“Long haul cognitive effects of Covid-19” in those who have “recovered” Live zoom presentation by Whittier Rehabilitation Hospital – it was a lively event.

MICHAEL SEFTON

Thanks for those of you who signed on the last night’s webinar.  The Zoom presentation will be available at the Whittier Health website in the next couple weeks if interested. As we learned, even patients’ with mild infection can experience long lasting cognitive impact from the Covid-19 virus in the areas of memory, concentration, mental endurance, organization and verbal expression. There are mental health concerns as well that should not be overlooked.  Recovery from the virus can take weeks to months after the termination of treatment.  

The presentation on the impact of cognitive and behavioral functioning on ‘long haul’ cases is somewhat concerning given the 32 million Americans who have suffered with the virus. This is the second in a series produced by WRH and follows the November 2020 presentation on the psychological impact of the disease.  We will have a post here on the discussion from the webinar in the coming days.  The early studies have shown data from the population in Italy who have recovered from the virus in the first wave of the pandemic.

The Psychological Impact of Pandemic: The best and worst of human behavior

On November 11, 2020, I presented a program on the Psychological Impact of Pandemic sponsored by Whittier Rehabilitation Hospital.  It was well attended with a mix of nurses, midlevel practitioners, social workers, and nonclinical participants. The program was presented on the zoom platform. I am now going to put to paper my perspective narrative espoused in my 90 minute presentation.  I had also invited members of law enforcement with whom I have regular contact as the information was drawn from the growing literature on mental resilience and its positive impact on coping with exposure to trauma.

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According to the PEW Research Group, 4 in 10 Americans know someone who has either been afflicted with Coronavirus or someone who has died from the virus. My mother was infected with the Coronavirus in mid April in the same nursing facility where I lost my 93-year old aunt in the first wave of the virus in May, 2020. My mother survived the virus but it has taken a significant toll on her physical and cognitive well-being. We were not permitted to see my mother during her illness and my aunt was alone on May 1 when she succumbed to the virus. Both living on a nursing unit that was doing its best to render compassionate care under extraordinary conditions, in some cases with nurses, aides, and therapists working round the clock. Both of these loved ones received extraordinary care. Nursing units across the country suffered unimaginable loss of life including over 70 elderly veterans at the Soldier’s Home in Holyoke, Massachusetts.  We all saw the images of refrigerated trucks holding victims in expiated purgatory hidden behind hospitals. It may bring horror to those who lost loved ones and never saw them again.

I saw my mother on November 12. She looked frail and disheveled.  The nurse practitioner had ordered a blood draw out of concern for her physical well-being. She is 92 and may have a blood disorder. They had three staff people hold her in place to obtain the small sample of blood which took over and hour.  She has always had difficulty having her blood drawn and this has gotten worse as she has gotten older. She fought and screamed from pain, and fear, I was told. It was torture for all those involved, including me.

Little did anyone realize the extent of disease, contagion, and trauma this pandemic would bring to the United States and the world. We waited in February and March with curiosity and vague forewarning from our leadership. We were led to believe the virus would dissipate once the weather became warm and it would essentially vanish in the heat of summer. This did not happen and public health officials at CDC and WHO were spot-on in terms of the contagious spread of covid-19 and the deaths it would bring.  Now with the approach of winter our fear borders on panic.

This virus poses significant stress and emotional challenges to us all. It raises the specter of both an overwhelmed medical system as well as increasing co-occurring emotional crisis and a collapse in adaptive coping, for many. Sales of alcohol went up 55 percent in the week of March 21 and were up over 400 percent for alcohol delivery services. Americans were in lock-down and many made poor choices. The link between stress and physical health and well-being is well documented and will be a factor as American’s find their way free from the grip of Covid-19. 

“The human mind is automatically attracted to the worst possible case, often very inaccurately in what is called learned helplessness”

Martin Seligman

Whenever human beings are under stress they are going to utilize skills they have learned from other times when they felt under threat. Chronic stress has been shown to have negative effects on health including autoimmune functions, hypertension, inflammatory conditions like IBS, and pain syndromes. Many find it impossible to think about anything but the worst case scenario. Marty Seligman described the concept of “catastrophizing” that is an evolutionarily adaptive frame of mind, but it is usually unrealistically negative.” This leads to a condition known as learned helplessness. In another book, Dr. Seligman writes about learned optimism published in 1990. His cognitive strategies hold true today.

So many use the same coping mechanisms over and over, whether they are effective or not like drinking or gambling to let off steam. These things may help in the short term but can cause further health and social problems later on. They are not adaptive strategies. Stress is unavoidable and the best thing we can do is to understand its physical impact on us and adapt to it in healthy, adaptive ways. Stress raises the amount of cortisol and adrenaline in the body activating the fight-flight response. For many, that meant an uptick in the procurement of spirits in late March to help bring it down. Others think differently. Many began a routine of walking or running or cycling. Regular exercise contributes to reducing stress and when kept in perspective, is an adaptive response to the threat of coronavirus.

Many people in our hospital were afflicted with the virus or some other health concern and became immersed in loneliness and isolation that can lead to disconsolate sadness. It is hard not to be affected by this suffering. Most reviewed studies reported negative psychological effects including depression, anxiety, post-traumatic stress symptoms, confusion, and anger, according to Brooks, et.al. Lancet 2020. At Whittier, we had many cases of ICU delirium where patients became confused and frightened by healthcare providers wearing PPE including face shields, masks, and oxygen hoods. Many thought they were being kidnapped or that the staff were actually posing as astronauts. This made it hard to help them feel safe and to trust the core staff including doctors, nurses, and rehabilitation therapists.

