Law Enforcement and Risk for Developing PTSD

 

Nancy Davis, Ph.D.

 

 

High-risk jobs are often those that involve a willingness to risk one’s life to protect or assist others, often strangers.   These jobs routinely expose workers to intensely traumatic incidents, and, as a result, can lead a worker to develop PTSD [Post Traumatic Stress Disorder], partial PTSD, complicated PTSD or other debilitating symptoms.  However, the men and women who choose to work in these professions generally do so because they feel exposure to traumatic incidents is more than balanced by the numerous positive and rewarding facets of their jobs.

 

Health care professionals and emergency service workers often choose their jobs because they involve helping others and have a positive impact on the world.  Saving a life and/or successfully conquering a dangerous task provide them with a sense of exhilaration and self-worth.  Many workers also thrive on the constant change, challenges and unpredictability of their jobs, and would be bored with a desk job (Moran, 1998).  Furthermore, in high-risk occupations, there is generally a strong sense of comradery where peers form a close-knit and sometimes insular fraternity.  These jobs provide a social structure, which not only provides support and a feeling of belonging to a group that is doing something worthwhile, but often consists of friendships which extend outside of the work environment and can last a lifetime.  For some workers in professions that involve helping others, the job represents the final step in healing their own personal trauma by helping others (Hallett, 1996; van der Kolk, 1995).

 

Law Enforcement Officers: Facts and Statistics

In the United States, there are over 17,000 separate law enforcement agencies with 740,000 sworn officers serving in varying roles (Males 89%; 12% females).  The average number of yearly line-of duty deaths involving law enforcement officers is 163.  In 2000, 51 officers were feloniously slain and 84 accidentally killed.  Law enforcement officers average 59,693 assaults and 18,995 injuries per year.  (National Law Enforcement Officers Memorial Fund, Inc., 2002; Uniform Crime Reports, 2001).

 

Studies of police officers have found rates of PTSD to be between 3% - 17%  (Boyd, 1994; Harvey-Lintz & Tidwell, 1997; Robinson, Sigman & Wilson, 1997).  Officers working in assignments that rarely deal with death, automobile accidents, domestic violence calls and traffic stops will clearly not have the same rates of PTSD found in officers who deal with the most violent, evil and horrific aspects of the job.  For example, college campus police were found to have levels of PTSD similar to the general public (Lambert, 1997).  Officers in other countries have also been found to have high levels of PTSD; Australia, 8.3% (Higgins, 1996); Netherlands, 3-7% (Carlier, Lamberts & Gersons, 1994; 1997); Germany, 5%, with 39% experiencing intrusive memories (Teegen, Domnick & Heerdegen, 1997).

 

Although in studies of PTSD resulting from accidents and crime, females have been found to have higher rates of PTSD than males, the results have been mixed when focusing on law enforcement officers.  Some studies found higher levels of PTSD in female police officers (Geick, 1998; Wellbrock, 2000).  Other studies found no difference between the rates of PTSD and job stress in male and female officers (Heredia, 2000; Pole, et. al., 2001).  Hispanic-American officers were found to have higher levels of PTSD than European American and African-American officers.  This replicates previous findings of higher levels of PTSD in Hispanic-Americans (specifically those from Puerto Rico) found in Vietnam Veterans (Neylan, et. al., 2002; Pole, et. al., 2001).

 

 A job in law enforcement has the potential to be highly traumatizing (Fell, Richard & Wallace, 1980).  For the law enforcement officer who often works alone, where violent attacks can come from anywhere and where split-second decisions can result in death of a citizen, a perpetrator or oneself, the job stressors and potential to be traumatized are tremendous. 

 

A law enforcement officer is frequently on his/her own in a critical incident, unlike fire department personnel, where a group of officers generally respond, usually with a supervisor on the scene.  Further, when a law enforcement officer is involved in an action that injures or kills a citizen or a perpetrator, there is almost invariably an investigation.  Supervisors or members of a “Shooting Board” or Internal Affairs Office commonly investigate the incident.   This can result in second-guessing decisions that were made in a split second during situations of extreme threat.  Research has consistently found that a positive level of support following a critical incident can mediate the development of PTSD.  However, for many officers, the reaction of their own department is not experienced as supportive and, in some cases, may become even more traumatic than the actual incident (Horn, 1991).  Comments by the news media, reviews by citizen boards, and legal actions in the courts can compound the impact of the trauma.  Officers incur additional stress from required yearly physical exams, re-qualifying with weapons, and often-required disclosure of finances and personal relationships.

