OHS Canada Magazine

Feature

Out of the Shadows

The passing of legislation presuming that post-traumatic stress disorder among Ontario’s first responders is work-related points to a growing recognition across Canada that occupational injuries are not just physical.


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Rae-Lynne Dicks remembers in vivid detail the call she took on May 8, 2000, while working as a 9-1-1 communications operator and dispatcher in Vancouver. Following a hang-up dial — a common occurrence in the phone room — she called back the number several times before a young man answered. He explained that he had attempted suicide by sticking a knife deep into his gut and had barricaded his front door. He was bleeding profusely and wanted to ensure that his body would not be left for days before being found.

“But above and beyond that, he was scared to die,” Dicks says. “He didn’t want to die alone.”

When police arrived at the scene, instead of hanging up the phone as Dicks was trained to do, she stayed on the line. The young man was not communicating with the police, who had their guns trained on him, so Dicks got his attention by yelling into the receiver. She convinced him to listen to the officers and leave his home. At that point, Dicks heard the officers jump onto the man and wrestle his knife away.

Dicks left the room crying. “I had never heard someone get taken down like that when they are injured,” she says. To this day, Dicks does not know if that man lived or died. In the years that followed, the incident has been the subject of many nightmares and flashbacks.

Not long after taking that call, Dicks moved to a part-time auxiliary role in which she could decide when she was available to work, due to distress. She attributes her failed marriage to the trauma associated with that call. By 2002, she was experiencing night terrors, having difficulty sleeping and diagnosed with post-traumatic stress disorder (PTSD) by a psychiatrist. Within a year, she returned to a full-time role as a call-taker and dispatcher. But in 2004, she received a call that triggered memories of the initial incident. At that moment, she says, she could not see the large, red button on her console used to make third-party calls. Panicked, she left the room in tears.

Dicks’ attempts to claim workers’ compensation for her disorder were unsuccessful. “They told me that I was trying to blame my horrible marriage on my job,” she says, “when the reality is [that] the trauma I experienced at my job caused me an injury. And yeah, my marriage was not strong enough to withstand it.”

According to Dicks, the board noted that she was upset about work assignments. But she clarifies that she was angry because her employer had disregarded a note from her doctor advising that she stay on fire-department calls, rather than return to the policing team.

Following the dispute, Dicks left her job. She says she still experiences significant cognitive impairment and aversion to conflict and has trouble sleeping. At her lowest point, she tried to end her life. Dicks believes that had she been awarded workers’ compensation benefits, she would have received proper treatment from a psychologist and been able to continue working in an accommodated role until her retirement. Today, she works part-time at a grocery store in a small town in British Columbia’s Okanagan Valley.

Chicken or egg?

Historically, PTSD has been associated with military veterans. With growing awareness of workplace mental-health issues, the potential for PTSD to be attributed to traumatic events experienced in other professions is gaining traction.

Some provinces are taking steps to address occupational PTSD. In 2012, Alberta became the first province to introduce presumptive coverage for PTSD in first responders. Manitoba extended similar presumptive coverage to all workers with work-related PTSD in January of this year. Ontario was the latest to jump on the bandwagon on February 1, when it announced a new PTSD strategy for first responders.

While job-related psychological injuries are generally covered under workers’ compensation in jurisdictions across Canada, with presumptive legislation, employees who get PTSD following a traumatic workplace event would not be required to prove that their work was the cause of the disorder.

“It is almost impossible to prove that you came down with post-traumatic stress disorder from your job. You can imagine that trying to do so is re-traumatizing, in a sense, and has been described as such by many folks who have gone through it,” explains Ontario MPP Cheri DiNovo from Toronto. She has been trying to pass legislation for presumptive coverage of PTSD in first responders since 2010.

“It becomes kind of a chicken-and-egg exercise,” DiNovo says. “Did your marriage split up because you had PTSD, or did you have PTSD because your marriage split up and you also witnessed a trauma over and over again?”

She equates the PTSD bill to presumptive legislation for firefighters who have been diagnosed with cancer. In 2014, the province reversed the burden of proof for firefighters with certain types of cancer. Although very few firefighters develop cancer, the burden of proof is no longer on these workers to show that the disease was the result of exposure to occupational factors, such as chemical fires.

After tabling DiNovo’s bill several times, the Ontario government introduced its own legislation on February 18. The bill was passed on April 5. Now, the Supporting Ontario’s First Responders Act (Posttraumatic Stress Disorder), 2016 gives presumptive coverage to police officers, firefighters, paramedics, communications officers, dispatchers and workers in correctional institutions, secure custody facilities, ambulance services and First Nations emergency-response teams.

On the frontline

While the development of PTSD does not appear to be common among first responders, their prevalence rates may be higher than in other professions, since they are responding to traumatic events daily. Experiencing a traumatic event or hearing about the trauma of a loved one is one criterion needed to make a PTSD diagnosis.

