffering from operational stress. These beds are specially designed for a particular type of program, but we also have access to beds in private clinics throughout Canada. There are currently five clinics with programs developed at the request of Veterans Affairs Canada and the Canadian Forces. These are specialized programs lasting up to 60 days for people suffering from both post-traumatic stress and substance abuse problems,wich can be up to 75% of the total. We have a sufficient number of beds—there are beds in virtually every region of Canada, and these beds are available to veterans suffering from these disorders.

We also have access to some clinics' programs. In at least one specialized clinic, there's a program which provides an adequate number of beds. So, the beds at St. Anne's Hospital are beds designed for a specific stabilization program, and we're currently conducting a needs-based assessment to increase the total number of beds throughout Canada. We are still looking at this whole issue.

That completes my opening remarks. I would welcome any questions you may have.

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

Thank you, Mr. Lalonde.

We'll proceed to questions.

Ms. Guarnieri, for seven minutes, please.

[Albina Guarnieri, Liberal, Mississauga East—Cooksville, ON]

Thank you, Mr. Chair.

I'd like to wish Mr. Lalonde a warm welcome.

I certainly want to take the opportunity to commend you for the difficult and challenging work that you and the staff at Ste. Anne's are doing for veterans, and in particular for those suffering from operational stress injuries. I'm certainly aware of the good work that Mr. Guptill does in his division. I know you're certainly up to the challenges ahead.

I've had the privilege of visiting Ste. Anne's on many occasions, and I've really seen a dedicated team of professionals who do their utmost for our veterans. That is fortunate, because it seems certain that we will be seeing a large increase in cases over the next number of years.

Mr. Guptill, you referred to the upcoming challenges. I wonder if you could provide the committee with the volume of cases you are planning for as a result of our Afghanistan mission. As I recall from the Gulf War, we had several hundred veterans being diagnosed with operational stress injuries. Obviously, the Gulf War had a relatively short duration with a limited number of soldiers involved on the ground. The Kandahar mission, of course, is significantly different. It's set to last at least another three years and involves many rotations of thousands of soldiers. So I wonder what the volume of cases is that you're projecting you'll handle. And how many years of treatment do you think the average veteran might require? Have you done projections to that effect?

[Bryson Guptill]

Thank you for that question. It's a good question.

We don't have a direct number that we've been forecasting in terms of the number of clients who would specifically have these occupational stress conditions. What I can tell you, and I think it is important to think about, is that the number of clients we've received who are going through our disability award process has decreased dramatically since we brought in the new Veterans Charter. We had forecast, in this year, that about 5,000 clients would go through our disability award program, and the number is dramatically less than that. I can't tell you exactly what it is off the top of my head.

That is indicative, I think, of what we've accomplished under the new charter in the sense that people are now coming in for rehabilitation and treatment as opposed to focusing purely on the financial benefit that was available and which is still is available under the disability pension and now the disability award. In fact, the number of people who are coming through the rehab gateway is bang on the number we had forecast, and that number is somewhere in the order of 2,000.

So although the tempo of operational stress injuries has increased dramatically as a result of deployments like Afghanistan, it is similar enough in nature to have client numbers that are pretty much along the lines of what we had forecast at the time of going forward with the new Veterans Charter.

I sense that we'll be much better equipped to deal with people suffering from occupational stress injuries as a result of the recent announcement under the budget of about $9 million to be dedicated to the establishment of new occupational stress injury clinics across the country and another $13.7 million to help the department deal with clients who are suffering from mental health and in fact physical health conditions.

More specifically, the casualties we're experiencing in Afghanistan, and in particular the number of people who have died in Afghanistan, have been dramatically higher than what anyone would have projected. I don't want to downplay that in any way. But there certainly is enough capacity in our forecast to deal with the financial aspects associated with that. We have in fact been tooling up to deal with people who are suffering from mental and physical problems related to those deployments.

[Albina Guarnieri, Liberal, Mississauga East—Cooksville, ON]

It's certainly good to hear that the new Veterans Charter is working the way it was meant to, and I always knew that my department, my former department—Freudian slip—would never mislead me in their forecasts.

On another current matter, on Monday, the Minister of Health mentioned the OSI clinics in the context of the challenges and the stress faced by military children. I wonder if you could confirm whether you are expanding any counselling for the children of currently serving forces personnel.

[Bryson Guptill]

That's a tricky question, as you know, in the sense that—

Let me answer it in this way. One of the features of the new Veterans Charter that I think is very important is that the wellness programs we provided under the new charter also extended to families. This was quite a new approach for the Government of Canada.

We are now able to provide counselling to families of veterans, and can do so in a much more aggressive fashion, if I can call it that. We don't have to wait until people have received a pension entitlement in order to deal with their families. That's given us a tool in our toolbox that we didn't previously have, and it's very useful.

That said, our legislation still refers primarily to the treatment of families of veterans. People who are still serving are not the responsibility of Veterans Affairs, as you would know. Rather, they are a responsibility of the Department of National Defence. The Department of National Defence prides itself on preparing for counselling the families of people who are deployed, preparing the families for all sorts of ideas about what the members themselves are going to face.