 

In many departments, officers who seek help can be sent for a fit-for-duty examination to evaluate whether he or she has emotional or physical problems.  The results of these examinations can lead to being assigned to the “rubber gun squad”, having their weapon confiscated, being placed on disability, or even fired.  In other words, rather than their department assuming responsibility for officer being traumatized by job-related experiences, he or she may face restricted duty or dismissal from the job.  The fear of being sent for a fitness-for-duty exam keeps many officers from seeking the assistance that would improve their job performance. 

 

“The worst part of a critical incident sometimes is not the critical incident but what happens afterwardBbecause they feel like they’ve done the best they possibly could under the set of circumstances that existed at the point they made the decision.  Yet, they are second guessed, maybe all the way to the Supreme Court for a decision they made in a split second.”  Horn, 1991 page 143.

 

Additional stress comes from an increasing tendency of criminals and the citizens to file civil suits against police officers for their actions.  In a nine-year period, suits for police misconduct increased 600% (Higgenbotham, 1985).  Even such tasks as investigating traffic accidents, which are routinely handled on a daily basis by officers, have the potential to give rise to significant levels of PTSD (Mitchell, 2000). 

 

A recent research study (Neylan, et. al., 2002) found that although only 7% of officers could be classified as having PTSD, 45% were having sleep difficulties typical of patients seen in insomnia clinics (Boyd, 2002).  In this study, stresses related to their work environment were strongly associated with sleep quality; sleep disturbances were associated with symptoms of PTSD.  “These high rates of insomnia are particularly alarming, because sleep deprivation can drastically hinder mental and physical performance” (Thomas Neylan, MD, 2002). 

 

Factors that Increase Probability of PTSD

 

Factors found to increase the probability of a law enforcement officer developing PTSD are:  (1) exposure to death and life threat (Marmar, et. al., 1996; Robinson, Sigman & Wilson, 1997; Teegen, Domnick & Heerdegen, 1997); (2) trauma severity (Carlier, Lamberts & Gersons, 1997); (3) personal history of traumatic experiences (Teegen, Domnick & Heerdegen, 1997); (4) use of deadly force (McDonough, 1996); (5) personal identification with a traumatic event (Higgins, 1996); (6) a partner being injured or killed; (7) experiencing high levels of emotional distress (including panic reactions) during the incident, (8) Catholicism (Higgins, 1996); and (9) feeling as if the event is unreal as it unfolds, as if they were in a movie or watching a videotape, a form of dissociation (Boyd, 2002; Neylan et. al., 2002).  No significant correlation was found between police stress and moral reasoning, coping mechanisms, age, church attendance (Burnett, 2001) or the degree to which an officer talked to family and friends about a traumatic experience (Southwick, Morgan & Rosenberg, 2000). 

 

Surviving spouses of officers killed in line-of-duty deaths were also found to have levels of PTSD equivalent to prisoners of war and hostages, regardless of whether the death was due to a homicide or was accidental (Stillman, 1986).

 

Example One: Law Enforcement Officer - Job-related trauma:

 

A wife’s perspective of her husband’s behavior after he had been through a critical incident at work where four people died:  He thought he would die.  His partner almost died - he had to rescue her - and a high official accused him of being responsible for two of the deaths, although he later received an apology.  The traumatizing event happened in early 1997.  The husband was a National Academy student (law enforcement officers attending three months of training at the FBI Academy). The wife was interviewed in the fall of 1999, when she visited him at the Academy, and was asked about husband’s symptoms.  Shortly before this interview, he had received MTP Level Four treatment for his trauma.  The treatment eliminated these symptoms in two sessions. The couple had been married eleven years and has given permission to use this information.

 

The Wife’s Perspective:

 

“His face lost feeling.  He stopped laughing (restricted range of affect; feelings of detachment).

