Healing the mind

Winnipeg clinic uses MBTelehealth to help treat PTSD patients closer to home

Operational Stress Injury Clinic team members, from left: Marnie Smith, Stan Yaren, Chris Enns, Debbie Whitney, Amber Gilberto, David Podnar and Kristjan Sigurdson.
Operational Stress Injury Clinic team members, from left: Marnie Smith, Stan Yaren, Chris Enns, Debbie Whitney, Amber Gilberto, David Podnar and Kristjan Sigurdson.
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What is post-traumatic
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About MBTelehealth

Winnipeg Health Region
Wave, March / April 2015

An RCMP officer for more than a decade, Janet Smith always considered herself to be tough enough to withstand the physical and emotional rigours of the job.

Then about five years ago, Smith (not her real name) started to realize that she might not be as tough as she had thought.

The first hint came when she began experiencing bouts of insomnia. When she did sleep she would have nightmares about terrible events she witnessed on the job, particularly one involving a little girl who died in a traffic collision.

"There would be panic, fear . . . and abrupt awakenings only to see faces in the corner of the room staring at me, and the outline of a little girl who died in a traffic collision, same age as my own daughter," she says.

She soon became preoccupied with the need to protect her children from some unknown harm.

"I felt like I was on constant duty, checking the doors and windows, and patrolling the house to make sure my kids were safe," says Smith. "Never in my wildest dreams did I think something like that would happen to me."

Smith did not realize it at the time, but she was experiencing some of the symptoms of post-traumatic stress disorder - or PTSD for short. The condition is defined by a cluster of mental and physical symptoms that can arise from exposure to horrific events and is known to affect large numbers of first responders, including RCMP officers and military personnel.

Eventually, Smith would find herself at the Operational Stress Injury (OSI) Clinic at Deer Lodge Centre in Winnipeg, one of 10 such clinics established across the country to treat patients with PTSD.

The clinic is staffed with a team of health-care professionals that includes nurses, social workers, psychologists and psychiatrists who provide mental health services such as one-on-one therapy to patients requiring help to heal the unseen wounds that are life-altering and, in some cases, life-threatening.

"We provide occupational health care for veterans and RCMP," says Dr. Debbie Whitney, a psychologist and clinical coordinator at the clinic. "If you develop a mental health difficulty as a result of the work you were tasked to do, then you come here for treatment."

In addition to accessing expert care, Smith learned that she would not have to make the three-hour trip from her home in rural Manitoba to Winnipeg once a week to receive it. That's because the OSI clinic is one of several in the city that uses MBTelehealth.

An ongoing program of the Winnipeg Health Region, telehealth provides access to high-speed videoconferencing to more than 140 sites around the province, allowing patients to receive care from health-care providers in Winnipeg and other regional health centres. In Smith's case, she is able to access telehealth in a clinic about 20 minutes from where she lives.

The OSI clinic network was established in 2001 (the Winnipeg clinic opened in 2004) to deal with the rising tide of PTSD cases among military and RCMP members.

A 2013 Statistics Canada survey of mental health within the Canadian Forces found that about five per cent of Canadian soldiers have PTSD - a number that has almost doubled since 2002, in no small part after soldiers began returning home from the war in Afghanistan, suffering its emotional toll. Between 2004 and 2014, 160 military personnel committed suicide, compared to 138 killed in combat over the same time period, according to the Department of Defence.

In Manitoba, the death of Ken Barker, a retired RCMP officer who committed suicide in 2014 after struggling with PTSD, raised awareness about the problem among current and retired members of the force. It has since been reported that 31 serving or retired members of the RCMP across Canada have taken their own lives in the last nine years.

While it's impossible to link PTSD to all of these deaths, Whitney says suicide is indeed a very real risk for sufferers if they do not get the help they need, which is why telehealth is such an important service.

"If you're (a soldier) stationed in Shilo, for example, you would otherwise have to drive two-and-a-half hours to come here and then drive two-and-half hours to go home," Whitney says. "You basically have to spend an entire day to be in treatment for an hour or 90 minutes."

Research carried out at the Winnipeg clinic by Whitney and other mental health professionals has shown that telehealth therapy for PTSD patients is an effective alternative to face-toface treatment. More importantly, the research shows the telehealth program serves as an important lifeline for those who would otherwise be unable to receive the care they need.

"We looked at the literature, but we also looked to our own clients to participate in a study of treatment effectiveness. Of 16 matched cases comparing in-person to telehealth treatment, clients reported equally good results with telehealth," says Whitney, also an assistant professor in the Department of Clinical Health Psychology at the College of Medicine, Faculty of Health Sciences, University of Manitoba.

This method allowed researchers to measure how patients receiving face-to- face care fared compared to those receiving it via telehealth. Rather than going to sessions at an OSI clinic, telehealth patients would visit a healthcare centre close to where they live, and receive therapy via a high-quality video link from a therapist at the clinic in Winnipeg.

"Over time, we looked at change in their PTSD symptoms, and what we found was the video conference therapy was effective."

Surveyed patients receiving telehealth therapy indicated they did not experience more significant symptoms of PTSD than those receiving it face-to-face. Moreover, they reported improvement in their mental health similar to those receiving in-person help at the clinic.

Whitney says the results are encouraging because it means practitioners can provide care effectively over a wide geographical area - the raison d'etre of the telehealth program.