There was a bit of attention a few weeks ago given to how much DND is doing and how much the Province of Ontario is doing in some particular areas. I was pleased to read in the media, as I'm sure many of you were, that this issue has now been resolved in the sense that Ontario and the Department of National Defence have sorted out a way to provide more proactive assistance to families.

Certainly one challenge—and this is something that you would have experienced previously, as minister—is that we don't also want to abandon military families or have them ghettoized in such a way that they can only get benefits or attention from the federal government. The provincial government has certain responsibilities for families as well. We want to make sure that this is a comprehensive approach that has everyone helping, and it's my sense that the provinces want to do that too.

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

Thank you.

Monsieur Perron, for seven minutes, please.

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

Good morning, Raymond. I take the liberty of calling you Raymond because we once had occasion to have a smoke together.

I'd ask you Mr. Guptill and Mr. Lalonde to not answer as if you were politicians but to get to the crux of the issue as quickly as possible.

I'm concerned about youth services. Clearly excellent service is provided to young people living in and around the major urban centres such as Montreal, Quebec City, Toronto, Edmonton and Vancouver. But what is being done for our young people in the far reaches of Abitibi, Medicine Hat and Elliott Lake? This is a problem.

The reason I use the example of Abitibi is because I come from that area. You are very familiar with this region of Quebec. Flying from Montreal to Rouyn-Noranda costs more than going from Montreal to France. It takes at least eight hours by car to go from Montreal to Rouyn-Noranda. So a young person from Abitibi can't go to Montreal for medical treatment and come home all in the space of one day. And yet, these people are entitled to these services.

Here's my suggestion, and I'd like you to comment on it. In your statement, you said that some psychologists work with you in some cities and towns. Why don't we know about them? I'd like to have a list of these offices.

When Dr. Biron made her presentation before us, she said that the majority of Quebec's psychologists, and those from elsewhere in Canada, know little or nothing about the problems associated with post-traumatic stress, that they need better training, and so on and so forth. She acknowledged that the plan that I'm putting forward made sense, that is to hire a psychologist or two on contract so that they can look after people in these regions and also make it know that the service exists.

You need to bear in mind that young people suffering from post-traumatic stress disorder are basically ashamed to admit that they have mental health issues. People are macho and tough when they are in the army. Asking for help with some sort of psychological disorder is a lot harder than seeking treatment when you need your hand or arm amputated or you suffer from some other physical problem.

Could you elaborate on your plan for the country's regions?

[Bryson Guptill]

Let me start by trying to answer your question in a more general way. Then I'll ask Raymond to deal specifically with some of the issues you've raised as they relate to regions in Quebec.

You've touched on the important issue that many of the folks suffering from some of these conditions are not located in Calgary, Edmonton, Ottawa, or even Quebec City. They're often located in more rural areas, and because of the nature of the illness they often retreat from society and go to even more isolated locales. So this is a challenge for us, there's no doubt about it.

Let me say initially that there is a shortage of people in Canada who have the right kinds of skills to deal with people with operational stress injuries. We recognize that, and in our new Veterans Charter we have an ability to provide treatment to these people. The treatment is a quasi-statutory right, so it's not restricted by any specific budget limitations. We can draw on the services on the basis of need, in other words. But we do find that there are shortages of skill sets, and that's why we've had to focus some of our attention on these areas where we've established a critical mass and clinics.

I'll give you an example from Calgary, because I was at our Calgary clinic just a few weeks ago. They are treating some people in the Calgary clinic who are living in some very isolated areas of Alberta. In some instances they've made the trek into the clinic, and in other cases they're dealing with people on a distance basis by phone and other means. They have been providing counselling to people.

Often the difficulty has been getting the message out. My colleague Raymond will talk a little bit about our peer support programs. But in the Calgary situation we were advised by the people who run the clinic that the most effective way to reach out to some of these people is to have former members of the forces, who are peers of these individuals, do outreach for some of them. They go to them in these remote communities and encourage them to come in for treatment.

I think we've established enough critical mass, and the expansion of a number of clinics will help us deal even more effectively with this. But there are certainly areas of the country, and the Quebec north shore is an area that comes to mind, where—

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

And what about in New Brunswick?

[Bryson Guptill]

It's the same thing.

Raymond do you want to—

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

Please make it a short answer.

[Raymond Lalonde]

Not all psychologists are able to provide services to veterans. Criteria have been developed based on experience and education. There is a plan being currently developed in order to improve the training programs offered to these service providers. In fact, on May 7, 8 and 9, we'll be holding a national symposium on operational stress injuries in Montreal. Researchers, clinicians, health service managers and presenters from the United States and Canada, people who are leaders in their field, will be present. Training programs are being developed.

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

Is this training being provided in conjunction with the association of psychologists?

[Raymond Lalonde]

Training courses are being developed at our centre of expertise. We work with clinicians in various clinics, and in conjunction with National Defence. We're developing programs with the National Centre for PTSD at the USDVA. It's not the training programs themselves that are a problem, but rather the way they are being delivered to service providers. They can be delivered in many ways. There is a conference. Each clinic is responsible for giving training sessions in its region. There are 10 of them; and there will be a variety of people involved.

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

Monsieur Lalonde, you can have a chance to come back to that.

Gilles, you will have a chance in another moment.

Mr. Stoffer is next, please, for five minutes.