Veterans Affairs Committee on Nov. 23rd, 2010

[The Chair, Conservative, Gary Schellenberger]

I call the meeting to order.

Welcome everyone, to the 30th meeting of the Standing Committee on Veterans Affairs. Pursuant to Standing Order 108(2), we are conducting a study of combat stress and its consequences on the mental health of veterans and their families.

For the first hour, our witnesses are William Maguire, as an individual, as well as Dr. John Whelan and Steven Cann.

We have only an hour. If you can keep your opening remarks relatively short--within 10 minutes would be nice--then our questions will be five-minute questions and answers, and we'll see how many questions we can get in.

Again, welcome.

Mr. William Maguire, would you like to go first, please.

[William Maguire, As an Individual]

I was up here in March. I recognize some faces and see some new faces. As I think I stated in March, you're going to hear it in a soldier's language. I don't beat around the bush. I shoot from the gut. I have nothing to prove to anybody.

Ladies and gentlemen, you are looking at an individual who has suffered with the dreaded affliction known as PTSD, post-traumatic stress disorder. I have been suffering with this mental disorder for the past 36 years of my life of 62 years. For the past four years, I have been under the care of medical professionals after being diagnosed with the disease in April 2006.

PTSD is a dreaded disease that one can be suffering with while looking completely normal to anyone who does not know what the veteran is fighting with on a daily basis. In other words, we all look normal. You walk in and see me and think, “There's nothing wrong with that guy. He's normal.” Well, I'm not normal, not mentally anyways.

One of the biggest factors that we constantly endure is the knowledge that once a veteran is diagnosed and the word gets out, then we are looked at as an enigma and are treated with distrust, not to be put into an area of responsibility. Basically we are treated like one with leprosy.

To try to cope and hide the fact that there was something wrong with me, I put on a phony act and tried my hardest to socialize, but in the end it all came crashing down, which damn near destroyed me. Many veterans cannot handle this daily battle with oneself and completely withdraw into a world of depression and what we refer to as “bunkering in”. That is, a veteran goes into his basement or his little room, and he stays there and will not come out. He becomes completely reclusive, not wanting to socialize or be bothered by anyone. There is a complete social breakdown.

As for me, I have been suffering from massive headaches, nightmares on a regular basis, bouts of anger to the point that I have scared individuals, frustration in not knowing what was going on with me, anxiety over having to carry out the simplest tasks, and an unwillingness to fully trust anyone close to me--i.e., at work or at home. I was always on guard, keeping my shield up at all times, constantly vigilant as to what was going on around me. I had social misbehaviour and run-ins with authority. These things are common in men suffering from PTSD. I use the word men because I have never worked with women with PTSD.

These conditions manifested themselves directly when I returned from Cyprus in December 1974, after a United Nations tour with the Canadian Airborne Regiment. After my first marriage broke up in 1982--I had been married for 10 years--my parting wife stated to me that she still loved me but did not know me anymore. Another statement she made was, “You are not the same man I married since coming home from Cyprus in 1974, and at times you actually scare me, as I do not know what to expect from you.” This is another one of the things that we have to face--the family support system, and loss of that system.

After returning from Somalia in 1993, I remarried, hoping beyond hope that I could find normalcy with the woman who I now love. This too fell to the wayside, leaving me in a daily battle with my conditions, which I call the roller-coaster ride of emotions: up one minute and down the next.

Presently, I am still suffering through many of these conditions, even though I am seeing a psychologist on a regular basis. Because of the constant struggle to find meaning in life while suffering from the black dog of depression--that is what I call it--my physical being has taken a beating faster than what I or the medical professionals predicted.

I may be wrong in making this assessment, but I blame the never-ending cycle of emotional ups and downs caused by PTSD for my failing health. To try to find some meaning in all of this, and to make a commitment to myself--in others words, for a get-out-of-the-house project--I volunteered to join the OSISS, occupational stress injury support service, as a peer helper. It is this experience with OSISS, of which I am no longer a member, plus taking on a workload of veterans on my own that I now draw upon.

I did my best, giving 100%-plus to help my fellow veterans until I went through what we call the burnout phase, something all peer helpers like me will go through, because you get too involved with the man that you're working with and you get burned out.