First responders are twice as likely as the general population to suffer PTSD, according to the Government of Ontario. Information from the Tema Conter Memorial Trust, which provides peer support, family assistance and training to public-safety and military personnel with PTSD, shows that there were 39 suicides among first responders across the country in 2015. While statistics on first responders with PTSD are not available, the disorder may be a contributing factor to suicides within the profession.

In Manitoba, PTSD represents a small fraction of workers’ compensation claims. In 2014 — the most recent year for which data is available — 10 successful claims were made and four were disallowed out of 30,202 reported injuries. The previous year, 10 successful claims were made, while three were disallowed out of 29,777 injuries. The numbers above may not include PTSD claims that were made after a physical injury.

“Traumatic events aren’t all that common. It takes a significant trauma to create a psychological injury,” says Warren Preece, communications director for the Workers’ Compensation Board (WCB) of Manitoba. “Of course, it is different for every person.”

The claims process can take as “short as a few days” and “as long as months,” according to Preece. Cases in which a worker has developed symptoms of PTSD many years after experiencing a traumatic incident are more difficult to adjudicate, he notes.

Prevent and cure

While Alberta, Manitoba and Ontario have become frontrunners in recognizing occupational PTSD, Manitoba’s new bill took things one step further by extending presumptive coverage to all workers eligible under the WCB who have been diagnosed with PTSD by a medical professional.

According to a spokesperson for the Manitoba government, Manitoba’s bill was conceived through consultation with firefighters, police, nurses and public-sector unions. “When someone experiences a traumatic incident in the workplace, we want to ensure that they don’t suffer in silence,” he says. “Presumption allows them to get [the] treatment and support they need to deal with traumatic incidents quickly.”

Preece says the board expects a “small bump” in claims as a result of the new legislation, but he assures that it is unlikely to lead to an increase in the average assessment rate. “We are in a strong financial position here in Manitoba. So we have got very healthy reserves, enough to accommodate some extra costs without affecting the average rate.”

But the Canadian Federation of Independent Business (CFIB) is concerned about the potential change in costs. “The provincial government has said that the cost will be manageable and they shouldn’t affect premiums, but we haven’t seen any fully-costed explanations,” counters Elliot Sims, director of Manitoba provincial affairs for the CFIB in Winnipeg.

Even if costs are manageable to the system overall, small-business owners may need to devote additional resources to get up to speed on the requirements of the new legislation and dispute claims that may arise. He adds that this new approach to claims will shift certain responsibilities that were previously under the purview of the WCB onto employers. According to Sims, Manitoba is one of four provinces in which the workers’ compensation board does not have an employer’s advocate office to assist employers with their claims.

But Preece thinks that this concern is unfounded. “Our duty to adjudicate remains,” Preece explains, clarifying that the duty to investigate PTSD claims remains with the board. “It is just that if it ends up being a toss-up between where do we think the source of the traumatic event was or is, then the presumption pushes us towards it happening at work.”

The investigation includes gathering information from the worker, such as whether other factors outside of work may have contributed to their symptoms, the mental-health provider’s diagnosis and doctors’ reports, if available. “If it turns out that in your history you have had other traumatic incidents that could be responsible for your PTSD, then it is possible that your claim could be rebutted or we could say, ‘No, this isn’t work-related,’” Preece says.

For Sims, it is important to ensure that a process is in place to adjudicate such matters. “There might be all sorts of other factors and conditions and situations that that person may have encountered outside of the workplace that may have triggered the PTSD or caused it to occur.”

While it is important to help those who have developed PTSD as a result of their professions, efforts must also be made towards prevention. “Let’s fix them before they get there,” stresses Paul Charbonneau, director of emergency and transportation services and chief of paramedic services for the County of Frontenac in eastern Ontario.

For Charbonneau, presumptive coverage is “a political answer to only one area of concern about mental wellness.” He sees PTSD on one end of a spectrum of mental-health conditions and would like mental-wellness training to be incorporated into paramedics’ education in colleges. Employers should also provide programs that deal with these issues.

Robin Bender, a mental-health first-aid trainer and founder of Mega Health at Work Inc. in Waterloo, Ontario, agrees. “Where we should be focusing, in my view, is on the prevention side, on the wellness side — investing money on people’s health and awareness and education around trauma and how to prevent PTSD.”

In Frontenac County, a paramedic who has responded to a traumatic call is taken off duty so that he or she can decompress. The county also offers a peer-support program in which paramedics are paid to counsel co-workers during their spare time. Also available are an employee-assistance program, a list of psychologists who can be booked for appointments and benefit coverage for sessions with psychologists and psychiatrists.

Charbonneau says employers have an obligation to put tools in place to help workers overcome mental-health stigma, but unions, too, have a role to play. “I see a lot of blaming about [how] management isn’t doing enough. Well, what are the unions doing?”

A long way

Recognizing PTSD has come a long way since Charbonneau, as a young paramedic, arrived at the University of Toronto where a student had fallen off the roof on March 17, 1975. “I didn’t really think I was going to see that kind of stuff on the job. Maybe I was naive. It bothered me,” he recounts. “I told my partner about it when we got to Toronto General [Hospital]. His exact words were, ‘Suck it up, buttercup. What the hell did you think you were going to see being a paramedic?’”

