Stress and Burnout: Understanding the human stress response and its malignant power to impair

The neurobiology of burnout starts with high levels of stress hormones coupled with perceived lack of efficacy and fatigue

Stress is well-known to the medical community and is treated with lifestyle adaptation and management of symptoms and disease. Once stress becomes too intense, it has a measurable impact on one’s own health.  I have posted blogs about a variety of stressful circumstances, some are associated with personal behavior and lifestyle choice; others are more in line with exposure to traumatic, stressful events experienced by first responders like members of law enforcement or front line healthcare providers. 

As well as impacting professional growth, research suggests that extreme stress levels can impair social skills, overwhelm cognitive ability, and eventually lead to changes in brain functioning. People who under constant stress pay a price in being unable to fully relax. They report feeling under constant threat from forces beyond their control and being stuck running in place. “In a recent study, job satisfaction, overall there were little differences between groups in ratings after a mindfulness program. The study looked at the impact on job satisfaction among members of a university faculty using weekly mindfulness meetings. Among those who participated, there was a significant link between feeling calm and relaxed, and greater workplace wellbeing, with those reporting less stress and anxiety also noting higher levels of job satisfaction according to Dr. B. Grace Bullock reporting on an Australian study in efficacy of mindfulness training.

Burnout can leave people exhausted, unmotivated, anxious and cynical – the consequences of which can be catastrophic to business and front line workers across all sectors of society. This is especially true among healthcare workers, where the stigma associated with mental illness still enables silence among those most in need. It is the real deal and probably underlies the recent exodus of nurses, doctors, police officers, and other front line professionals who have had enough and are moving on from their jobs. At our rehabilitation hospital more and more staff nurses are opting for a shorter commute by changing jobs. Some are leaving to become stay-at-home mothers after 18 months of fighting the fight with the virus, all the while their children were home in quarantine – going to school on their laptop computers.

“In a recent study, job satisfaction, overall there were little differences between groups in ratings after a mindfulness program but there was a significant link between feeling calm and relaxed, and greater workplace wellbeing, with those reporting less stress and anxiety also noting higher levels of job satisfaction. B. Grace Bullock 2017

Stress tends to create significant reactivity within the body. This brings forth rampant chemical flooding by the adrenal cortex and other stress hormones. These chemicals can add to a decline in physical well-being.  These over active hormones are lethal for the medically infirm and physically vulnerable. Yet, for some people, stress is like a drug and creates a circular pattern of sensation seeking as described in the prototypic type A personality.

 The neurobiology of stress and PTSD is being studied and may be linked to primitive brain circuits involved in the fear conditioning response and its eventual, sometimes refractory extinction or habituation of on-going perceived threat (Do Monte, Quirk, Li, and Penzo 2016). As an example, Police work carries with it a neurobiological underpinning that is well documented in terms of the impact of repeated stress and exposure to traumatic events. 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. “The human brain, having evolved to seek safety in numbers, registers loneliness as a threat” as reported in a recent NY Times piece. 

Stress effects all aspects of how we feel. Most physicians know that mindfulness techniques lower subjective levels of stress. However, even though paced breathing puts the brakes on sympathetic overdrive, people do not use it long enough to create habits. “Meditating”, according to Dr. Woolery-Lloyd, initiates “the relaxation response,” which activates the body’s parasympathetic nervous system and decreases cortisol and inflammation.” Yet even our primary care physicians and physicians in emergency rooms across the country are at risk from frontline stress, burnout and area at higher risk of suicide. This taken from a story written by Jessica Defino about the impact of stress on human skin in NY Times on 12/08/2020. The point being that the stress response is pervasive in human functioning and can wreak havoc on physical health including the integumentary system – our largest organ – our skin.

“Why don’t we come up with a program before bad things happen?” asked Dr. Englert. “Bad things are going to happen. When they do, the person, the individual, and their family will be more resilient, more able to recover quickly from that event.” said Alexa Liacko, ABC News interview. It is in being vulnerable that we are able to stretch our emotional experience that brings forth growth and reduces stigma. You cannot expect frontline healthcare and first responders to walk through water and not get wet.


Lloyd, C et al. (2002) Journal of Mental Health 11, 3, 255–265

Get rid of behavioral health stigma once and for all

This video is about an introduction to a post that will be forthcoming in a short while it is reference to law enforcement officers and the suicide death of officers who carry trauma. The video tells about LEO stigma associated with officer behavioral health and its decline. In it, Michael Sefton, Ph.D. describes the need for understanding fluctuating moods among mid-career law enforcement officers – those most at risk for trauma-related crisis. Sefton implores departments everywhere to analyze deaths by suicide for consideration of “line of duty” designation. In stigma, behavioral health problems are 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. He published a report about suicide in the NYPD during Mental Health Awareness month in May 2018. Over 300 clinicians and law enforcement personnel came together at police headquarters in Manhattan in April 2019 in an effort to take on law enforcement suicide. I sat amongst a row of NYPD sergeants and enjoyed their company as we learned about how to let go of the stigma and understand the impact of personal job-related experience.