Michael Sefton

We have had some very difficult cases including a man who found his wife on the floor without signs of life. He fell trying to get to her and both lay there for over 2 days. He was unable to attend her funeral because of his broken hip. We had another man who pushed us to be released from the hospital. He worried about his wife who needed him to assist in her care at home. She has Parkinson’s disease. He was discharged and died shortly after going home. His wife fell while getting ready for his funeral and is now in our hospital undergoing physical rehabilitation and receiving support from our psychology service. The table below is a list of observations from recent admissions:

  • Anxiety – what will my family do while I am here?
  • Deep felt sense of loneliness
  • Depression – loss of support; loss of control 
  • Exacerbation of pre-existing conditions i.e. sleep disturbance, asthma, uncontrolled diabetes, hypertension
  • Slower trajectory toward discharge
  • Debility greater than one might anticipate to diagnosis
  • Subtle triggers to prior trauma – changes in coping, regression, agitation, sleep and mood

What is left for us to do? Have a discussion about what it means to be vulnerable – talk about family members who have been sick with non-covid conditions like pneumonia or chronic heart disease, COPD, etc. It is important to be ready to work from home again such as when schools switched to remote learning this spring and when governors’ call for closing things down. Consider the return of college kids as campus dorms everywhere are likely to close this winter.

The 1918 Spanish Flu pandemic killed 50 million people worldwide. 500 million people were infected with the virus that lasted 2 years. The virus was said to have been spread by the movement of troops in WW I. The website Live Science reported that there may have been a Chinese link to the Spanish flu as well due to the use of migrant workers and their transportation in crowded containers leading to what we now call a super spread event. We know a lot more about this virus than we did in March 2020 when it first took hold but we need to understand the eradication will be a herculean task driven by science.

“The coronavirus has profound impact on the emotional stability of people around the world because of its unpredictability and lethality. It evokes fear, and uncertainty as it spreads unchecked. Later, the virus can serve to trigger long hidden memories in a way that can sabotage healthy human development leading to vague anxiety, physical symptoms, loss, and deep despair” said Michael Sefton, Ph.D. during a recent Veteran’s Day presentation. People must have resilient behaviors that foster “purpose in life, to help them survive and thrive” through the dark times now and ahead, according to police consulting psychologist Leo Polizoti, Ph.D. at Direct Decision Institute in Worcester, MA.

 

Officer distress in Bangkok, Thailand

“Today police morale and emotional health have hit rock bottom, he said, because of a number of factors, including botched policy-making when it comes to their career path that doesn’t take into consideration the officer’s needs and desires.” Bangkok Post December, 2019

And the year 2020 was not any better and very likely triggered added stress and tension among the working wounded in Bangkok and beyond. Shortly after I visited Bangkok, in early 2020 a member of Thai Army service in the Northern Province went off and killed his superior officer and over 20 people in his community. Very rare in the Thai history. My former Chief and I had met another commander from the Northern Province detail and liked him a lot. He smiled and seemed confident before returning to the Northern Province. Gun violence in Asia is rare and mass shootings are more rare still.

Next came the virus. Thailand got out in front of the contagion and closed things down and required both social distancing and masks. The total number of cases per 100,000 souls is much less than here and most other places.

Meanwhile, Thailand is offering a softer, gentler service to those officers who sign on to be law enforcement officers trying to accommodate the needs of the police service.

What are protective factors in law enforcement: Ballistic vests notwithstanding

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Officer wearing ballistic vest

A new paper was just published in the Journal of Police and Criminal Psychology that has to do with high rates of depression in some police officers. It is written by Emily Jenkins (2019) who is a biostatistician and epidemiologist at the National Institute for Safety and Occupational Health in Morgantown, WV.  Her co-authors include John Violante who himself is an epidemiologist and former New York State Trooper now researching police officer health and suicide.  Basically, the authors say there are factors in personality and behavior that serve to reduce the new incidence of depression in LEO’s and to reduce the associated physical debility that may be co-occurring in cases where a history of depression was previously reported. One might see this protection as a ballistic vest for emotional health and career hardiness. High resilience leads to career success, satisfaction, and reduced likelihood of developing depression. Resilience refers to adaptability and flexibility in dealing with stressful situations.  Resilience officers are able to tolerate highly stressful situations without becoming debilitated by stress and negativity.

I find the study interesting but it doesn’t connect with the troops in the field. For example, one feature listed as helpful against depression is “active coping” that includes things like agreeableness, conscientiousness, and having social support. Understanding protective factors leads to understanding who is most at risk of developing depression.  The goal is to reduce depression among LEO’s and lessen the long-term impact of depression once it has been diagnosed.  The paper cites links to depression and poor coping skills to personality features such a high neuroticism and low conscientiousness and low extraversion.  These variables may lead to higher risk for substance abuse, reduced hardiness, and a host of physical signs and symptoms.  These personality features are the biomarkers of chronic stress and its harsh consequences. They make sense to me but I rarely encounter a police officer, or anyone else for that matter that actively thinks about the core set of personality features that have defined them throughout life.

Officers across the country are being trained in peer support and crisis intervention training. At the Direct Decision Institute we are providing a variety of training programs designed for this same issue – increased officer hardiness and reduced risk of burnout, depression, and suicide. These are intuitive concepts and when talking with active duty LEO’s, I feel like the rank and file understand the words they hear but rarely will an officer offer up a personal example of times he or she may have had behavioral health issues. I have heard officers become very emotional when telling the stories of friends who have suffered with mental illness but rarely a personal story.

