Veterans Affairs Committee on Dec. 8th, 2016

[The Chair, Liberal, Neil Ellis]

Good afternoon, everybody. I'd like to call the meeting to order.

Pursuant to Standing Order 108(2) and the motion adopted on September 29, the committee resumes its study on mental health and suicide prevention among veterans. Today we have witnesses from the Department of Veterans Affairs: Dr. Courchesne, director general, health professionals division, and chief medical officer; and Michel Doiron, assistant deputy minister, service delivery branch.

We'll start off with your 10 minutes, and then we'll go to questions.

Welcome again, and thanks for coming.

[Michel Doiron, Assistant Deputy Minister, Service Delivery Branch, Department of Veterans Affairs]

Thank you, Mr. Chair.

Good afternoon, Mr. Chair, vice-chairs, members of the committee, ladies and gentlemen. As mentioned, I am Michel Doiron, assistant deputy minister of service delivery at Veterans Affairs Canada. With me today is our chief medical officer and director general of health professionals, Dr. Cyd Courchesne. As you may recall, Dr. Courchesne oversees the VAC team of health professionals.

It is our pleasure to be here this afternoon to talk about mental health supports and transitional services for the CAF, RCMP, and family members. This is very timely given that last week members of the Veterans Affairs Canada team participated in the 2016 Military and Veteran Health Research Forum in Vancouver, British Columbia. I believe some of the members attended as well. The forum was co-hosted by the Canadian Institute for Military and Veteran Health Research, or CIMVHR; the University of British Columbia; and the University of Victoria.

The annual conference is a key event for sharing knowledge among our researchers. This year attendees explored a variety of research topics related to the health of military members, veterans, families, and first responders, with presentations by leading Canadian and international researchers and experts. Themes included mental, physical, and social well-being; advances in trauma care; health technologies; the transition to civilian life; occupational health care; care ethics; and gender differences in health.

As mentioned, I'm aware that some of the members did attend the forum. I encourage members to attend when possible, because it is a very good sharing of information.

Much has happened since my last appearance in April, and I was here with you on Tuesday.

As of November 2016, Veterans Affairs Canada has hired more than 300 new frontline employees to ensure veterans and their families have the support they need, when and where they need it.

We have also hired additional case managers—to better support and serve veterans and their families and help veterans navigate a successful transition to civilian life. With the new staffing levels, case managers will serve, on average, 25 individuals each.

We have successfully implemented the increase to the earnings loss benefit from 75% to 90% of a member's pre-release salary. The earnings loss benefit supports a veteran financially as he or she undergoes physical rehabilitation, vocational retraining, and counselling, giving them peace of mind financially as they work towards physical and mental well-being. The goal, of course, is to ensure that military personnel have the support in place for an optimal transition to civilian life and that veterans and their families know they have ongoing resources to help them overcome life challenges.

A large part of our focus is on mental well-being. Veterans Affairs Canada is committed to ensuring eligible veterans, retired Royal Canadian Mounted Police members, and their families have the mental health support they need, when and where they need it.

I am proud of the wide range of mental health services, supports, and information VAC provides to veterans and their families. The document you were provided with earlier, which was also shared with our stakeholders at the last stakeholders summit, lists VAC's mental health services, supports, and information.

In particular, Veterans Affairs funds a network of 11 operational stress injury, or OSI, clinics across the country, 10 outpatient and one in-patient as well as satellite clinic service sites closer to where the veteran lives. I think some of you have visited some of our OSI clinics. These clinics are complemented by the Canadian Armed Forces network of seven operational trauma and stress support centres that mainly serve still-serving military personnel. This network continues to grow. More OSI clinic service sites will open across the country.

Each OSI clinic has a team of psychiatrists, psychologists, social workers, mental health nurses, and other specialized clinicians who understand the experience and unique needs of veterans. To further improve accessibility, each OSI clinic provides services through telehealth, or distance health services, to support those living in remote areas.

Our clinics also are using specialized software, called the “client-reported outcome measuring information system”, or CROMIS, that has been developed and implemented within these clinics. This system is used to track veterans' mental health outcomes by ensuring timely access to psychological and psychiatric assessment and treatment. CROMIS speaks to how well a given veteran is actually responding to the treatment. It tracks and reports client-reported emotional distress and satisfaction with social and vocational function on a week-by-week, session-by-session basis. When used in accordance with published guidelines, it significantly improves clinicians’ ability to identify those at risk of deterioration and/or premature termination and also to significantly improve outcomes.

We also have a well-established national network of around 4,000 mental health professionals who deliver mental health services to veterans with post-traumatic stress disorder and other operational stress injuries.

