Traumatic Stress Disorder
Post Traumatic Stress Disorder Intervention in Law Enforcement:
Posttraumatic intervention protocols have come a long way in policing. This article challenges reliance on pathogenic intervention approaches which may script police officers into traumatic symptoms. By scripting , we mean that pathogenic methods, rigid techniques, and strong group participation can cognitively re-structure an individual's perceptions about trauma symptoms. A pathogenic model that not only assumes trauma symptomatology but also provides an immediate, rigidly defined remedy is thus very attractive to many police agencies. These approaches may well overwhelm the personal positive strength, resiliency, and potential of officers for growth and trauma resolution.
Post Traumatic Stress Disorder Intervention in Law Enforcement:
Police officers are exposed to traumatic events in their work on a continuous basis. Expectations of trauma are ever present among officers, and police training emphasizes how to deal with the worst case scenario event at work. As a result, police officers are at risk for the development of post traumatic stress disorder (PTSD). Intervention protocols have come a long way in policing, with mental health professionals attempting to help police officers deal with traumatic adversity in their work and lives. But, have we accomplished the worthy goal of assisting officers to deal with traumatic stress? Have we intervened properly and effectively enough to bring about psychological well-being, or have we made the problem worse?
This article challenges reliance on pathogenic intervention approaches which may script police officers into traumatic symptoms. By scripting , we mean that pathogenic methods, rigid techniques, and strong group participation can cognitively re-structure an individual's perceptions about trauma symptoms. Pathogenesis presupposes the sick role. In other words, if the officer weren't sick (i.e., affected by trauma), they wouldn't be at an intervention in the first place.
A second problem concerns the ready acceptance of pathogenic approaches. Contingents of police agencies, firefighters, emergency and disaster workers, and others exposed to traumatic incidents are all looking for a quick fix to this problem. This is not necessarily wrong, but precisely what is accepted for this fix can have an impact on exposed individuals. A pathogenic model that not only assumes trauma symptomatology but also provides an immediate, rigidly defined remedy is thus very attractive. Many police agencies are attracted by the expediency and convenience of such approaches.
This article approaches the process of police traumatic stress intervention from a different perspective. The officer can be viewed as a resilient active agent in the process of healing, along with supportive help of professionals. If we attempt to script police officers into a passive sick role, we may well overwhelm their personal positive strength, resiliency, and potential for growth.
First, we outline attributes of current pathogenic intervention methodology. Second, we discuss an individual adoption of the sick role facilitated by pathogenic approaches. Third is a discussion of salutogenic approaches to intervention and how individual qualities such as coping abilities, hardiness and resiliency may affect trauma exposure outcomes.
The process of trauma intervention developed in response to an increasing public perception that trauma affects a large number of people. Trauma intervention gathered its largest impetus from emergency service occupations, such as police, firefighters, and emergency workers, where individuals are chronically exposed to traumatic incidents. These interventions have two purposes: (1) to allow individuals to talk about the traumatic incident; and (2) to facilitate a discussion among participants so that they could be educated about stress reactions, personal strategies and counseling resources. Mitchell (1983) first termed this type of intervention process as Critical Incident Stress Debriefing (CISD), and popularized its use throughout many occupations highly exposed to traumatic incidents.
A number of studies have been undertaken to substantiate the efficacy of post trauma interventions. Research has found that police officers, firefighters, rescue personnel, and emergency medical workers do develop Posttraumatic Stress Disorder in relation to duty exposure, but not universally (Violanti, 1996). Some studies suggest that immediate trauma intervention represents reasonable care for mental injuries sustained in occupational roles exposed to traumatic events (Dunning, 1998, in press). Many studies have demonstrated that brief trauma intervention such as CISD works well in ameliorating symptoms (Mitchell & Bray, 1990; Mitchell & Everly, 1995; Robinson & Mitchell, 1993). Other research, however, has found that brief intervention may not be effective. Busuttil and Busuttil (1995) found that the presentation of traumatic material during intervention may serve as a retraumatization for some. Bisson and Deahl (1994) suggest that brief interventions at best may afford some protection against later psychological sequelae, but at worst make no difference. Deahl and Bisson (1995) suggest that there are a lack of controlled studies supporting the efficacy of brief trauma interventions. Carlier, Lamberts, Van Uchelen, and Gersons (1998) found no difference over time in trauma symptomatology between groups who received brief intervention and those that did not. Tucker, Pfefferbaum, Vincent, Boehler, and Nixon (1998) results seriously question the wisdom of advocating brief trauma intervention. Rapheal, Meldrum, and McFarlane (1996) suggest that brief intervention meets symbolic needs after trauma, but that it negates the need for more individualized longer term treatment. Kebardy, Webster, Lewin, Carr, Hazell, and Carter (1996) found that brief intervention made no difference among 195 disaster workers in Australia. Dyregrov (1997) suggested that their be a continued exploration of brief intervention process issues.