Two recent exceptions to this notion are Sergeant Mark DiBona, a recently retired sheriff’s department officer from Florida and Joe Smarro, an officer from Texas who is recently featured in an outstanding documentary entitled Ernie and Joe released in May, 2019 with great acclaim.  It should not be this way and there is still great secrecy behind the veil of police service.  It takes great courage to share personal struggles and one’s private experience.  Police officers are most uncomfortable with this. Officers who are signing up for CIT and peer support courses are carefully chosen and may be more open to personal self-disclosure exhibiting greater positive coping skills, hardiness, extroversion and emotional resilience.

In order to reduce stigma associated with law enforcement behavioral health issues all members of the police service need greater self-awareness, openness to self-disclosure, and understanding of the effects of repeated exposure to violence and its broad ranging vicissitudes. This is nothing new and is being taught in academy training. Police psychologists who provide pre-employment screening should analyze the test data carefully and avoid selecting men and women who are most at risk of developing depression and who are outgoing, confident, and emotionally sturdy.

Violence and psychotic people

Among the most dramatic and menacing forms of mental illness are the psychotic disorders. These include people who have uncontrolled paranoid schizophrenia, bipolar disorder, depression with psychotic features, substance intoxication, and perhaps intermittent explosive disorder. Violence is not associated with mental illness per se.  There are factors that increase violent behavior among those who are mentally ill including persecutory ideation like suspiciousness and fear, and co-occurring alcohol dependence.  The most important way in which to reduce violence among citizens who are mentally ill is to provide some form of treatment to them.  Those who go without substantive treatment including psychotherapy are at greatest risk for becoming aggressive or violent according to Coid et al. (2016). These are the citizens who fly above the radar and are seen pacing the street corners in cities everywhere reciting from some unwritten preamble.  People walking avoid eye contact further pushing them to the margins of civility.  Eventually, the bottom falls out and the preamble comes to an incoherent end.  Either they move on or they are picked up for evaluation.

There are even greater numbers of psychotic people living under the radar.  Making their way in society, flying by the seat of their pants.  These people are often cared for by family members including elderly parents. When they relapse or “go off the rails”, caregivers often need the help of police to gain compliance with their loved ones.  Sometimes the police are called to restore the peace and compel the emotionally disturbed person into treatment.  For those individuals who relapse and are substance dependent i.e. alcoholic, the risk for violence is elevated.  These people require special understanding and sensitivity in order to establish a trust and to help them see their behavior patterns and risk taking behavior for themselves.  No easy task.

More recently, meta-analyses and case register studies concluded that psychiatric disorders are associated with violence, but that the relationship is largely or entirely explained by comorbid substance misuse. Fazel et al. (2009)


Fazel S, Gulati G, Linsell, L, Geddes, JR, Grann, M. (2009) Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 6: e1000120.
Coid, JW,  Ullrich, SP, Bebbington S, Fazel, R,  Keers, R (2016). Schizophrenia Bulletin, Volume 42, Issue 4, Pages 907–915, https://doi.org/10.1093/schbul/sbw006 taken May 9, 2019

The Field Training Officer: Important things they may not know

Most departments has active field training protocols that recruits must pass after leaving the academy.  This means they ride along with the FTO until they are ready to function independently as LEO’s.  The specific time line for this depends on FTO daily observation reports during the phases of field training.  These begin with close supervision where the trainee does little of the daily work. In the latter phase of training the FTO may pull back and provide intervention only if needed by allowing the trainee to be the lead on all calls.

Officer resilience depends upon solid field training with adequate preparation for tactical encounters, legal and moral dilemmas, and mentoring for long-term physical and mental health.  Michael Sefton, Ph.D. 2018

Law enforcement officers begin their careers with all the piss and vinegar of a first round draft pick.  This needs to be shaped by supervised field training and inevitably will be effected by the calls for service each officer takes during his nightly tour of duty. Much like competitive athletes, law enforcement officers at all levels exhibit “raw” talents, including leadership abilities and the cognitive skills to go along with them.  Moreover, like competitive athletes, these raw abilities have to be honed, refined and advanced through a combination of modeling, coaching and experience in order for the officer to develop the skills needed to improve performance, as well as prepare them for career advancement according to Mike Walker.  This important task falls upon the field training officer (FTO) and is a critical phase in probationary police officer’s development.  “The FTO is a powerful figure in the learning process of behavior among newly minted police officers and it is likely that this process has consequences not only for the trainee but for future generations of police officers” according to Caldero and Crank (2011).  In 1931 the Wickersham Commission found over 80 percent of law enforcement agencies had no formal field training protocols for new officers entering the field of police work described by McCampbell (1987). In 1972, formalized field training protocols were introduced by the San Jose, CA police department that became a national model for post academy probationary field training.

Just before I was promoted to sergeant while working for a law enforcement agency, USCG Vice Admiral John Currier, a friend of mine said to me: “Michael, move up or move out”.  I wasn’t sure what he meant by that but given my 9 years as a patrolman, I started to lobby for a promotion to sergeant.  The agency at which I worked had little turnover in the middle ranks so I was never sure I would get a chance for promotion.