"Our goal was we wanted to increase access, but we also wanted it to be safe and private," she says. "And it needed to be of sufficient video and audio quality that you could just talk and forget that you are communicating through a computer."

The telehealth program has turned out to be a boon for dozens of the approximately 250 patients at the OSI Clinic in Winnipeg, including Smith.

As a single mom, Smith found the threehour drive to Winnipeg onerous. Trips involved taking days off work and making arrangements for babysitters, but they were more than an inconvenience.

"Just the thought of leaving my home was dreadful to me," she says. "The fear of going into Winnipeg - oh my god! - it was unreal."

This is a common experience among many PTSD patients, Whitney says. As a result of witnessing or being subjected to one or several traumatic events, PTSD sufferers generally have a profound sense that they had no control over what has happened to them. And it's a feeling that can be hard to shake, persisting into their civilian lives.

"You don't decide you are going to have PTSD. The brain decides," Whitney says. "It retains that memory of the traumatic event differently from normal memories."

These memories tend be more vivid, and difficult to suppress. And certain environments trigger the memories as if they're being experienced all over again.

Consequently, PTSD sufferers can go into a state of high stress called the flight or fight response.

"Anything that reminds you of that event - sounds, smells and visual stimulation: a car the same colour; your brain automatically goes, 'Oh, oh!' and then initiates a cascade of chemical reactions," Whitney explains.

Busy, crowded and chaotic places often unleash a torrent of unpleasant, raw emotions associated with the traumatic events they experienced, Whitney says.

"Obviously, it's very unpleasant and uncomfortable and over time, people start to withdraw from those situations."

Many suffer from other mental health problems too: depression, anxiety and substance abuse.

What's more distressing is they generally are not aware of what is happening to them. In fact, the change in behaviour and their mental health can be gradual, taking weeks, months and even years to become deeply problematic.

Other than its location and the fact that it's delivered over a secure Internet network, Smith and the many other OSI patients' telehealth experience does not differ radically from face-to-face care.

"We're using the same treatments like prolonged exposure, which is a kind of cognitive behavioural therapy," Whitney says. "That's where we review in memory traumatic events from the past, and then have patients slowly expose themselves to day-to-day reminders of these traumas. The reminders, though emotionally agitating, are probably things they want to get used to in order to live comfortable, normal lives."

Whether face-to-face or by telehealth, this kind of therapy generally involves a two-step process.

One, they get used to holding the bad memory in their minds so they can understand and analyze their feelings surrounding the experience.

It can be a difficult process because these memories release unpleasant emotional and physical sensations. That's why it's important to do this in privacy and safety. Initially practitioners were concerned whether telehealth could provide this.

Yet because telehealth locations within health-care facilities are private and set off from the rest of a health clinic, most patients indeed felt safe during sessions, Whitney says.

The second part involves patients slowly immersing themselves in situations where they are going to encounter reminders that can trigger their PTSD.

"For example, that may be driving, going to a movie, going to the mall or anywhere with a lot of people and loud noises," Whitney says. "It's done in a planned, gradual and thoughtful way - not saying to someone whose PTSD is set off by driving in traffic to go drive down Portage Avenue in rush hour to face their fears."

This, too, does not require face-to-face sessions because patients can do this on their own terms in small steps, working their way toward a goal like going to a big box store in the city.

Whitney likens this to getting over a fear of water by first wading into the shallow end and slowly venturing deeper into the pool rather than jumping into deep water and struggling to keep your head above water.

Other effective therapies, like eye movement desensitization and reprocessing (EMDR), involve learning to activate different parts of the brain that reinforce positive emotional states when negative feelings are triggered by PTSD. EMDR via telehealth is done with a device held in both hands that provides alternating vibration and stimulates both sides of the brain.

Yet perhaps the most important part of therapy is the diagnosis itself.

"The diagnosis was a major breakthrough," Smith says. "Being an A-type personality, I felt I could take everything on and not being able to do that, and not being able to put a name to the condition - I was always thinking I was weak."

But her telehealth therapy session with OSI helped her realize that weakness and personality have little to do with who gets PTSD.

"It affects everybody differently," she says. "For me, I'm my own harshest critic, but instead of thinking I was losing my grip on reality, somebody came along and said, 'No, there's a name for it and this is why - because of these incidents you've gone through for the last 15 years, you are where you are today.'"

And the telehealth program has proven instrumental to Smith's and dozens of others' recovery so they can return to some semblance of normalcy.

"Just having that option of not having to drive that far outside my comfort zone has been a saviour to me," Smith says.

Whitney and other mental health-care providers often hear similar responses from other telehealth patients at OSI.

"The general response has been, 'I might prefer face-to-face, but this is pretty darn good, and it sure is a lot better than having to take a whole day to come to the clinic, or missing appointments because it was too hard to schedule.'"

While patients find telehealth treatment helpful, many practitioners still worry about adverse reactions, like thoughts of suicide, when patients are treated at a distance.

"We don't have established base rates for the frequency of adverse events in face-to-face therapy so we can't be certain if there are comparable rates for telehealth treatment, but so far, it appears there aren't more adverse events in a telehealth setting," Whitney says. "Finding out if patients' risks are similar with both modes of treatment is the next step in the research."

In the meantime, patients like Smith will continue to benefit from therapy using telehealth as they work to overcome the effects of PTSD.

Joel Schlesinger is a Winnipeg writer.

Wave: March / April 2015

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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