The majority of studies on brief intervention models seem to indicate that more research is needed to clarify the impact on trauma symptoms. In some of the studies mentioned above, such intervention made no difference or actually worsened symptoms in police officers.
The sick role is a social role which one assumes when they perceive that they not in good health. The concept was first introduced by Parsons (1951) in an effort to explain socialization influence on medical patients. A primary factor determining the extent of sick role adherence is the doctor-patient relationship. As Gartly (1979) has established, the doctor is the expert in medicine and the patient is the novice. Thus, the doctor has a distinct advantage in defining whether or not the patient is sick. Given this advantage, most individuals will strive to be good patients (Gartly, 1979). Patients seek to fulfill the sick role by being complacent, trusting, respectful, and confident in the doctor's diagnosis (Maykovich, 1980). In essence, the paradigm of sick role is based on illness as acquiescence and the physician as an agent of social control (Gallagher, 1976; Kronenfield & Glik, 1989). The notion of the sick role has also been applied to mental health (Barginsky, Braginsky, & Ring, 1969; Goffman, 1971; Segall, 1979). Goffman's (1971) classic insanity of place describes the socialization process of becoming labeled and classified as mentally ill.
The use of pathogenic models to intervene in trauma may produce an effect on individuals similar to sick role socialization. Pathogenesis assumes sickness; persons are present at sessions because they have exposed to trauma and are presumed ill with trauma symptoms. The mental health professional conducting the intervention is viewed by participants as experts who can cure them, much as the doctor is during medical diagnosis. Persons who attend are urged to fulfill the requirements of the pathogenic intervention (e.g., to cooperate, trust, and respect) much like medical patients (Kronenfield & Glik, 1989). This , in essence makes them patients who are presumed ill and in need of care. Following the script is the way out of professed suffering from traumatic stress.
The sick role has its benefits, both individually and politically. An increasing number of police officers, for example, are being retired on stress disability due to job exposure to traumatic incidents. Such disabilities may be financially lucrative for individuals (Manocchia, Keller & Ware, 1997). In one state, police officers retired for psychological disability receive two-thirds of their pay for the rest of their lives. Most of these officers may legitimately deserve such disability, but the force of pathogenic trauma intervention may erroneously place them in such situations.
Politically, pathogenic models can also legitimize an organization's efforts to deal with trauma among its members. Over the past fifteen years, many police agencies have initiated employee assistance programs and teams to help officers exposed to stress and trauma in their work. While many of these programs are worthwhile, they sometimes serve as facades for organizations to demonstrate that they are doing something about trauma. The organization may fear liability issues, or may be pressured to fulfill contract demands by unions. Thus, the process comes full circle; affected officers are first presumed to be sick, and the organization proclaims to provide the cure pathogenic intervention. In this way, both individual and organizational political goals are attended. Most trauma units or shooting teams in policing are specifically designed to help the officer deal with presupposed trauma. I once heard a police shooting team leader say to an officer: if you didn't feel anything after you shot that guy, there is something wrong with you. You are not human.