All law enforcement officers should have a career path when they graduate the academy that lays out a career path based on officer interest, career improvement goals, on-going training interests, and agency needs.  Training opportunities offer new officers the chance to gain experience in anything from specialized investigations i.e. sexual assault and child abuse, firearms instructor, domestic violence risk assessment to bike patrol and search and rescue.  Our chief believed strongly in incident command, active shooter response, and emergency medical technician training.  I went on to take the paramedic technician course at a local college in 2011-2012. In many ways my former agency was well ahead of the curve in training opportunities and tactics including use of body worn video cameras, taser training, stop sticks, and individually deployed patrol rifles.  I was encouraged by my chief to participate in a research opportunity I was offered in domestic violence homicide from a case in northern Maine, a community much like the one I served. From this research we introduced a risk assessment instrument developed by  Jacquelyn Campbell.

The chrysalis for me came in August, 2012 when I was appointed by the Select Board to sergeant at the recommendation of my chief.  Before this could occur, I had put in a significant amount of time developing a field training program, domestic violence awareness and lethality assessment protocols, and police-mental health encounter training. I learned the hard way that most police officers do not like working with citizens with mental illness and hate attending training classes on mental health awareness and crisis intervention training. I realized that I needed to become a leader and in order to do so I needed to become better in communicating with the troops and with those up the chain of command. In order to develop leadership I was sent to sergeants school but what I learned was the importance of being a role model for those in training and to teach by doing, teach by example. I also learned that field training is demanding, exhausting work if done with the precision needed to fully socialize the trainee and provide needed modeling while gradually offering greater independence for the trainee.

cropped-images.jpgField training involves months of practicing ‘what if‘ scenarios, learning the ropes of the police service, use of force, and writing reports. Early in the phase of training the tough discretionary decisions faced by a probationary officer are made by the senior training officer based on prior judgement, experience and what is most prudent for the specific incident and conditions on the ground.  “Agencies should thus maintain a greater degree of FTO supervision, not just trainee supervision. Such an effort would go a long way toward improving FTO programming and better informing the needed research base” Getty et al. (2014, pg. 16). Field training is often time limited with special consideration for officers who need additional training in specific skills or personal areas of concern. Some officers are put on career improvement plans and extended field training, when needed, and some probationers are discharged from the agency because of skills or behavior that are not compatible with police work. Law enforcement agencies want active police officers who represent the core beliefs of the agency and individual community needs.

Field training has perhaps the most potential to influence officer behavior because of its proximity to the “real” job according to Getty, Worrall, and Morris (2014).

Probationary officers can be taught the how and when of effecting an arrest but the intangible discretionary education comes from FTO guidance and socialization that takes place during the FTO training period.  Research has revealed that officers’ occupational outlooks and working styles are affected more by their FTOs than formal “book” training, Fielding, 1988.  The selection of who becomes an FTO is not well defined.  In a study at Dallas PD probationary trainees were exposed to multiple FTOs over 4 phases (Getty et al. 2014).  The study revealed a correlation between new officer behavior – in the 24 months after supervision, as measured by citizen complaints and the FTO group to whom they were assigned. It is conceivable that the results in the study may be due to the relative brevity of training at each phase may have stopped short of instilling good habits or extinguishing bad habits in many new police officers. I have worked in agencies where only the sergeants were the FTO’s by virtue of rank and supervisory acumen long before systematic field training programs were introduced.  In Dallas, results showing officer misconduct via high citizen complaints may too have been associated with unprepared FTO’s who were drafted to supervise the trainee and who were not prepared for that role.

“Bad apple” and/or poorly trained FTOs may thus have a harmful influence on their trainees. Getty et al. (2014)

Choosing successful FTO’s is of critical importance for new officer development and for future generations of law enforcement officers. The values espoused by the FTO have enormous impact on the behavior, habits, and professionalism of new police officers. It has been shown that the quality of this training belies post-supervision job behavior and success.  Haberfeld (2013) has offered a supportive assessment of the assessment center approach to FTO selection suggesting there are qualities that may be quantified in the selection process. This may be helpful in the selection of FTO’s who are professionally resilient and emotionally hardy as they lead the new probationary officer into his career. If officers are randomly assigned to provide field training without forewarning or preparation this may staunch career growth in the probationary LEO.  If this becomes the norm then FTO’s may have provide more of what probationary officers need such as correct values, discretionary wisdom, and perhaps less negative socialization that can lead to embitterment, misconduct, and citizen complaints.

At times of high officer stress when high lethality/high acuity calls are taken the probationary LEO is apt to require greater support and guidance from the FTO. It is during these critical incidents that post hoc peer support and defusing may take place.  Training LEO’s should be permitted to openly discuss and express the impressions they experience to calls that may be more violent, and outside of the daily norm for what he or she has been doing.  In doing so, the impact of these high stress exposures may be mitigated and emotional resilience may germinate. The responsibility of FTO’s to reassure and invigorate trainee coping skill and mindful processing of critical incidents cannot be under emphasized.  FTO’s understand that healthy police officers must be permitted to express horror when something is horrible and feel sadness when something leaves a mark. They will become better equipped in the long run if allowed to fully appreciate the emotional impact that calls for service will elicit in them.  The stigma of high reactive emotions from high stress incidents, i.e. homicide or suicide, is reduced when officer share the call narrative and its allow for its normal human response.

Michael Sefton, Ph.D.
2019

REFERENCES
Caldero, M. A., & Crank, J. P. (2011). Police ethics: The corruption of noble cause (3rd ed.). Burlington, MA: Anderson.
Fielding, N. G. (1988). Competence and culture in the police. Sociology, 22, 45-64.
Getty, R, Worrall, J, Morris, R. (2014) How Far From the Tree Does the Apple Fall? Field Training Officers, Their Trainees, and Allegations of Misconduct. Crime and Delinquency, DOI: 10.1177/0011128714545829, 1-19.
Haberfeld, M. R. (2013). Critical issues in police training (3rd ed.). Upper Saddle River, NJ: Pearson.
McCambell, M. Field Training for Police Officers: The State of the Art (1987). DOJ: NIJ, April.

