Another look at self-destruction in law enforcement and its septic underpinning

This is a photograph produced by Dave Betz who lost his son (pictured) in 2019 to suicide.

Officer Dave Betz lost his son David to suicide in 2019

The code of silence.  It surrounds the culture of police work and always has.  I was once told there are two kinds of people: police officers and ass holes.  If you were not a police officer then you were an asshole.  It was a brotherhood with a formidable blue line that defined the police service as a singular force against all that is bad.  Some have said that law enforcement offers a front seat to the greatest show on earth.  Until what is viewed in the front row cannot be unseen and slowly chips away the veneer of solidarity by threatening the existing culture.  For police officers to have long term career success the organization must come to grips with its membership and relieve them of the stigma they feel that prevents them from coming forward. Who would go for that?

If the organization devalues its rank and file for experiencing the natural, neurobiological reaction to repeated, high lethality exposure to violence and death, then who would join such an organization?  Fewer and fewer applicants are signing on in 2019. If a police officer is emotionally denuded by the job why would he or she step up and break the code of silence and be labeled a “nut case” only to lose his badge, firearm, and police authority?  No one will sign on for that kind of treatment.

Each time a member of the law enforcement community takes his or her own life the unspoken silence becomes a lancing wound to the festering emotional infection that is from repeated exposure to traumatic events. The reappearing wolf in sheep’s clothing cuts his teeth on the souls of unwavering academy graduates now paired with senior field trainers who promise to teach the tricks of the trade. Academy graduates come forth like professional athletes with all the confidence and enthusiasm of an elite athlete.  They need experience and mentoring so they know what they are up against.  I was asked to speak at the annual Society of Police and Criminal Psychology meeting in Scottsdale, AZ in late September, 2019 on the importance of the field training program on long-term officer wellness and career satisfaction.

Country music blared from the car radio as Dave, dressed in pajama pants and a t-shirt, stood over his son and realized he was dead.

Father of 24-year old police officer David Betz, 2019

The psychological autopsy may provide insight into the manner of death and must include prior exposure to trauma.  How many first-in homicide calls had the decedent handled? How many unattended SIDS deaths?  How many death notifications? How many cases of domestic violence where the victim was too frightened to speak about the nightly horrors in the marital home? How many times did he witness the remnants of a violent motor vehicle crash with ejection?  Each time he bears witness to this inhumanity he risks never coming back. Some spouses will say they remember when they lost a husband or wife. “It was after the 4-alarm fire – sifting through the rooms for possible causes and finding the old woman who rented the place in an upstairs bathtub” or “the time the addict threw his newborn son off the 14th floor balcony because his baby mama did not return from work when she was expected.” Many espouse the use of the psychological autopsy as a way of honoring an officer who died by suicide as a means of linking the suicide to their tour of duty. 

High lethality calls must be tracked allowing for paid psychological defusing time in the aftermath of these calls.  Defusing and psycho- education can be provided for the entire group who handled the high lethality call rather than identify a single officer.  Aftermath check-ins and peer support should follow. An officer who begins to exhibit changes in his normal work routine, e.g. increased tardiness, citizen complaints, or substance abuse should be referred for psychological follow-up that is linked to annual performance reviews and recommendations for corrective action.

In truth, the reader may wish to put himself into the position of the first arriving police officers at Sandy Hook Elementary School in a place called Newtown.  In December, 2012, twenty seven people were violently murdered – most were first grade students. I have read the Connecticut State Police report of the Sandy Hook shooting and was left feeling numb and physically sickened. It is over 1000 pages of grueling detail.  Now, when I see TV images of LEO’s running on campus toward the sound of gunshots, I know they must step over the desperate victims, some of whom take their last breath reaching for a pant leg or a blue stripe or a black boot covered in blood all the while begging to live.