In order to be considered for line of duty status following suicide, law enforcement must offer annual stress assessments and tracking and defusing after high lethality incidents. This will link any stress and behavioral health issues to calls for service that officers had during the reporting period. Just as psychological screening is done pre-employment, so too should annual stress assessments be undertaken for officer longevity and career satisfaction. Men and women found to have an elevated stress response and symptoms may rotate to other roles in the department while receiving support. After a period of time they return to their prior status and duty. This is more difficult to achieve in smaller or more rural agencies.

“The NYPD is making use of psychological autopsies, a research-based approach that attempts to better understand why someone took his or her life.” 

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.” This is well known. But there are factors that interfere with coping as stress increases. These factors must be studied and applied to law enforcement officers who are most at risk. Those officers who grow more distant and see fewer and fewer options for life. It is in this decoupling of frontal decision making and problem solving circuits and the narrowing of focus that suicidal behavior becomes a plausible next step. At some point, a suicidal person believes there are no other choices and that the world would be a better place without him or her.

The run away fight/flight mechanism that keeps us on guard plays a primary role on how people feel after episodes of high stress, both normal and abnormal. Career longevity depends upon developing healthy coping skills to deal with all life has to give including accumulated traumatic experiences. Feelings of frustration, irritability, lack of focus, chronic fatigue, and even depression can result from an over reliance on social media stimuli like an unfed addiction. 

The domestic killing of another Gabby Petito: Send me dead flowers and I won’t forget to put roses on your grave

Gabby Petito with boyfriend Brian Laundrie on cross country trek
By all appearances Gabby was a smart and loving companion. She wanted to impart her love for Brian Laundrie and the life she hoped they would have together using social media. They were engaged to be married but this would never occur. Now she is the victim of homicide. “The loneliest time in a life is being in the wilderness in the middle of night, with a person you once loved, now killing you. “If you scream for help in the wilderness and there is no one there to hear it except your killer, was there ever really a scream?”” Personal correspondence from B.F. Gagan. New website: http://www.arrestbrianlaundrie.com for details on the $25,000 reward for finding Brian Laundrie. Details on the site. There have been at least 11 questionable tips transmitted to the FBI tip line as of October 4, 2021. The media reports keep Laundrie’s picture in the news cycle.  Just today someone reported seeing him on the Appalachian Trail where hikers go from Northern Georgia and finish at Mount Katahdin – the highest peak in Maine. Mr. Laundrie has done parts of the trail and is familiar with its isolation from society. He may feel that he can make a safe getaway while remaining off the grid. But someone recognized him today in South Carolina. Or a look alike. 
Gabby Pitito is a case study for intimate partner abuse. From the outside, we saw a beautiful couple enjoying the wonders of the American West. Social media accounts updated with regularity bringing hundred or even thousands of likes. Gabby had a gift for creating an image.  Only now have we learned the imagery was deeply flawed. Friends of the pair described Brian Laundrie as a jealous and controlling partner as described by Rose Davis, a friend of Gabby Petito.  Common among abusive partners is separating intended victims from their emotional support systems leaving them isolated and without friends and needed help. It is a common red flag in most cases of domestic abuse and more commonly, domestic violence homicide. In most cases the abuser has an underlying pathological jealousy and in some cases, delusions of his partner “hooking up” with someone whenever she is out of his site. Once while on duty with the police agency for whom I served, a jealous husband came crashing into town hall hoping to catch his wife in a tawdry affair while she stood in line to cast her vote in a 2015 election. He had been sending her text messages from the parking lot like “Where are you? Who are you with?” Ultimately, the man needed an escort out of the building and was given a trespass warning. For her part, she felt pangs of guilt, resentment, and fear for keeping him waiting. Shortly after Election Day the family moved away from town. It happens all the time. 
“You can’t say that nothing can be done, because nothing will be done,” said Michael Sefton, a former Westbrook police officer who now works in Massachusetts and retired from the the New Braintree Police Department.
Women are kept from seeing friends and family members in an effort to disempower them of any sense of self. We now know this got worse during the pandemic where people were isolated anyway and those living in domestic fear became further inhibited and marginalized. By outward appearance Gabby Petito was terrified of her boyfriend at the time they were stopped in Moab, UT. This behavior speaks volumes about the state of the relationship just as Supervisory Agent Melissa Hulls said after they encountered Gabby and boy friend Brian Laundrie in late August 2021. I have reached out to Supervisory Ranger Hulls on two occasions without hearing back. I am interested in hearing from few friends of Gabby Petito with their appraisal of what they saw happening to the couple during pandemic? The pair had been together over 2 years and managed to get through waves of pandemic only to be set free on the cross country junket. Both seemed physically fit and healthy. Had the pandemic and subsequent quarantine changed them in any way? How did the couple decide to embark on this journey? Whose idea was it?  “Brian has a jealousy issue,” Rose Davis of Sarasota, FL said in the September 17, 2021 New York Post article. “I’m her only friend in Florida to my knowledge and that’s not because she can’t make friends, he just didn’t want her to have friends.” Gabby Petito and Brian Laundrie at the Narrows in Zion National Park on July 18th.