Law Enforcement – M.H. encounters – New documentary April 27, 2019 in Somerville

A new documentary featuring the law enforcement CIT model of police-mental health response is being featured as part of the 2019 Boston Independent Film Festival.  This entry won a prestigious award the SXSW in its film debut.  As I retired from police work my interest in law enforcement mental health interactions deepened.  As a result I met these officers in San Antonio was was taken for some days of first hand observation of their work.  The documentary took 2 years to complete and gives the viewer a front row seat in the model from San Antonio PD and Bexar County that works. The film debuts here in Boston at the Somerville Theater in Davis Square on Saturday April 27, 2019.  I strongly urge readers in the area to attend.

In many police agencies the call volume for mental health encounters is at or above 50 percent. That means that every other call for service requires that officers dispatched to the call have an understanding about encounters with citizens experiencing a mental health crisis. Many LEO’s lack training and are uncomfortable with these calls. Importantly, this does not mean that 50 percent of all calls involve mentally-ill citizens but those individuals experiencing some behavioral health emergency – like a job lay-off or impending divorce or financial problems. They are not mentally ill and should not be treated any differently than any other 911 call for service. Police are often called when bad things happen to normal individuals who become emotionally overwrought often made worse by chronic use of alcohol or drugs.

Training for encounters with citizen’s experience a mental illness is part of the early career academy education. Many officers are provided 40 or more hours of crisis intervention training (CIT). In-service programs are being introduced across the country because of the importance of having expertise and understanding in basic de-escalation. Agencies around the country are playing catch up in learning how best to deal with abnormal behavior. Police in Albuquerque, NM are using a monthly supervision model where the department psychiatrist case conferences specific calls and officers learn techniques for de-escalation and process details about how better to respond to future calls.

Crisis intervention training teaches law enforcement officers what to expect and allows them to practice using role playing to see for themselves how to intervene with people in crisis using de-escalation techniques. “Law enforcement officers’ attitudes about the impact of CIT on improving overall safety, accessibility of services, officer skills and techniques, and the preparedness of officers to handle calls involving persons with mental illness are positively associated with officers’ confidence in their abilities or with officers’ perceptions of overall departmental effectiveness. ” Bonfine, 2014. “When a police officer responds to a crisis involving a person with a serious mental illness who is not receiving treatment, the safety of both the person in crisis and the responding officer may be compromised especially when they feel untrained” according to Olivia, J, Morgan, R, Compton, M. (2010).


Bonfine N, Ritter C, Munetz MR. Police officer perceptions of the impact of Crisis Intervention Team (CIT) programs. Int J Law Psychiatry. 2014 Jul-Aug;37(4):341-50. doi: 10.1016/j.ijlp.2014.02.004. Epub 2014 Mar 11.PMID: 24630739

Olivia, J, Morgan, R, Compton, M. (2010) A Practical Overview of De-Escalation Skills in Law Enforcement: Helping Individuals in Crisis. Journal of Police Crisis Negotiations, 10:15–29.
While Reducing Police Liability and Injury

Police officer vulnerability previously ignored, hidden from plain site

What is currently understood as repeated exposure to trauma and its emotional impact was once thought to be a testament to toughness invoking the specter of a wall of silence. Law enforcement and first responder suicide has increased over the past several years and now exceeds the number of LEO’s killed in the line of duty. Why are cops choosing to take their lives? This is especially felt in Chicago where seven officers have taken their own lives in the last 8 months. In more than one case an officer committed suicide in the police vehicle or in the police department parking lot.

My colleague Dr. Leo Polizoti, Police Consulting Psychologist at the Direct Decision Institute, Inc. has been active in law enforcement training, fitness, and prescreening for over 40 years. He served over 30 agencies across New England and provides supportive psychotherapy as needed.

Dr Polizoti and I were recently involved in a symposium on Police Suicide in Chicago sponsored by Daninger Solutions from Daytona Beach, Florida. Among the presenters were Dr Thomas Joiner from the University of Miami, recognized expert in suicide, police sergeant Mark Debona from Orlando, Florida and Dr Daniel Hollar, Chairman in department of Behavior Science at Berthune-Cookman University in Tallahassee, Florida and CEO at Daninger Solutions.

There are many reasons why police officers have an increased levels of depression and stress.  Most are associated with repeated exposure to traumatic events like exposure to dead bodies, violence, childhood injury or death, terrorism, fatal car crashes, and more.  Most officers are able to remain professionally hearty when provided the opportunity to defuse the exposure soon after an incident. Career performance should include reducing officer depression and embitterment by building resilience starting in the academy and lasting throughout an LEO’s career.

The Mind-Body connection is well established and the role of stress in LEO career well-being is becoming a agency focus beginning in the academy.

“Not only must we as negotiators learn to take care of ourselves emotionally and physically – we must also be prepared to intervene with an actively suicidal officer. “

Dave DeMarco FOX News Kansas City

Is it any wonder officers lose hope and resilience.  There are inherent risks that LEO’s assume when they sign on like forced overtime, changing shifts, off-duty court appearances, the chance they may become injured, disabled or killed while serving the community.  There are also systemic stressors like supervisory bullying, professional jealousy, lack of opportunity to have an impact on policy, career stagnation, and paramilitary chain of command that often devalues education and innovation.  Agencies are beginning to track exposure to trauma and its correlated change police officer resilience in real time.