 

“His breathing changed when he was driving, sometimes it kind of bubbled when he breathed out, or he would breathe in a very shallow way (shallow breathing is a sign of stress).

 

“His speech was choppy; he would say three words and pause, three more words and pause (difficulty concentrating).

 

“He stopped playing with the kids.  He had roughhoused and tumbled with them, and he stopped.  He became intolerant, focused and single-minded.  We had shared picking up our son from private school, but I got so I didn’t call him to pick him up, because he seemed “put off’ (irritability) and I was afraid that he would be that way with our son.  I started having our neighbor pick him up.  I thought ‘I’ve lost him for a life time’.  My kids just responded like he was dead.  I told them that their daddy had been through something that had hurt his heart so much that it had changed him (restricted range of affect; diminished participation in significant activities). 

 

“He had lots of trouble sleeping.  The first month, he had a lot of nightmares (distressing dreams).  Since then, he yelled out and was frantic in bed, about once a month and he jerked in his sleep, especially in his legs.  If I tried to wake him up to stop the nightmare, or bumped him in his sleep, he was instantly and loudly awake.  If he fell asleep on the floor, I could not wake him up gradually...he startled awake. (Problems of arousal, problems sleeping, hypervigilence, flashbacks).

 

“His stomach was really bad for months; he said it just ached.  He gained 20-30 pounds, even though I couldn’t see that he ate any more than he used to”  (the response of the body to stress; high levels of cortisol secreted during times of stress can cause weight gain and deposit fat in stomach area).

 

“He drank a little more, but not much.  I’m not sure if this helped him to sleep”.

 

“Ever since this happened, he would say, ‘You’re not listening to me, I just told you that.’  But he hadn’t just told me that.  I think he must have been thinking the words in his head, and thought he said them to me, but he didn’t” (feelings of detachment or estrangement from others)

 

“If I wanted him to listen to me, I had to make direct eye contact with him to make sure he was listening, or he wouldn’t hear me.  He was in his own world. (Feelings of detachment from significant others)

 

“He would tear out things from magazines and keep them; things seemed to mean more to him than they had before.

 

“Before this happened, we related as adults...we listened to each other, and respected each other and helped each other.  My first marriage had been to a very controlling man and we had agreed that he would not try to control me, tell me what to do and we would be a team of two adults.  After it happened, he wanted things his way.  He started treating me like a child and tried to control me.  He started wanting me to do things like he wanted them done.  He even started telling me what to do with problems at work.  I thought, ‘Oh no, he’s acting just like my first husband’ “(Safety issues)

 

“If something bothered him, he left.  He would go in the next room or out in the back yard, or leave in the car (efforts to avoid recollections of the trauma).  Before this happened, he never wanted to be away from home.  After it happened, he did not want to be around groups of people he knew; we would be the last to arrive at a party and the first to leave.  He didn’t want to be around his friends (diminished participation in significant activities; paranoia due to sleep deprivation).  He would sit in the dark for hours and smoke.  We used to drive around on Sundays in the car and just talk - that stopped.  One day he came home and just picked me up and put me outside.  He never got violent and he was slow at expressing anger, but he just couldn’t stand to be with me (irritability; feelings of detachment).  I called his Chief and the Chief said he hadn’t noticed that there was anything wrong with him.

 

“Sex decreased in frequency and became mechanical“(feelings of detachment).

 

“He lost patience.  He couldn’t tolerate standing in line, being stuck in traffic, doing the normal things that make a family run, like paying bills (irritability). We had shared the duties, but I had to take over all of them (diminished participation in significant activities).  He thought most things weren’t important enough for him to participate in.  It was as if this event was so important that nothing else could compare, so he didn’t want to hear the normal everyday problems of the children and me.  I started having to handle them all.”

 

“When driving, he was more rigid, forceful and impatient (irritability).  He drove faster and the safety zone between him and the car in front of him disappeared.  One time he was driving and a tunnel was ahead.  I could tell he was having a flashback and I didn’t think he was going to make it through (re-experiencing of the trauma through a flashback).  He did it, but I could tell he was scared.  He also froze when we took the kids to a water park and they wanted to go through a long tube with water in it.  He did it, but I could tell it took a lot of determination for him to do this (re-experiencing of the trauma through a flashback).”