Why do pathogenic models make assumptions that all exposed to trauma are afflicted? Such assumptions may be based on the insecurity of not knowing precisely who is suffering from trauma exposure, or it may the belief that a shotgun approach to intervention will in the least help those who are afflicted. But, what of those who were not affected by the traumatic event? Do pathogenic models talk them into trauma ? These are important questions. It is difficult to imagine that intervenors would deliberately harm individuals exposed to traumatic events, yet there is continual use of intervention models which remain unproven. Often the individual is not given the benefit of the doubt and assumptions are made that only intervention experts can solve problems associated with trauma.
It must be noted again that not all the consequences of traumatic exposure result in trauma, and that the experience may prove to be a positive growth experience for many. In fact, it has long been administrative procedure in law enforcement to rotate as many police officers as possible at a mass casualty scene in order to give as great a number of officers as possible the training experience. Here, trauma exposure seems to be a well accepted practice of a source of growth and development (Dunning , in press).
Scripting does not necessarily have to be detrimental to trauma intervention. If intervenors employ a positive rather than negative perspective (assumption of affliction with trauma symptoms) persons exposed to trauma can utilize their own personal strengths along with the support of professionals. In other words, affected individuals can be scripted positively instead of negatively, leading to salutogenic amelioration.
Salutogenesis refers to the individual's ability to not only survive traumatic events but to also to achieve greater personal strength, understanding and purpose from the event (Antonovsky, 1987). Antonovsky (1993) first posited that a salutogenic orientation has far wider implications than simply focusing on the pathology of traumatized persons. Suedfeld (1996) refers to this human quality as invictus, meaning unbeaten or unconquerable. Michebauam (1995) refers to persons who develop learned resourcefulness from stressful situations. Salutogenesis views difficult or stressful life experiences such as trauma as promoting growth in the direction of positive change (Decker, 1995). Tedeschi and Calhoun (1996) organized growth from trauma into three broad categories of self-perception, improved personal relationships, and a positive philosophy of life. These approaches oppose pathogenesis, which assumes individual helplessness and ignores the individual's capacity for self-exploration and personal growth (Yalom and Lieberman, 1991; Jaffe, 1985)
The Salutogenic Approach recommends that the mental health professional perceive their role as facilitator in a debrief process that occurs informally as the professional participates in organizational processes of trauma recovery. We address below some individual actions which may help to reduce trauma: coping and vulnerability.
Pathogenic models seldom pay tribute to the ability of individuals to cope effectively with trauma or distress. A salutogenic model would instead posit that the perception of positive benefits resulting from traumatic events may be the result of individual coping processes as well as outcomes of intervention (Tedeschi, Park & Calhoun, 1998). For example, positive reinterpretation of events, positive reframing and event interpretive ability (Carver, Pozo, Harris, Noriega, et al 1993; Rothbaum, Weisz & Snyder, 1982 ; Park, Cohen, & Murch, 1996; Lazurus, 1986). individual coping differences may thus account for successful trauma amelioration (Stroebe, Hansen & Stroebe, 1993). Carver et al, (1993) found that negative coping strategies may impede adjustment of trauma while positive coping may increase positive responses to trauma. In addition, social support may be an important factor in helping individuals to find meaning in a traumatic event (Lyons, 1991; Park et al , 1996).
The present author conducted a study of police recruits situated in an extreme high stress training situation (Violanti, 1993). Results demonstrated that highly distressed recruits utilized effective coping strategies more often than lower distressed recruits. The positive, controlled type of coping used by these recruits indicated that the training experience taught them how to more effectively deal with high stress and handle problems.
Coping was assessed by the 66-item Ways of Coping Check List (WCCL), used extensively by Folkman and Lazarus (1985); Folkman et al. (1986), and others. The Ways of Coping Check List determines a broad range of coping and behavioral strategies that people use to manage internal and external demands in a stressful situation. Folkman et. al., (1986) reported that their scale measures eight types of coping responses: (1) confrontive coping; (2) distancing; (3)self-control; (4) seeking social support; (5)accepting responsibility; (6) escape-avoidance; (7) planful problem solving; and (8) positive reappraisal. Measures of psychological stress and life events were also employed. The task was to determine what coping strategies were employed by highly stressed police recruits.