In Worcester, Massachusetts, LEO’s are required to attend defusing sessions following high lethality/high acuity exposure.  These sessions are kept private from members of the command staff and records are saved by the police consulting psychologist. The department has nearly 500 officers who are paid for their participation when they attend. It has been proposed that officers undergo annual “wellness checks” as a routine in some agencies such as KCMO. I have proposed a system of tracking officer call acuity and invoking mandated behavioral health assessment after a specified number of high acuity/high lethality calls for service. This is one way of reducing the stigma that officers face when they are sent for “fitness” evaluation or any sort of behavioral health care. The stigma associated with mental health may be reduced by having specified referrals following identified high profile incidents. Officers may be considered to be getting peak performance training at these defusing sessions as they are designed for enhancing officer awareness and reducing the human stress response.

Now, the KCMO department has mandated yearly wellness exams for officers in certain units like homicide and those dealing with child abuse. This was initiated to decrease the impact of traumatic events on police officer well-being. Officers at KCMO can also get up to six free anonymous visits to a mental health clinician each year, and the department has a peer support team.  Mental health clinicians must have experience working with law enforcement officers for best results.  Training for clinicians should be provided to best work with LEO’s and first responders. This is especially true for officers who self-refer.  Clinical hours should be supervised by the police consulting psychologist.

Police Stress Intervention Continuum: An introduction for LEO’s and command staff to reduce officer suicide

Scope of the Problem: Police Suicide and the goal to eliminate it
Police job-related stress is well-identified and reported in the media daily and the rates of suicide nationwide are being debated by Aamodt and Stalnaker. They are actually less than one is led to believe but even one law enforcement officer suicide is too much.
Stress is defined as any situation that negatively impacts an officer’s well-being. The rate of suicide and divorce among law enforcement is approximately the same or lower than the general public according to a meta- analysis conducted by Professor Michael Aamodt.  But there are areas in the country and agencies that have higher rates of self-inflicted death.
When the suicide rate of police officers (18.1) is compared with the 21.89 rate for a comparable demographic population, it appears that police officers have a lower rate of suicide than the population according to Aamodt, 2008.
Incidence of suicide tend to be elevated in cities like Chicago, where chronic gun violence and a murder rate in the hundreds per year means cops see a staggering amount of trauma and may gradually become numb to the exposure of pain and suffering (Joyner, 2009). A Department of Justice report found that the suicide rate in the Chicago Police Department is 60 percent higher than the national average.  According to the Chicago Sun Times, in a note to department members Wednesday, CPD Supt. Eddie Johnson said, “Death by suicide is clearly a problem in Law Enforcement and in the Chicago Police Department. We all have our breaking points, a time of weakness where we feel as if there is no way out, no alternative. But it does not have to end that way. You are NOT alone. Death by suicide is a problem that we can eliminate together” CST September 12, 2018.  Chicago PD is not alone with the problem of suicide among its men and women in blue.
Law enforcement officers (LEO’s) encounter the worst of all experience on a routine basis. The people who call the police may be society’s best upstanding citizens but on this occasion it could be the worst day of their lives and they seek help from police.  Many times it is not the pillars of society seeking help but those people in the fringes or margins of society now victims of violent crime or abuse.
According to Hartley, et.al., 2007, “repeated exposures to acute work stressors (e.g., violent criminal acts, sad and disturbing situations, and physically demanding responses), in addition to contending with negative life events (e.g., divorce, serious family or personal illness, and financial difficulties), can affect both the psychological and physiological well-being of the LEO population.” When these officers are identified there needs to be a planned response using a peer support infrastructure that provides for a continuum of service depending upon the individual needs of the LEO and the supports available. In many agencies, especially smaller departments lacking resources, officers’ languish and sometimes spiral downward without support and without somewhere to turn.  Police officers must have support available to them long before they are expressing suicidal urges.
As programs are identified and service continuum grows the risk of peer conflict over perceived betrayal of trust must be addressed. This must be addressed in the peer support training with emphasis on preservation of life over maintenance of confidentiality or the status quo of abject silence. “In itself, it’s a product of centuries of police culture in which perceived weakness is stigmatized. Cops know their brothers have their back, no matter what, but they still don’t want to be seen as the one who’s vulnerable.” according to a recent Men’s Health article written by Jack Crosbie in a report about suicide in the NYPD published during Mental Health Awareness month in May 2018.
The argument is made that the recurring uncertainty of police calls for service often leave LEO’s with low-level exposure to trauma of varying degrees. It is common that LEO’s move from one violent call to the next without time to decompress and process what they have seen.  The repeated exposure to trauma can slowly whittle away LEO resilience – defined as the capacity to bounce back from adversity. In a national media study published by Aamodt and Stalnaker, legal problems were a major reason for the law enforcement suicides yet no other study separately cited legal problems. In another study, relationship problems accounted for the highest percentage of suicides at 26.6% (relationship problems plus murder/suicide), followed by legal problems at 14.8%. In nearly a third of the suicides, no reason was known for LEO suicide.
Police suicide has been on the radar of advocates of LEO peer support for months or years.  The incidence of suicide has remained stable across the country but some agencies have higher rates of suicide.  Smaller departments – those with less than 50 officers in general have the highest rates of suicide.  This may be linked to the lack of availability of peer support programs and a paucity of local practitioners to provide professional service with knowledge in police psychology. “While police officers may adapt to the negative effects of chronic stress, acute traumatic incidents necessitate specialized mental health treatment for police officers (Patterson, 2001)”.  A referral to the department EAP often falls flat and makes it more difficult to make the hand-off when peer support is not enough.
Real-time model of change
The use of force continuum is well described in the LEO literature and ongoing criminal justice narrative. What does that have to do with stress intervention in police officers? It sets the tone for officer behavior whenever they meet potential resistance and or increased aggression during citizen encounters. It may also be used for initiating peer support needs whenever an incident use of force has occurred.  LEO’s change the force response based on the situation they encounter in real-time in a flexible and fluid manner. In this same way, peer support programs can flexibly shift to the needs of a presenting LEO and intervene early on – rather than when an officer is at a breaking point. “This continuum (use of force) has many levels, and officers are instructed to respond with a level of force appropriate to the situation at hand, acknowledging that the officer may move from one point on the continuum to another in a matter of seconds.” NIJ publication.  Peer support too, must accommodate a law enforcement officer in real-time to begin the process of building a healthy, resilient response to sometimes horrific exposures and provide a continuum of unbiased employee assistance and when necessary professional consultation.
Protective Factors begin in Academy training
What topics should addressed while LEO recruits are in training?  Ostensibly, the resilience of LEO’s depends upon the opportunity for in-service training in topics of mindfulness, stress management, physical health maintenance, nutrition, and trust.
“Emotional resilience is defined as the capacity to integrate the breadth of police training and experience with healthy, adaptive coping, optimism, mental flexibility and healthy resolution of the traumatic events. In general, resilient people are self-reliant and have positive role models from whom they have learned to handle the stressful events all police officers encounter” according to Leo Polizotti, Ph.D. a police consulting psychologist (Sefton 2018).
Police programs for health maintenance
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The Police Stress Intervention Continuum or P-SIC, involves a system of police support that varies in its intensity depending upon the continuum of individual needs of the LEO including physical debility or other significant components impacting career success and satisfaction. The intervention protocol is flexible and fluid as well. The entry point into the peer support continuum initiates from supervisory observations of LEO history and behavior, peer recommendations, and exposure to a range of traumatic events.