 

“He stopped talking and going out with his friends from the job (efforts to avoid people that arouse recollections of the trauma).  The only friend he would talk to was a friend whose son had died.” 

 

The Officer’s Perspective:

 

“I slept about two or three hours a night.  I got earphones so I could watch television and not bother my wife while she was sleeping (problems sleeping).” 

 

“Whenever I turned on the shower, it reminded me of everything in the event.  I hated how it made me feel. It colored everything I did and said and felt and thought (recurrent and intrusive recollections of the event).”

 

“My mind was always racing and on a thousand things; I would be hearing someone’s voice, but I would be thinking about all kinds of other things.” (Persistent symptoms of arousal; problems concentrating; feelings of detachment).

 

“I don’t think that I ate more; perhaps I was less active.”

 

“I looked but never saw.  I became paranoid.  I kept wondering what everyone was thinking about me” (persistent avoidance of stimuli associated with the trauma; feelings of detachment; paranoia, probably related to lack of sleep).

 

“I couldn’t concentrate or read (problems concentrating).  I wasn’t interested in anything (feelings of detachment; numbing of general responsiveness; efforts to avoid stimuli associated with the trauma).  I just sat in the dark and smoked; when I was sitting in the dark, I spaced-out, I didn’t feel anything.”

“I was very shut down.  I know the trial is coming up and I am going to have to go through this again.  I dread it” (feelings of detachment; avoidance of stimuli associated with trauma).

 

Wife’s New Perspective after Husband Received Treatment.  

 

“The smile is back on his face; he’s laughing.  We’re talking about things like we used to.  It’s like the old husband is back, but deeper.  His breathing is calmer and his speech isn’t choppy any more.  He was listening to me and paying attention.”

 

“I noticed that he did not get too close to cars or drive as fast.  He didn’t jump in his sleep and he woke up slowly.  He slept well the whole night.  We talked and talked and talked.  I noticed on the way from the airport, I was reading the map and he was treating me like an adult.  In the past two years, he would have been telling me what to do.  He let me read the map myself, without his advice.”

 

The Officer’s Perspective Following Treatment:

 

“I’m sleeping; I’m laughing, I’m calm and I can read.”

 

When asked about the weekend he had just spent with his wife, “Sex was great...better than its been in years”

 

Example Two: Female Law enforcement officer - Job-related trauma:

 

“It happened to me over a series of months and while working traumatic situations.  My family and friends recognized what was happening to me before I did.  I gave up my hobbies, stopped reading anything I didn’t have to read (difficulty concentrating), and stopped food shopping.  I ate whatever was available.  I didn’t care about nutrition (markedly diminished interest in significant activities).  I continued to exercise, that was not affected.  However, I started isolating myself (feelings of detachment or estrangement from others).  I didn’t call my friends or talk to my family about the problems I was having.  I very much wanted to talk about the horrible things I saw and was having to do on the job, but I didn’t want to upset them.”

“I had disturbed sleep...I was just sleeping a couple hours a night, waking up all night, having nightmares (difficulty staying asleep).  I went to a sleep clinic; the doctor reported that I never got into REM sleep.  He told me, ‘You have to learn to cope with stress or get out of the job.’  He didn’t help me at all.  I worked harder and became obsessed with the job and working.  I was disappointed that I was not being recognized for all the work I was doing - and all I did was work.  When I took time off, that is when it ‘caught up with me’, so I didn’t take time off (efforts to avoid thoughts, feelings or conversations associated with the trauma).  I didn’t have a Christmas or New Year’s for the past four years.  I had to work on some, volunteered to work on the others (markedly diminished interest in significant activities).  Even with working, I had time to see my family, but I isolated myself (feelings of detachment or estrangement from others).  I didn’t feel like having fun or being with a group of people.  It was easier to be alone.  I had more illnesses (the response of the body to stress).  I was exhausted and short-tempered everywhere and with everyone.  I had very little patience and I snapped at people inappropriately (irritability).  I felt overwhelmed and stopped enjoying simple pleasures.  I had snap flashbacks of a moment, a scene, a feeling (traumatic event is persistently re-experienced).  After working the scene of an airplane crash, I couldn’t eat certain seafood.  I got nausea just looking at them (triggers which remind of the traumatic event).  I started drinking too much (efforts to reduce symptoms).  I stopped caring what I looked like, how I dressed (markedly diminished interest in significant activities).  I dropped out; I was not in touch with friends and family.  I wasn’t talking to anyone...they were reaching out to me and I was telling them, ‘I’m too busy, I’m too busy’ (feelings of detachment; numbing of general responsiveness). They were telling me that they could hear it in my voice that I had so much stress.  I didn’t hear it.”