Our Veterans Affairs Canada assistance service offers a 24-hour toll-free help line, short-term face-to-face mental health counselling and referral services, to military and RCMP Veterans, and their families.

The operational stress injury social support, or OSISS, program offers confidential peer support to CAF members, veterans, and their families impacted by an operational stress injury. The support is provided by trained peer support and family peer support coordinators who typically have first-hand experience with these injuries.

We have collaborated with a number of partners in developing a series of free online and mobile applications that can be used by veterans and their families. PTSD Coach Canada and OSI Connect are mobile apps that provide valuable information to CAF members, veterans, and their families impacted by an OSI. The operational stress injury resource for caregivers is a self-directed online tool for caregivers and families of CAF members and veterans living with an OSI. It provides self-care, problem-solving, and stress management techniques for managing the challenges of being a caregiver. “Veterans and Mental Health” is an online tutorial designed for anyone who is wanting to learn about service-related veteran mental health issues or who is supporting a loved one with a service-related mental illness.

Medically released veterans and their families have access to seven military family resource centres, or MFRCs, across the country, as well as the family helpline and familyforce.ca website as part of the veteran family program. This program is part of a four-year pilot to provide veterans and their families with access to the MFRC supports and programs, traditionally only available to still-serving members of the Canadian Armed Forces.

The Government of Canada has launched a Canadian veteran-specific version of the mental health first aid in partnership with the Mental Health Commission of Canada. This program provides mental health literacy training for veterans in the community.

The government is also providing funding for the Mood Disorders Society of Canada to provide skills development training and support services to unemployed veterans with mental health conditions, to assist them in establishing a new career.

A partnership between VAC and Saint Elizabeth Health Care has also recently been established to design, develop, and deliver, in the summer of 2017, an online caregiver training program to support informal caregivers of veterans with an OSI.

Naturally, we continue to collaborate with the Department of National Defence to create two new centres of excellence in veterans care, including one with specialization in mental health, post-traumatic stress, and related issues. We're also collaborating with our partners at DND to develop a joint suicide prevention strategy for Canadian Armed Forces and our veterans.

These mental health services and supports are examples of how VAC is delivering on the commitment of care, compassion, and respect for our men and women who have served their country, and their families.

Thank you again for the opportunity to address the committee. Dr. Courchesne and I look forward to your questions.

Merci. Thank you.

[The Chair, Liberal, Neil Ellis]

Thank you.

We'll start off with Mr. Kitchen.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, Mr. Chair.

Thank you both for being with us again.

As you may be aware, I did go to CIMVHR. It is an excellent program. There is so much information, and so little time to sit in. It was a pleasure to be there, and I learned a significant amount.

Interestingly, what I took home from it was that oftentimes we're dealing with a moral injury. A moral injury is a brain injury, and recognizing that moral injury is often the biggest challenge we have to deal with. In reality, in order to focus on repairing it, we need moral repair to make that happen. I just wanted to say that this phrase resonated with me very well. Basically what happens to these soldiers is a violent contradiction of moral expectations, and they're dealing with that aspect of it.

That said, in the conference there was a lot of talk about dealing with families as well. I'm wondering if you can expand on whether, in a lot of the services we're providing, they are being resourced to families.

[Michel Doiron]

Thank you for the question, Mr. Chair.

First and foremost, under the various acts, Veterans Affairs is for the veteran. Most of our services, disability awards or pensions and things like that, are aimed at the veteran. That said, we strongly encourage family members to attend the OSI sessions, peer support, and various other programs. It's been proven that having the family involved in treating the illness usually works better.

The other thing we've learned is that often the member may say they're doing okay, but the family member may not be quite in agreement with the diagnosis of the member.

However, that being said, there is a full range of services that we provide to the family, without going through the veteran. As an example, the 1-800 phone number is 24/7. A family member, a child, or a veteran may call there and get help online immediately and/or, depending on the severity of the situation, be referred to a psychologist or a mental health care provider for up to 20 sessions. Veterans Affairs pays for this, regardless of whether it's service related or not service related, or whether the veteran is a client. A lot of the apps I just mentioned are available to family members.

As we're advancing in our program, we are looking at how to have better programs for families. We have the family caregiver program, but again that is through the members themselves to help the caregiving side.

[Dr. Cyd Courchesne, Director General, Health Professionals Division, and Chief Medical Officer, Department of Veterans Affairs]

To reinforce what the ADM has said, all the OSI clinics offer services to the family members of the clients they see. Whether it's immediate family, the spouse, or the children, they're all included.