The results demonstrated that highly distressed recruits gained effective ways to cope through the experience of military-style police training. Keeping themselves mentally distant, controlling emotion and responses, accepting self-responsibility, and positively reappraising the situation were used more by highly distressed recruits than by lower distressed recruits. In essence, highly stressed recruits grew in their ability to cope with stress through the process of extreme stress conditions. This was viewed by many recruits as a positive attribute to help them deal with stress in police work. As one recruit commented I was a nobody before I came to the academy. This training showed me what I was made of. I feel like I can handle anything now.
This study provides an example of how individuals under extreme stress conditions can adapt and grow to the task. To some degree, efficacious coping and a positive outlook may be related to individual personality traits such as hardiness and resiliency ( Tedeschi & Calhoun, 1996). These are not generally considered in a pathogenic framework. The concept of hardiness was developed to describe individuals who continuously rise to their life challenges and turn stressful experiences into opportunities for personal growth (Kobasa, Maddi, & Kahn, 1982). Hardiness also represents the ability of an individual to face difficult conditions with absolute courage (Williams, Weibe, & Smith, 1992; Bartone, Ursano, Wright, & Ingraham, 1989; Funk, 1992). Kobasa et al (1982) describe hardiness as significantly influencing how people cope with stressful events. Resiliency, as defined by Bartone et al (1989), involves the capability to recover after a stressful encounter and to make quick adjustments through coping.
Exposure alone cannot account for the relationship between an individual's psychological distress and traumatic event. There are many persons so exposed who do not suffer psychological consequences and yet others who experience extreme reactions. One possible factor which affects the degree of trauma impact is individual vulnerability. Vulnerability may be defined as the force with which trauma impacts on the psychological distress of the individual (Kessler, 1979). Each individual has his/her own degree of vulnerability. Individual vulnerability is additional consideration to help officer deal with trauma. A good history of the officer is helpful here. Knowing the officer's past experience with trauma and his/her potential for dealing effectively is important.
Personal positive growth resulting from traumatic events and traits such and hardiness (Kobasa, et al, 1982) and resiliency (Bartone, et al, 1989) may help to resist trauma symptomatology. As mentioned in this article, vulnerability may be increased by exposure to pathogenic interventions which assume trauma symptoms already exist.
Throughout this article, we have often mentioned the concept of scripting trauma. To reiterate, scripting refers to the effect produced by pathogenic intervention models that assume sickness (symtomatology) due to trauma exposure. Such methods, with their rigid protocols and lack of follow-up can cognitively re-structure an individual's perceptions about trauma symptoms.
Lacking in pathogenic approaches is the utilization of individual strengths to deal with trauma. Indeed, an officer in a pathogenic trauma intervention may not be sick at all, and may have resources such as coping, hardiness and resiliency to such an extent that they will successfully deal with the traumatic event. Perhaps we sometimes forsake the notion that police officers are really quite resilient individuals. The majority of them deal with all of the negative exposures day in and day out and still maintain good psychological dispositions. As much as we think we know, the inner strength of every human being is still beyond our scientific comprehension. We must continue to explore this untapped resource that can make even the most tragic personal event one of positive and enduring growth.
It is most of all essential for intervenors to recognize that individuals have their own script for dealing with life adversities. If pathogenic interveners continue to preach preordained trauma, people may continue to believe them. Individuals should be allowed to make their own appraisal of just how sick they are when exposed to trauma. Police agency policy that mandates attendance at PTSD debriefings should not exist. Attendance should most certainly be voluntary, based on the officer's own decision of just how affected he or she is by the traumatic exposure.
Individual coping is an essential part of recovery from any stressful life event. Trauma intervention protocols would do well to incorporate transactional models of coping in their systems. Transactionism views psychological distress as resulting from the interaction of many factors, including individual appraisal of the situation (Aldwin, 1994). The individual's ability to cognitively fit coping to an appraisal of the traumatic event should not be underestimated (Conway & Terry, 1992; Vitaliano, DeWolfe, Mairo, Russo, & Katon, 1990). In sum, trauma, individual appraisal, coping, and psychological well-being all occur in a dynamic transactional relationship (Lazarus & Folkman, 1984). This is contrary to the static and rigid nature of present enduring pathogenic PTSD intervention models.
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