It was during these episodes of burnout that I suffered severe depression and a deep bunkering in period. As you can imagine, this took its toll not only on me but also on my relationship with my loving wife, which was already at the breaking point. It was during these black dog times that I completely cut myself off from the outside world, missing important medical appointments and basically cutting back on my duties to help my fellow veterans.

This part really upset me, as I consider it my duty to keep in contact with them. That's the old thing about soldiering. You help your buddies, and in return they help you. When you can't do that anymore, then it falls on your shoulders: you've let them down. We've all gone through it.

These episodes would last for weeks to months at a time. While I have suffered through these horrible times in my life, my loving wife has constantly stood by my side, even though I would spend days in my bunker, not washing, shaving, or changing my clothes, and only going upstairs to eat every now and again. She has endured quite a lot over my illness through the years, and has even threatened to leave me on a few occasions. I would not blame her in the least if she did, as I think she would be better off without me.

As time passed and my condition worsened, she kept cutting back on her hours at work so she could be with me more and more as she was concerned that I was going to kill myself. When she could not cope anymore at work, she decided to quit her job to be with me at all times. Even though this was a great boon to me, it cost us dearly financially, but we manage. This is more stress put upon us. Besides all this, I have not been able to sexually satisfy her for over 10 years. You can imagine what stress this has put on our relationship.

I see my life as one of constant pain and suffering. My life as I knew it is in ruins, and at times I feel that there is no sense in carrying on under these relentless circumstances. I have to admit and I say without malice that PTSD has taken a great toll on me and on hundreds of other veterans.

This is what I have experienced over the past four years.

First, PTSD will ruin the veteran's family and social life until they turn to addictions such as alcohol and prescribed or illicit drugs, gambling to the point where they are no longer in control of their finances, or dangerous sexual overactivity that may turn to prostitution. Or they might become workaholics. By carrying out these manifestations, they ruin any chance of getting self-respect or battling the effects of PTSD.

Also, I must state that when someone is suffering from one or more of these addictions, it makes the diagnosis of PTSD more difficult, as the person must first be treated for these addictions. This period of assessment is very stressful to the member, as it will more than likely ruin his marriage, if he is married, or any relationship that he is in. With the loss of family support, which is critical for the veteran's recovery process, he will more than likely end up as a recluse or come to the point of attempting suicide.

If he can maintain family support, which is hard and stressful not only to the veteran but to the family as well, then he has a much better chance of living with the effects of PTSD. On the other hand, if a member is single, then the battle is waged on a different scale--that is to say, it is harder on him to seek help and he will probably turn to other means such as addictions. If he is not fortunate enough to get medical help immediately, he will normally self-destruct.

Because of the constant mistrust by veterans towards authority and the banishment they feel by the system in place, they will rebuke any help and form themselves into splinter groups to seek advice and help from one another. This is what I refer to as a speeding car going down a one-way street--a very dangerous street at that. Instead of gaining help from one another, all they are doing is putting their lives in jeopardy by not seeking proper medical assistance. Meeting in one's basement or a garage does not solve anything, especially when they do most of their discussions over a couple of cases of beer or illegal tobacco. All they end up achieving is more anger, frustration, mistrust, and the threat of oncoming deep depression. I have personally witnessed these occasions twice, and must admit that it totally shocked the hell out of me.

I have personally attended two group sessions held by my psychologist, which have helped me considerably to further understand the effects and causes of PTSD. These, as well as one-on-one sessions, have taught me how to cope during times of undue stress and anxiety, and have taught me the triggers that set me off. These sessions have considerably helped numerous fellow veterans to try to live a normal life. I will not go as far as to state that they are a magic cure, because they are not designed as such, but they will further benefit the veteran in their daily battles with PTSD and help them put trust in one another. The veteran can only get out of the program what they are willing to put into it. In other words, what I've put into it is what I receive. If I don't want to meet the psychologist halfway, he will not meet me. Then it's a waste of time for both individuals.