The MFRCs also look after the families. As well, outside the more acute care of the OSI clinics, we have mental health first aid, which is available to everybody in the veteran's circle, as well as the online caregiver module. We're developing educational tools for people to self-help. It goes all the way to the OSI clinic, where they can participate in the veteran's treatment as part of their treatment.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

In your report you mentioned two new centres of excellence, and we talked about this a year ago. Can you update us as to where we're at on that, what locations are being looked at, and what research will be done? In other words, what sort of structure will be implemented?

[Michel Doiron]

We are still working on the centres of excellence and where they're going to be.

The first one we know will be on mental health and PTSD. I'll let Dr. Courchesne provide more information on that, but we're still working on some of those details. I can't share a lot of those details, because we're going to be proposing something in the budget, and the budget's confidential. I can't relay a lot of information, and I apologize, but we are working on it.

However, the first one will be on PTSD and mental health. We like to say “mental health” because it encompasses a lot more.

For the second one, we're working with our research group to determine what the best second centre of excellence would be. We have a couple of proposals in front of the minister for a final decision. It will be for the health of the veteran, absolutely, but we want to make sure we have the right one. That one is to come.

[Dr. Cyd Courchesne]

For the centre of excellence on mental health and PTSD, we've been consulting with the minister's mental health advisory group as to what they see being needed in that centre.

What we want out of that is to better understand mental health, operational stress injuries, PTSD, because there's still a lot to learn there. We want to be able to develop innovative practices and best practices, advance and build on what we're doing already, and provide education, and not just education internally for our own OSI network. This will generate knowledge that any care provider in the country who's looking after a veteran or someone dealing with PTSD can come to as a resource. It will be a centre of excellence that will generate that level of knowledge and expertise.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair.

Thank you, again, for coming.

Mr. Doiron, we've heard a lot about veterans transitioning out of the military and finding what's referred to as the “new normal”. We've heard about the complex system at VAC. Navigating the services and benefits can be a burden. It can weigh heavily on some of these veterans.

What's your department doing to help veterans in this regard, from the navigation standpoint?

[Michel Doiron]

Thank you, Mr. Chair, for the question.

It is true that our system is hard to navigate. There are a lot of policies, programs, and processes. There are a couple of things we are doing to address that.

The first thing we've undertaken is something called the service delivery review, which is looking at how we can simplify our processes and improve transition, because it is a mandate of the minister, as associate minister of National Defence, to eliminate that seam to the extent we can. However, more concretely, what we are doing, and we're piloting it right now, is looking at something we're calling “guided support”, but I like your term of “navigator”.

What we're realizing is that when a soldier gets ready to release, they don't know our programs. They may start talking to a military case manager and they may start talking to one of our case managers, but they don't know the programs. This guided support would be meeting with a Veterans Affairs employee during transition, and that employee would go through their entire file, what we think they're entitled to, and even trying to get the cases adjudicated before they're release from the armed forces.

It does not mean they would not come back five, 10, or 50 years later. We have people who show up 50 years after release, but at least if you're moving to a certain part of the country and you have special needs and maybe you'd have a hard time receiving the specialized medical help you need, you would know if you eligible for a disability or what type of employment opportunities there are. That's why we're calling it “guided support” or the “navigator”. It's to get them better suited for transition, because we know that 27% of the people transitioning have a hard time. Most of them transition well, but 27% do not.

The reason we're concentrating on this is that we've concentrated a lot on the medically releasing individuals. We've been doing a lot of work in transition in eliminating the seam for the medically releasing individuals. We just realized, because our researchers had done some work on it, that of that 27%, 60% are actually non-medically released people who are having a hard time. We've been concentrating on the medically releasing, and now we have to make sure we're taking care of the non-medically.

Most of them want to be released with their head high, no stigma, but then they realize when they get into the Canadian population, it's a little different.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

All right. Thank you.

Mr. Kitchen had asked about the centres of excellence. I know you've said there's a lot that you can't talk about right now because of the situation. Is there anything that you can share with us at this point on the types of centres or how these centres would assist veterans?

[Michel Doiron]

We have a lot of centres presently helping veterans. There are the OSIs, and my colleague on Tuesday night was talking about Ste. Anne's and some of the expertise we have.

I think the OSI clinics are actually recognized even internationally. I thank the member for her comment, I believe it was yesterday, about Parkwood. It's true; we have very good OSI clinics that have very specific expertise.

In addition, we partner with CAF. I think we all know that CAF has a partnership with the Royal Ottawa, and we're going to piggyback on that to ensure that expertise is not lost.