 

Generally speaking, a police officer’s behavior change is a function of the resilience they develop throughout their careers. Greater attention to physical health and emotional well-being are now being espoused in police academies across the country.   Greater awareness of the correlation with the recent trauma and frequency of exposure to trauma such as the death of a child, exposure to dead bodies, suicide of a colleague, etc. have negative impact on officer well-being.  Perceived support from supervisors and the organization hierarchy builds resilience.

Career success requires that officers learn stress tolerance and healthy habits to manage the daily challenges of police service. Physical exercise and healthy routines often afford the stressed officer an outlet for reduced risk of stress-related physical afflictions in addition to the emotional and health effects of repeated exposure to unpredictable violence.

The cumulative stress associated with a career in law enforcement cannot be understated.  In the setting of police stress and stress support there is an intervention protocol that relates to the peer-support program continuum.  Depending on where officers enter the peer support network will impact the level of intervention they may require in the P-SIC program.  Peer support is not psychotherapy but officers occasionally must hand off the officer in trouble to a  higher level of care.  These hand-offs are key to linking at-risk LEO’s with range of professional support needed to keep them on the job. Yet fear of reprisal for acknowledging the cumulative impact of stress and its impact often derails the hand-off to the professional. The highest risk for suicide to a LEO is when he is denuded of badge and gun because he may be a threat to himself.
The career success they have may be directly related to the application of resiliency training to build and maintain physical and emotional hardiness that lasts a lifetime according to Leo Polizoti, 2018. Before this can happen the stigma associated with reaching out must be reduced.

Points of entry to Peer Support – Stress Intervention Continuum
copyright Michael Sefton
  • Exposure to highly stressful events in close sequence
  • Change in work assignment, district/station, deployment undercover or return from deployment
  • Increased absenteeism – over use of sick leave
  • Increased use/abuse of substances – impacting job functioning, on-the-job injury
  • Community – citizen complaint(s) for verbal abuse, dereliction of duty, vehicle crash
  • Citizen complaints of excessive force during arrest, supervisory or peer conflict, or direct insubordination.
  • Abuse of power using baton, taser or firearm, recurrent officer involved use of force. Officers are sometimes strongly embittered and angry at this point in their career due to perceived lack of support and powerful feelings career disappointment and alienation.

NIJ Publication (2009). Use of Force Continuum. https://www.nij.gov/topics/law-enforcement/officer-safety/use-of-force/Pages/continuum.aspx. Taken November 17, 2018
Aamodt, M. G., & Stalnaker, N. A. (2001). Police officer suicide: Frequency and officer profiles. In Shehan, D. C, & Warren, J. I. (Eds.) Suicide and Law Enforcement. Washington, D.C.: Federal Bureau of Investigation.
Aamodt, M. (2008). Reducing Misconceptions and False Beliefs in Police and Criminal Psychology. Criminal Justice and Behavior 2008; 35; 1231 DOI: 10.1177/0093854808321527.
Patterson, G T. (200l). Reconceptualizing traumatic incidents experienced by law enforcement personnel. The Australian Journal of Disaster and Trauma Studies, 2.
Joyner, T. (2009) The Interpersonal-Psychological Theory of Suicidal Behavior: Current Empirical Status. Science Briefs, American Psychological Association, June.
Sefton, M. (2018). Police Training: Revisiting Resilience Blog post: https://msefton.wordpress.com/2018/07/27/police-training-revisiting-resilience/. Taken November 18, 2018
Hartley, T., et.al.(2007). Associations Between Major Life Events, Traumatic Incidents, and Depression Among Buffalo Police Officers. International Journal of Emergency Mental Health, Vol. 9, No. 1, pp.
John M. Violanti, Anna Mnatsakanova, Tara A. Hartley, Michael E. Andrew, Cecil M. Burchfiel. (2012). Police Suicide in Small Departments: A comparative analysis. Int J Emerg Ment Health. Published in final edited form as: Int J Emerg Ment Health. 2012; 14(3): 157–162.