Many veterans have been refused help from the medical system because many doctors and psychologists refuse to take us on as patients. They do not know how to treat us, nor do they understand the effects PTSD can cause on the human body. Training is also a big issue. By their refusal, veterans feel even more isolated and mistrustful toward the system. This is one of the main causes of mistrust. If I go looking for help and I can't find it, I don't trust anybody. Then we go to the splinter groups. It's like you're on a speeding car going down a fast hill with a brick wall in front of you. There's no way out of it.

One other major factor that we all suffer from is trying to be understood and properly cared for by a respectful system. That can have very serious effects on the veteran if not found in time. Without proper medical facilities and care, we are basically doomed.

Suicide is on the rise, and I again refer to my own personal experience in stating this. During the last group session I put forward a question to my fellow veterans in attendance. When I asked how many in the group had contemplated suicide, seven out of eight put up their hands. When I asked how many had plans to carry it through, four put up their hands. When I asked how many had tried, three put up their hands. I was one of the three. I have personally suffered through five suicides plus numerous attempts. This has taken its toll on me, as can be well imagined.

Before closing I would like to state that PTSD—and this is coming from a veteran—cannot be cured, but it can be controlled if caught in the early stages. I was not lucky enough to be properly treated at an early stage, even though I requested help back in 1985 and the early 1990s. I knew in 1985 that there was something wrong with me, and my biggest fear was that I was going crazy. That is the first thing a veteran will think when he starts misbehaving and becoming a social outcast. He thinks, “I'm going nuts. I'm the only one out there suffering.”

When I went to the base surgeon in CFB Shearwater in 1985 and explained my concerns about loss of control and nightmares, the medical doctor stated that it was all in my head and that over time I would heal myself.

Well, here I sit, and I am far from being healed.

Signed, Mr. William D. Maguire.

[The Chair, Conservative, Gary Schellenberger]

Thank you, Mr. Maguire.

We now go to Mr. John Whelan, from Whelan Psychological Services Incorporated.

[Dr. John Whelan, Director, Assessment-Treatment Services, Whelan Psychological Services Inc.]

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.

[Steven Cann, Representative, Whelan Psychological Services Inc.]

My name's Steve Cann. As well as working at Whelan Psychological, I'm also a contracted clinical supervisor at the addiction treatment program in Stadacona, Halifax. Prior to this, I was a district psychologist, and prior to that I was a case management officer for Correctional Service of Canada.

My comments pertain to two issues: case management and addiction interventions. Before addressing these points, I'll provide a snapshot of our experience as private providers working with these issues with veterans.

In our experience, there are approved services for veterans and there are many others that are necessary but not approved. Efforts to effectively help veterans often mean moving into multiple roles, to the point where our clinical roles become seriously distorted. For example, we are often asked by veterans to act in advocacy roles for them, such as helping them to complete pension applications or referring to civilian physicians or psychiatrists.

There have been instances where we have had to move into the case management role, which can be a source of confusion and conflict. While we are acutely aware of our roles as primary support for our veterans, we are not viewed as being part of any system. We are treated as a resource to be used in a very restricted manner.

There has been much discussion in the past several years about a client-centred approach to veteran treatment. In our experience, a client-centred model of care places the identified client and his family in the centre of a hub surrounded by a collaborative team, all of whom have shared an understanding of the complexity of the issues, have clearly defined roles, a shared commitment to client goals and to the team process, and, importantly, a strong oversight to ensure commitment to these goals. The client and the family form an integral component of this team and are continually involved.

However, what seems to exist can be best described as a “service eligibility” model where each service--psychotherapy, medications--represents a discrete hub with one provider and one veteran working in isolation from two or three other independent hubs involving the same veteran. In this model, there is no opportunity for interaction among the providers and there is no coordinating oversight. Case managers who coordinate client care and have the authority to refer directly to treatment providers are essential for a client-centred approach to function effectively.

As a provider, we find our responsibilities confused by the role adopted by the case managers of Veterans Affairs. In our experience, they do not manage the case. Case management through the department appears to be one of authorizing or denying funding for the recommended interventions based on an insurers list of approved services. Changing the role to one where the case manager is clearly identified as the case leader and coordinator, in consultation with providers in the community, a team approach, would be a big step toward a collaborative model.

