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.