Recruits enter the police service with high hopes of making a difference but quickly learn that their purpose in life is being sucked out of them like embalming fluid moving though the lifeless remains of a brother or sister officer who could endure no more. Coming forth and asking for help is not a sign of weakness but a sign of strength, resilience, and heroism. There should be no penalty or secondary administrative sanction when an officer comes forth.  They must be provided behavioral health treatment and a pathway to return to the job.  

Police officer suicide impacts police agencies everywhere in America and across the globe. Many officers feel abandoned by their agencies and become marginalized because they struggle with depression, substance abuse, and PTSD after years of seeing the worst life has to offer. It is time to lessen the expectation of shame among the troops who serve communities large and small. No father should be first in at the suicide death of his own son and be expected to stand with a photo and share his story at the same time he remains stoic and brave.

SGB: Are these 3 letters that we should remember?

Neurobiology, PTSD, and Hope

Treatment for depression and trauma
SGB. I just saw the 60 minutes story on SGB as a possible treatment for PTSD. SGB stands for Stellate Ganglion Block. Ganglion simply means a bundle of nerve fibers. We have numerous ganglia in our bodies. The Stellate ganglion is different and offers a potentially serendipitous treatment option for posttraumatic stress disorder (PTSD) that heretofore has been refractory to conventional psychiatric therapy. If so, these 3 letters may offer hope to thousands of law enforcement officers and even more returning military veterans who experience the symptoms of PTSD. The availability of the SGB procedure for law enforcement is unknown – I have seen no studies involving members of law enforcement. My hope is to bring the protocol to the fore front by starting the dialogue in these pages. By now, thousands of interested clinicians, physicians, and patients who are diagnosed with PTSD and those who should be diagnosed with PTSD have seen the compelling case for SGB. According to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), PTSD is defined by 4 clusters of symptoms: (1) intrusive re-experiencing of a traumatic event, (2) avoidance of trauma-related stimuli, (3) negative changes in mood and cognition, and (4) persistent physiological arousal and reactivity. Diagnosis of PTSD requires that the symptoms significantly impair functioning and last for at least one month (taken from Peterson, et al (2017). Symptoms emerge in response to exposure to events that are outside what is considered to be “normal” human experience like seeing dead bodies, witnessing the death or a friend or fellow officer, child victims of war or domestic violence, death and dismemberment from motor vehicle crash, and other. These are the worst of all cases of human behavior, depravity, and emotional poverty. “Chronic exposure to traumatic scenes and a host of other factors gradually elevate the hypothalamus-pituitary-adrenal (HPA) axis in the brain and body of typical career LEO’s.” There are neurological changes that evolve from repeated exposure to trauma (Sefton, 2019). It is this automatic response that the SGB protocol is designed to mitigate reducing or eliminating symptoms as a result.
“These nerves help control the brain’s fight or flight reactions, signals that go haywire with PTSD.”   60 Minutes June 17, 2019
The use of a small amount of anesthesia provides a risk free blockade of the autonomic nervous system overflow that contributes to the toxic levels of anxiety and stress among people with PTSD. This elevated arousal puts them on high alert. All the time on high alert. It is hard to function when the body signals the brain that a threat exists around every corner – whether on duty or off. This is the enduring problem when LEO’s are exposed to threat after threat without chance to defuse. Currently only 12 of the 172 V.A. hospitals offer this treatment but it has gone into clinical trials to determine its true efficacy versus placebo according to the 60 Minutes story broadcast 6-17-19. The sympathetic system activates the bodies internal survival mechanism by raising the threat level needed to fight or to flee. It is almost instantaneous. The fight/flight mechanism exists in all animals having an evolutionary value needed for survival and defense against potential prey. “Stellate ganglion has been demonstrated to have second and third order neurons connections with the central nervous system nuclei that modulate body temperature, neuropathic pain, the manifestations of PTSD, and many other areas.” Lipov, et al. (2009). I am no expert but a risk-free protocol to break the neurobiologic underpinning of PTSD is something I would try if I needed to. It has been used for conditions such as chronic pain, migraine headaches, upper extremity pain, and symptoms of menopause in women. Only recently has it been shown to relieve the suffering of people with this debilitating and chronic condition. However, a study by Hanling et al (2016) was equivocal in its report that the SGB was no more effective than a Sham injection. This seems like a set back for this hopeful treatment. Other studies have emerged that support the utility of SGB for PTSD including the Peterson et al. paper published in 2017. Findings from a case series of 30 active-duty military service members with combat-related PTSD suggest that people with predominantly hyperarousal and avoidance types of symptoms may be more likely to benefit from SGB according to Lynch et al. in 2016.