Other federal organizations have case managers who act in this role--for example, parole officers through my old job with Correctional Service of Canada. However, a major obstacle to this change in role is that VAC case managers are not permitted to refer or to direct clients to services. These decisions are currently made by outside providers, who may have little or no expertise in the likely outcomes of combat trauma.

Our clinic deals primarily with veterans who are referred for PTSD and addiction. The model of treatment employed at the clinic is an integrative PTSD addiction model, which has shown in our preliminary research to have positive outcomes. Integrated treatment is treating multiple issues and problems simultaneously, such as PTSD, addiction, and depression.

Integrated treatment has been recommended for coexisting disorders for a number of years. Treated alone, the risk is that one disorder can exacerbate the other. For example, the veteran being treated for PTSD becomes overwhelmed emotionally, triggering a relapse to heavy alcohol use, which places him at high risk for self-harm.

In conclusion, as treatment providers we would offer the following suggestions under systems of care: a truly collaborative, client-centred approach be enacted where the veteran and the expert providers collaborate on a team to achieve client goals; teams have a qualified case manager with the knowledge base and the authority to act; and mechanisms be established to ensure continuity of care when serving members who have been treated for OSI are released, thereby helping them avoid treatment relapse.

Under treatment options, we make the following recommendations: first, adoption and implementation of integrative treatment models of care for veterans with coexisting mental health problems; second, decisions about treatment modalities, individual/group medications, or family therapy should not be based on whether it exists on an approved list, but rather it should be made by a collaborative team, based on the evidence and client outcomes; third, in-patient capacity should be sought in local regions for veterans with coexisting mental health disorders to reduce the financial costs and family disruption that occurs when veterans are required to travel to available centres in other areas of Canada, such as Ontario.

Thank you very much.

[The Chair, Conservative, Gary Schellenberger]

Thank you.

We have only a half hour left for questions, so I will be stringent on the time. Members have five minutes for both questions and answers, so we'll try to keep both questions and answers as short as possible.

Ms. Sgro.

[Judy Sgro, Liberal, York West, ON]

Thank you.

Mr. Maguire, I will start by thanking you for your contribution on behalf of all of us as Canadians, and also for the courage you have shown today in coming to talk to us. This is an important issue for all of us, as it is for you, and it will be your comments, and others', that will help us to come forth with some recommendations that I hope will make a difference.

After the difficulties you've gone through, what do you think should be the first stop for someone coming home from theatre in order to start getting connected and to receive the necessary help?

I can only believe that everybody coming from theatre has to suffer from PTSD. I cannot imagine anyone not suffering in different degrees. I would think everybody would. If we use the analogy that everybody coming from theatre is going to suffer from PTSD to a degree or another—

[William Maguire]

No, ma'am, it doesn't work that way. I would say probably 60% of the soldiers who come home have no visible effects of PTSD. Of the 40% who are left, I would say probably 20% show visible signs, and after a couple of years the other 20% will kick in.

It took me roughly 10 to 15 years before I started seeing things from a different perspective, and then I thought I was the one at fault. I started having nightmares, which have never ceased: I'm on guard duty in the middle of the night, with nothing to guard, basically, just patrolling around the areas.

The first step for a soldier returning home to Canada is that they should be observed. You cannot take everybody in and say, “Are you suffering from PTSD?”

What is PTSD? Are you going to explain to the soldier what PTSD is? Are you going to say, “Are you having nightmares?” No. Are you going to say, “Are you having flashbacks?” No.

What do you do with him then? Do you pat him on the back and say, “Thank you, carry on--next, please”?

[Judy Sgro, Liberal, York West, ON]

Very often the—

[William Maguire]

What I'm trying to explain, ma'am, is that when the soldiers come back, the medical staff have to be trained to recognize the visual effects of PTSD. You get a man who's loud and boisterous and all of a sudden he's quiet and withdrawn, that man is suffering from something. Or it could be just the opposite; it could be a man who's withdrawn and quiet who all of a sudden becomes outlandish, does stupid things for attention, gets adrenalin rushes, that shows that he's craving for something, that he's missing something in his life. Normally it's the adrenalin rush that coincides with battle.

