Thank you, Chair.
I'd like to thank the committee for the opportunity to be here today. Mr. Cann and I represent Whelan Psychological Services. We're a private practice of psychologists working primarily with military-related OSIs in Nova Scotia.
By way of background, I served in the Canadian Forces from 1977 to 1985. For the past 15 years I've worked as a clinical psychologist, first as director of addictions services for the navy in Halifax. For the past five years I've been in full-time private practice, working primarily with serving and retired military and RCMP.
My remarks today will focus not so much on departments but on the current system of care in effect for veterans.
Our clinic was established in 2005, as an eight-week intervention program in response to a joint RFP by DND and Veterans Affairs, an initiative that was never used. Our work began with referrals of veterans from other civilian providers and family physicians, and self-referrals through the OSISS network. Many of these crisis cases, unknown to the military or Veterans Affairs at the time, were referred by civilians because of addiction or depression problems, and were often assessed and diagnosed by us for the first time.
Recently the situation has improved, in that more referrals to the practice have been previously diagnosed with an OSI by the military. After leaving, they are often referred to us. We tend to have more complicated cases referred to us, which, as Mr. Maguire said, involve a variety of other conditions.
Of the 400 military and RCMP clients referred to our practice over the past five years, approximately 70% are experiencing chronic problems with addiction and post-traumatic stress, which is often further complicated by chronic pain from physical injury, suicidal preoccupation, or anger control problems. Some of these clients, particularly younger veterans and serving members, can do exceptionally well and end treatment successfully. However, in general, the prognosis for successful treatment is guarded, and relapse is the more frequent outcome.
Consistent with the research, veterans with PTSD, and particularly with chronic addiction problems, usually do not respond to treatment as usual for treatment of post-traumatic stress. They often have multiple chronic and comorbid conditions that are difficult to manage on an outpatient basis. They cycle between stability and crisis. Many do not have medical or psychiatric support in the civilian community after they leave their organizations. Suicidal risk is an ongoing concern.
Despite earlier identification and treatment of OSIs by the military, from a continuity of care perspective, there appear to be major gaps in the system. Veterans under medical care in the military often become deeply distressed upon leaving the military, and they go underground, sometimes for years. They're often unemployed, isolated, and pessimistic about any change or possibility of change. Some require hospitalization for attempts of suicide or psychosis; others require close clinical monitoring. In our records, four have died prematurely because of PTSD-related problems.
As outlined in Senator Kirby's 2006 report, “Out of the Shadows”, there are formidable challenges facing the delivery of mental health services across Canada, as we know. In particular, he said,
The...“clash” between mental health services and addiction services has created substantial problems for clients, particularly those with concurrent disorders.
When it comes to managing mental health problems among veterans, then, the question is whether this Canadian average is the expected standard of care.
In our region, services for veterans rely heavily on a collection of approved mental health providers and public health services, when available, such as physicians or psychiatric support, and they may have limited or no expertise in managing veterans' concerns. Under this system there are no mechanisms in place to determine expertise beyond professional credentialling. As well, there are no opportunities for these providers to communicate or coordinate their efforts when a veteran has two or more independent providers.
In contrast, the Canadian Forces in Halifax seem to be working towards a collaborative model in treating military OSIs, including staff cross-pollination and efforts at interdisciplinary cooperation. This model could be considered for application in other jurisdictions. Our attempt to replicate this within a small private practice setting has been very challenging.
The problems faced by veterans are complex and multi-faceted. The solutions will likely require fundamental shifts in organizational cultures, systems of communication, and professional attitude, which must change from one of “experts know best” to one in which client and family needs are identified, valued, and actively managed.
In terms of established evidence in the trauma field, we know that the gold standard involves cognitive behavioural therapy, often in staged approaches that can last one to three years, on average.
In brief, prior to engaging in any treatment of a military-related or an RCMP-related traumatic stress reaction, stabilization is imperative. That includes problems with suicidality. This often means medication management, fostering a stable home environment, managing addiction problems, and reducing overall stressors.
For many of our clients, it is extremely challenging to move past this first stage of treatment. Loss of employment structure and military identity, family dissolution, unmanaged pain, active addiction, problems attaining medical supports, and a persistent preoccupation with pension application and appeal processes results in a perpetual state of instability. As a result, some of these clients may never get to a point of second-phase treatment, which is when they would actively address the specific OSI.
During this time, of course, these clients become even more disillusioned and angry and depressed, which can turn into a chronic state of traumatic reaction.
Mr. Cann is going to complete our remarks.