What is driving the killing: Update on the Myth of Mental Illness

After a spate of bomb threats and mass shootings there are still many myths about the attribution of these events and the underpinnings of violence.  The knee jerk reaction is to attribute the recent Thousand Oaks, CA nightclub shooting to a “crazed gunman” but that would unfairly place the blame on the mentally ill.  12 people were left dead in a despicable sequence of events during which the shooter Ian David Long posted that he had no reason for doing it except boredom.  In truth, most people with mental illness are not dangerous, and most dangerous people are not mentally ill.” Liza Gold, 2013. But Long had a history of violence and aggressive behavior that may have been linked to his service as a decorated US Marine. Published information suggests Long’s mother was terrified of making him angry out of fear that he would harm or kill her. Was Long’s terminal behavior attributable to mental illness or the result of traumatic events he experienced in the service of his country?
“Fact is I had no reason to do it, and I just thought….(expletive), life is boring so why not?”  Ian David Long via social media post (now removed)
Psychological experts believe mentally ill persons lack the higher order planning to execute the complex steps necessary for anything more than petty crime – more often associated with co-morbid substance abuse.  It is the co-occuring illness of drug or alcohol addiction that is a confounding variable in all police-mental health encounters.  “Doctors and scientists know that the perpetrators of such violent behavior including incidence mass shooting events are frequently angry young men, who feel they have been mistreated by society and therefore seek to exact revenge” described in a BBC the report Criminal Myths published in November.
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“Confounding variables such as a history of childhood abuse or use of alcohol or drugs can increase the odds of violence.” according to a BBC report debunking the belief that people who commit mass murder are mentally ill  by Rachel Newer in November, 2018.  The vast majority of cases are committed by a person or persons without mental illness.  In fact, people with mental illness are more likely to be victims of crime and are not prone to violent behavior. The Thousand Oaks killer refused any mental health support and was not driven by demons
The interaction of substance abuse and mental illness is complex.  Persons with drug and alcohol addiction must be expected to become sober with the help of substance abuse treatment and family support. The risk of violence and suicide declines when sobriety can be maintained.  This is essential and will help to reduce officer involved use of force against the mentally ill substantially.  What to do?

Red flag indicators are often demonstrated in behaviors that are observable and measurable sometimes for weeks and months before the terminal event according to Michael Sefton, 2015.

The incidence of mental illness leading to mass shooting may be illustrated in the 2007 Virginia Tech shootings.  The Virginia Tech shooter Seung-Hui Cho had been treated for depression and was hospitalized on an involuntary basis prior to the rampage in 2007. Cho exhibited a life-long pattern of withdrawal from interpersonal relationships. He was often nonverbal and did not respond to people who reached out to him including direct family members.  His mother prayed for God to transform her son.

I strongly believe that mental illness does not mitigate citizens from responsibility for crimes they commit. I agree that alternative sentencing may be a powerful tool to bring these individuals into treatment. The substantive goal of streamlining encounters between police officers and citizens who suffer with untreated emotional problems belies the mission of these gifted officers and can teach others the role of discretion in mental health encounters.

Ostensibly, building relationships with network psychotherapists, physicians, addiction specialists, court judges, and other support service like Child and Family Services is essential. This is the area of most vulnerability.  When LEO’s fully buy-in to the mental health – police intervention model including the use of de-escalation techniques there must be receiving facilities available to initiate treatment and keep patients and citizens safe. The development of a fully integrated infrastructure for jail diversion, intake, and providing for the needs of the mentally ill is certainly a work in progress.

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Washington POST photo

“And when it comes to mass shootings, those with mental illness account for “less than 1 % of all yearly gun-related homicides” a 2016 study found. Other studies indicate that people with mental disorders account for just 3-5 % of overall violence in the US”  – Paul Appelbaum, M.D. taken from BBC by Rachel Newer 11-1-2018


Nuwer, Rachel (2018) http://www.bbc.com/future/story/20180509-is-there-a-link-between-mass-shooting-and-mental-illness taken 11-10-2018
Sefton, M. (2017) https://wordpress.com/post/msefton.wordpress.com/4561
Mentally ill American’s and their proclivity to act out against authority.
Washington Post (2007) Rescue and Recovery: A story of resilience that began with the scene in this photograph, Blog post: taken on April 16, 2007. https://www.washingtonpost.com/graphics/local/virginia-tech-five-years-later/?noredirect=on&utm_term=.cd170ba2ac09 taken 11-10-2018
Sefton, M (2017) Police as crisis interventionist: CIT as it is meant to be. Blog post: https://wordpress.com/post/msefton.wordpress.com/3653 Taken 11-10-2018
Sefton, M. (2015) Unappreciated Rage: The Dissembling Impact of those living in the Margins. Blog post: https://msefton.wordpress.com/2015/08/27/unappreciated-rage-the-dissembling-impact-of-those-living-in-the-margins/ Taken 11-10-2018