Thirteen years later, former paramedic Vince Savoia says PTSD was still unheard of within the field. That was when Savoia encountered 25-year-old Tema Conter lifeless on her bed after being raped and murdered in her Toronto apartment. It was his sixth year as a paramedic. “When I pulled back the bed sheets to do my patient assessment, that was when I froze, because when I looked at Tema for the first time, I thought it was my fiancée.”

After that call, Savoia developed anger issues, had difficulty making decisions and became socially withdrawn and emotionally fragile. “I would cry at the top of the dime,” recalls Savoia, who also developed hyper-vigilance. “I started to become extremely overprotective, almost a paranoid state of trying to protect my wife and my kids from danger.”

Getting the Word Out

When it comes to workplace mental health, many employers are clueless, according to Robin Bender, founder of Mega Health at Work Inc., a Waterloo, Ontario-based training and consulting company offering workshops on workplace mental health and wellness. She says that it took 15 years of working as a disability manager before she finally received training on mental illness from the Canadian Mental Health Commission (CMHC).

“If you don’t know what PTSD is,” Benders says, “how are you going to manage it?” She adds that employers have a responsibility to educate themselves on mental-health issues.

Bender believes that every university and college should train students in mental-health first aid. Through the CMHC, her consultancy firm offers a two-day certification program that teaches participants how to support someone who is struggling with mental illness, as well as provide information about various disorders, including risk factors, symptoms, behaviours and warning signs.

Among first responders and nurses, she says there is a lot of stigma surrounding mental illness, because they see themselves as “helpers”. For healthcare workers who suffer from mental-health issues, each case is handled differently. For example, Bender notes that many people with PTSD can continue to work, because they can manage their symptoms, while others may be waiting for treatment. As well, each worker may be at a different stage in recovery, depending on when they were diagnosed and if they have been in active treatment.

If the worker has taken time off work due to PTSD, the return-to-work process should be a collaborative effort between the employer and the employee, as well as the union if the workplace is unionized. And ongoing communication is vital, Bender advises. Often, employers do not work with employees to create a plan that gradually returns them to their pre-injury positions. She recommends regular meetings between the employer and worker, so that the former can find out what support the worker needs in the return-to-work process.

For paramedics and police officers, one modification that can be made for a worker suffering from PTSD is to put them on lower-priority calls, which are generally less traumatic, before gradually increasing their exposure to higher-priority calls. “But you need the on-boarding and assistance of the person [and] their treating professional,” she stresses. “You, as an employer, are no expert and doctor to be able to make those calls.”

Another classic symptom of PTSD is the questioning of one’s morals and values. Savoia calls this a “spiritual” symptom of the disorder, which can cause a person to question why misfortune befalls good people. “That is when something like PTSD becomes extremely difficult to handle, because your morals and values may be shattered. You just can’t make heads or tails as to why circumstances are what they are.”

Four years after that call, Savoia decided to leave emergency medical services and went into the financial-planning field. He says he had no idea at the time that he had PTSD. “I did not make any claims at WSIB. It just wasn’t spoken about. I didn’t tell anybody about it. I kept it quiet.”

But he never forgot Conter. In 2001, he founded the Tema Conter Memorial Trust in her name. The organization offers $30,000 in scholarships annually to public-safety students conducting research on acute stress, compassion fatigue, vicarious trauma and post-traumatic stress. It also provides a support line for first responders, a mental-health-referral program and a family- and peer-support assistance fund for mental-health services. This fall, the organization will launch an online first-responder trauma-management and -recovery program with Simon Fraser University.

Moving forward

Savoia and his organization applaud Ontario Labour Minister Kevin Flynn for the province’s new PTSD strategy. He says giving presumptive coverage to first responders is a good start, although he considers the recently introduced presumption that applies to all workers in Manitoba “the gold standard.”

Savoia suggests that raising awareness through training and education is as important as making available measures that take care of first responders after they have been traumatized. “You can’t prevent PTSD,” he says, “because PTSD is normally caused by one experiencing a traumatic event that is outside of their normal range of experience.”

He encourages all first responders, especially those who are new to the profession, to see a therapist every six months. “By visiting a mental-health professional when you are healthy, you can now establish a baseline for future claims,” he advises. In the event that PTSD does develop, the first responder can follow up with the same mental-health professional and get the proper care and support needed.

Charbonneau has developed several mechanisms for coping with traumatic incidents over four decades in the paramedical field. He seeks support from his wife and colleagues and, when necessary, uses his employee-assistance program. “You talk about it, you compartmentalize it.”

But Charbonneau continues to be disturbed by some of the things he saw on the job. Soon after the birth of his first child, he was called to the scene of a murder-suicide where a woman had jumped off a bridge in Toronto with her baby.

“I was just so excited about having a baby and a son that I couldn’t comprehend why would a mother do that. But it wasn’t mine to comprehend,” he says. “I have to deal with it, but I can’t own it.”

Carmelle Wolfson is a writer in Toronto.