[Judy Sgro, Liberal, York West, ON]

Mr. Maguire, you said it was 10 years after you came home that you started having erratic behaviour. You are no longer in the forces, you're living your own life, and you're starting to have a variety of issues come out. You wouldn't necessarily think that maybe this is a result, would you?

[William Maguire]

Ma'am, I was suffering from these things well before I was out. Back in 1985 I knew there was something wrong with me. I knew I needed help. When I went looking for help, it was denied. It was refused. They told me to go to sleep, take some sleeping pills, get back to work the next morning.

[Judy Sgro, Liberal, York West, ON]

And it will go away. That's just terrible.

[William Maguire]

They tell you to fill your load station--“load station” being an old army term--to which you might say you're “on the gun”.

[Judy Sgro, Liberal, York West, ON]

What years would those have been, Mr. Maguire?

[William Maguire]

I started feeling the effects probably in the late seventies, early eighties, and thought it was just something I could deal with.

In 1985, when I was in Shearwater, I actually started scaring people. People on the detachment that I was sailing with refused to have me sleep in the mess. They wouldn't socialize with me. They were actually scared of me. I was very aggressive. I wouldn't think twice about striking out.

I said, “Okay, there is something wrong; this isn't the Billy Maguire I knew five or ten years ago.” I knew then that there was something wrong. When I went to get help from the medical system in place at that time—I agree now the medical system has changed for the better—I was refused help. I was told to get my ass back up to work.

[Judy Sgro, Liberal, York West, ON]

Thank you, Mr. Maguire.

[William Maguire]

And pardon for the slip of the tongue.

[Judy Sgro, Liberal, York West, ON]

Not to worry.

[The Chair, Conservative, Gary Schellenberger]

That's okay.

Monsieur André.

[Guy André, Bloc, Berthier—Maskinongé, QC]

Mr. Chair, I would like to know if I actually have seven minutes.

[The Chair, Conservative, Gary Schellenberger]

Five minutes.

[Guy André, Bloc, Berthier—Maskinongé, QC]

I will be sharing my time with Mr. Vincent.

My message is to everyone. I would like to address the issue of mental health problems Mr. Maguire talked about. I am sure that you, the psychologists, will agree with me. The situation has improved over the years. In the 60s, 70s and 80s, there were many taboos and prejudices around mental health. As you pointed out, Mr. Maguire, whatever the problem was, the tendency was to tell someone with a problem to go get some rest and take a sleeping pill. I feel our society has made progress. You have been following this issue very closely, just like Mr. Whelan and Mr. Cann. Could you tell me what improvements have been made to treat PTSD? Has there been an improvement? I can only imagine how things were in the 70s and 80s. My father was in World War II and retired in 1955. I always said that he had PTSD but he lived with it. That's the way it was: you would get out of war and leave. Have there been improvements?

What you are saying is important. The screening does not take place. But, over the years, we have still managed to develop tools for detecting PTSD in those at risk. Given the high percentage of people with PTSD, should we not invest more in the screening process and make it almost mandatory? As you said so well, Mr. Maguire, the sooner we treat people and establish they have PTSD, the sooner we will be able to reduce the future impacts of this problem. That's my question.

[William Maguire]

I'll give you a short answer. You are correct in stating that the sooner the individual is pegged as suffering from PTSD, the more chances there are of his being accepted into a social normalcy.

Also, care facilities should be placed in the areas where they can be utilized. The only one that we have available, I think, is up in Ontario, and the waiting list is a mile long. I mean, they only have so many they can deal with. I hear there is program now on the fifth floor at Stadacona, which is running a fabulous program, but that's geared toward addictions.

What we need is a centre where I can walk in after being diagnosed with PTSD and have men like this—psychologists and medical doctors like Heather McKinnon—who can say, “Now we are going to treat you, you are coming in here at this percentage of normalcy and we're going to increase that, if we can, to a point where you can be taken back into the social sphere of things.”

The biggest thing is getting us to socialize again. We don't want to socialize. We want to be left alone. Again, it comes down to trust. It's such a teeter-totter. If you get me on a good day, I'll talk to you; if you get me on a bad day, I won't even look at you.

[The Chair, Conservative, Gary Schellenberger]

We have four minutes left. If Mr. Whelan is going to answer, we do have to proceed.

Sorry for interrupting.