 

“I hid my problems from my supervisor and from other people in the office.  I was afraid that my job would be affected and, if they found out, it would be career ending.  No one knew that I wasn’t sleeping, or was having flashbacks.”

 

Following Two Sessions of MTP:

 

 “People are saying, ‘we have you back.  You’re smiling again.  You look so happy.’  I’m dating again; in fact, guys are coming out of the trees.”

 

Specialized Programs Necessary for Those Regularly Exposed to Trauma

 

 Employees in high-risk occupations and/or emergency services where exposure to traumatic incidents is routine, require mental health services that are often quite different from mental health services required by the general population.  To be accepted for employment in high-risk occupations, employees often must pass extensive psychological evaluations, physical examinations, endurance tests, as well as written examinations and interviews attempting to assess judgment, intelligence and reasoning.  Therefore, employees hired after passing these tests could be expected to have a level of physical and psychological functioning higher than that of the average U.S. worker.   This does not mean that many of these workers in high-risk occupations have not experienced traumatic incidents when they were children and adolescents.  However, their ability to pass the tests required for employment is a clear indication that they have developed coping mechanisms that have kept past traumas from incapacitating them.

 

After becoming employed, the majority of fire fighters, paramedics and law enforcement officers will be exposed on a regular basis to traumatic incidents of greater magnitude than most people encounter even once in their lifetime.   Even when agencies provide education and stress reduction programs, peer support and debriefing, many emergency service workers will develop PTSD, partial PTSD or other symptoms which will interfere with their job performance and quality of life. If ignored, these symptoms can lead to increasingly greater difficulties in all areas of their personal life and job functioning.  Even programs offering superior support would not have prevented many fire fighters, paramedics and law enforcement officers from being traumatized by their involvement in collapse of the World Trade Center on 9-11 and its aftermath.

 

Mental Health Services available to employees working in agencies where responding to traumatic incidents is a routine part of the job, should have the following qualities:

 

·       Employees experiencing symptoms that are debilitating, whether or not they lead to the level that would warrant a diagnosis of PTSD must first be identified.  Employees may self-identify, realizing that they need help; peers, co-workers, managers and spouses are additional avenues of identifying employees who would benefit from treatment.

 

·        The employee should be required to attend the treatment sessions (but not required to attend debriefing). 

 

·       Mental health providers must have the trust and confidence of the employees; those providing services should have an extensive knowledge of the unique demands of the job and the types of events which are particularly traumatizing and stressful to the employees they serve.

 

·       Communication within the treatment sessions must be confidential unless there is a danger of suicide or homicide.  This may mean that few, if any, treatment notes are taken.  Some states have laws that do not honor doctor-patient privilege under specific circumstances; employees may not feel safe in seeking treatment if they fear treatment notes may be used by management or the courts.

 

 

 

·       Mental health workers who assess fitness-for-duty should not be the same individuals who provide mental health services to employees.  The goals of these two roles are in direct conflict with one another.

 

·       Treatment must be effective and time-limited.  Professionals experiencing repeated job-related trauma rarely have the time or the patience to attend regular weekly sessions lasting for months.  For this reason, the length and location of sessions has to be flexible.  Meeting places and/or offices should be available in areas outside the regular workspace so that employees can avail themselves of services, without being observed by other employees.  Treatment techniques must be those designed to provide quick relief of symptoms.  Research has proven that “talk therapy” provides little help to employees with PTSD and may make them worse.

 

·       If exposure to job-related traumatic incidents has lead to PTSD or other symptoms, it would seem reasonable that employees would not have to pay for their treatment.