Does anyone still believe that PTSD is merely a psychological problem? It is not. In fact it is more a biological response by primitive structures in the brain that are activated when the human being is exposed to highly traumatic events such a those occurring during times of extreme violence like war. “A 2016 longitudinal study comparing functional MRIs and symptom scores of 72 Veterans with and without PTSD during which PTSD patients received trauma-focused therapy suggested that higher baseline dorsal anterior cingulate cortex (dACC), insula, and amygdala activation may predict poor response to PTSD treatment.” van Rooij, 2016. This has been demonstrated in subjects over and over. These brain regions activate as a protection against the threat of extinction or death triggering our instinctive drive to survive. https://www.cbsnews.com/news/sgb-a-possible-breakthrough-treatment-for-ptsd-60-minutes-2019-06-16/

REFERENCES

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013. Hanling SR, Hickey A, Lesnik I, et al (2016) Stellate Ganglion Block for the Treatment of Posttraumatic Stress Disorder: A Randomized, Double-Blind, Controlled Trial Regional Anesthesia & Pain Medicine; 41:494-500. Peterson, K, Bourne, D, Anderson, J, Mackey, K, and Helfand, M. (2016) Evidence Brief: Effectiveness of Stellate Ganglion Block for Treatment of Posttraumatic Stress Disorder (PTSD). https://www.ncbi.nlm.nih.gov/books/NBK442253/#vaganglionblock.s25 Taken June 17, 2019 Lynch JH, Mulvaney SW, Kim EH, de Leeuw JB, Schroeder MJ, Kane SF. (2016) Effect of Stellate Ganglion Block on Specific Symptom Clusters for Treatment of Post-Traumatic Stress Disorder. Military Medicine. Sep; 181(9):1135–1141.Evidence Brief: Effectiveness of Stellate Ganglion Block for Treatment of Posttraumatic Stress Disorder (PTSD) Lipov, E, Joshi, J, Sanders, S, Slavin, K. (2009) A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Medical Hypothesis. Volume 72, Issue 6, June 2009, Pages 657-661 https://www.sciencedirect.com/science/article/abs/pii/S0306987709000413?via%3Dihub American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013. Sefton, M. (2019) The Neurobiology of police work. Linkedin publication: https://www.linkedin.com/pulse/neurobiology-police-work-michael-sefton-ph-d-/ Taken June 17, 2019 Hanling SR, Hickey A, Lesnik I, et al (2016) Stellate Ganglion Block for the Treatment of Posttraumatic Stress Disorder: A Randomized, Double-Blind, Controlled Trial Regional Anesthesia & Pain Medicine; 41:494-500. Peterson, K, Bourne, D, Anderson, J, Mackey, K, and Helfand, M. (2016) Lynch JH, Mulvaney SW, Kim EH, de Leeuw JB, Schroeder MJ, Kane SF. (2016) Effect of Stellate Ganglion Block on Specific Symptom Clusters for Treatment of Post-Traumatic Stress Disorder. Military Medicine. Sep; 181(9):1135–1141. van Rooij SJ, Kennis M, Vink M, Geuze E. Predicting Treatment Outcome in PTSD: A Longitudinal Functional MRI Study on Trauma-Unrelated Emotional Processing. Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology. Mar 2016;41(4):1156–1165.