[Dr. Cyd Courchesne]

Again, we work closely with our CAF colleagues. They have a chair in military mental health at the Royal Ottawa. We have our OSI clinic at the Royal Ottawa. They have an institute of research and several chairs looking at sleep and PTSD, and suicide. We want, through our CAF partners, to be able to tap into that expertise.

Nonetheless, we're exploring all options, again, in consultation with the veteran stakeholders and the minister's mental health advisory group, which has representation from national mental health organizations, like the Mental Health Commission of Canada, to make sure that what we propose is going to capture the most expertise.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

All right, thank you.

VAC has a partnership with the Canadian Institute for Military and Veteran Health Research. In your opinion, what are the areas of research that you think need the most attention?

[Michel Doiron]

I think mental health absolutely. This committee has been studying mental health. There's a lot more we can learn on mental health, and its entire complexity. I'm not a psychiatrist or a doctor, but it's clear to me that there's still a lot of work do to. I know Public Safety is working on the first responders also, and we're collaborating with them to ensure that is not lost.

I also think there are issues on the pain management side. Often we see mental health issues related to pain, and how we handle pain. I don't know if there's any research right now.

There are a lot of nice things out there—and VAC has been really investing in this—that people say help. They seem to help, but I think the research is not always there behind them. I know it's been in the media this week, but there are things like the entire service dog issue. We absolutely know it helps, but let's make sure we have the right evidence. That one is more advanced, but there's equine therapy and things like that. Those are all areas I think CIMVHR could be looking into.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Great. Thank you.

[The Chair, Liberal, Neil Ellis]

Thank you.

Ms. Mathyssen.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Thank you, Mr. Chair.

Thank you very much for noticing the comments about Parkwood. We are very proud of it in London. I don't think a day goes by without someone indicating how very significant it is as a facility in their lives to help them and their families. We're very lucky to have Parkwood.

Thank you for being here.

I wanted to ask a few questions in regard to veterans who, unfortunately, have committed suicide. I wonder, do you track the suicide rate at all in regard to the veterans who are served by Veterans Affairs?

[Dr. Cyd Courchesne]

Thank you for your question.

I just wanted to add that your comments were a great morale booster for the clinic. We had lots of feedback from them, so thank you very much. It's good for them to hear some good recognition.

With respect to suicide in the veteran population—and this more in the realm of our directorate of research—if a veteran is in our care and they commit suicide, we know about that, so we can track that part of the population that we serve, which is about a third of all the veterans who are in Canada. What we have difficulty tracking is those who are not in direct receipt of our services. That doesn't mean that we can't; it's just that it's difficult. Our researchers work with the Canadian Armed Forces and with Statistics Canada to try to capture that information.

That information is not available on a punctual basis. They have to do it over several years to try to track and report. The next report on the CAF and veterans mortality study is going to be released in 2017. Right now we have rates up to 2013. They go in three- to four-year cycles to gather that data, but it's difficult for us to track it because, unlike the Canadian Forces, we're not a health care system. They're not our patients, so it happens a little bit outside of our reach.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Right. You would need those external experts, like psychologists and psychiatrists, to help to understand if there was a pattern or something significant that you could learn from in terms of knowing what's going on out there.

[Dr. Cyd Courchesne]

Because veterans receive their health care in their communities, under their own provincial health authorities, we don't have access. We have no right to have access to that type of information unless it's shared with us. Our review and analysis is only based on what we know of the veteran, but it's an incomplete picture, unlike for our colleagues in the Canadian Forces, who have the entire medical record and can go more in depth. But, again, with the help of Statistics Canada and with the CAF, we can paint as complete a picture as we can.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

I imagine that would be very useful in addressing that tragedy among our veterans.

The figure of 4,000 professionals providing mental health care has been utilized. Is that 4,000 enough? Do you need more?

We tend to think of psychiatrists being the first group that we go to. Has the department looked into other providers, like psychologists?

I ask this because I had a meeting very recently with the London Regional Psychological Association and they said very clearly that they would love to be of assistance to our veterans but they didn't know how to reach out and provide that kind of support.

[Dr. Cyd Courchesne]

The 4,000 providers in the community are a mix. There are psychologists and social workers. We have occupational therapists who work in clinical care manager roles, so they're not just psychiatrists. It covers a wide range of services because, as you said, everybody doesn't need to see a psychiatrist. If they have a mental health condition there are many more professionals out there who can assist.

With respect to if we have enough psychologists, the CEO of the Canadian Psychological Association is on the mental health advisory committee and they communicate with their entire membership. They know that our third-party administrator, Medavie Blue Cross, registers providers, so there is no limit to how many people can register to become a provider in communities across Canada.