Rose Davis says Gabby Petito and Brian Laundrie progressively got into “more and more arguments.”
“He was always worried she was going to leave him,” she said. “It was a constant thing to try to get us to stop hanging out.” She previously described him as a controlling and manipulative boyfriend with jealousy issues, and said Petito had sometimes stayed with her to put some space between them according to the New York Post interview with Davis. These are among the most common red flag warning for DV and DVH.

Supervisory Park Ranger Melissa Hulls
The Moab city Utah police were called to a possible case of domestic violence. The interview was caught on officer worn body camera and showed Gabby in an anxious, tearful state. Any physical signs should have been met with arrest of the likely perpetrator whether or not Gabby wanted to prosecute. The police report from Moab indicated that the officer believed something was not right! But he did not move on that feeling or was untrained as to what he might anticipate could happen next. She reported that her mental health was not good. Why? Was she in fear that the relationship was fragile and taking an unhealthy turn. Had the fuse been lit? At the very least Gabby should have been assessed for changes in her mental health and given her history, law enforcement missed the chance to understand the  underpinnings of her sudden loss of control and tearful anxiety? The care-free beginning of the exciting trip became suddenly serious enough to get on the local police department’s radar. A female national park ranger Melissa Hulls interviewed Gabby along side officers from Moab. She tried to advise Gabby that her relationship with Laundrie was had become toxic and put her in jeopardy. And just as quickly, Gabby and her fiancee fell off the police radar, leading Gabby into oblivion. Ranger Melissa Hulls saw the relationship for what it was and very likely feared for Gabby’s safety. Most murder-suicides involve intimate partners (72%) and the vast majority of these cases are women murdered by intimate partners using a firearm (Violence Policy Center, 2015). I have experience with domestic violence and the various red flag warnings of terminal anger and have tracked the downward spiral of a sick relationship. “We knew the system had failed Amy Lake” said Brian F. Gagan, a former Westbrook police officer who helped research the first psychological autopsy report, “We did not know how.” as published in the Portland Press Herald 11/30/2011. We learned plenty over the course of 200 hours of interview data and considered only confirmable facts and presented the findings to the Maine Attorney General’s Domestic Violence Homicide Review Board in the state’s Capitol. At very least, in the death of Gabby Petito, Brian Laundrie’s parents must be charged with harboring a fugitive, and aiding in the escape of a person of interest following a murder. The senior of the two responding officers in Moab is at risk of state decertification and may be charged criminally with statutory Utah failure to arrest. The officer will grope for the excuse that “neither party wished to charge” …which is not material to “Utah Mandatory Arrest”, according to Gagan. Gabby Petito’s body was found Sunday 9-20-2021 near an undeveloped camping area that’s surrounded by woodlands and brush, located about 30 miles (48 kilometers) northeast of Jackson, Wyoming. Her death was a murder according to the county medical examiner who has released very few details. Research has shown time and again that separating the couple for a “cool off” time out does little to stop domestic violence and often makes the violence increase. Meanwhile, I have seen the “neither party wants to prosecute” narrative too many times in my law enforcement career until there is serious injury to one of the partners – usually the female. I am fortunate to have never had a case go to the terminal stage of DVH, aside from Albert Flick – a Westbrook, ME case from 1979, police detectives Ron Allanach and Wayne Syphers handled while I was in the Juvenile Bureau. Flick went on to kill again, within weeks of his release from prison for killing a woman while her children looked on. The domestic victim never wants to prosecute because they have been conditioned against doing so over the years and are afraid they will be killed. Those most in fear of being killed by their partner are likely reacting to a primitive warning signal in the brain. The gift of fear  with a book by the same name highlights the subtle but powerful fear some women feel during courtship with violent men.  So, when these fears are realized, the terminal stage of violence begins the spiral downward when a domestic partner can no longer bind his angry, jealous impulses, and need for control. In spite of what the intimate partner may report to be deep felt “love” for his wife, girlfriend, and innocent family members, it comes down to murder for the sake of owning the life of a spouse and his children and feeling justified in his action. Gabby Patti’s cell phone has never been mentioned in published reports nor has her expansive social media reporting been studied. We have recommended that a safety plan be written omitting all social media whatsoever.  Everyone has a cell phone that can be tracked using triangulation data from cellular towers anywhere there is service. People who are lost can be easily found as long as cellular service is available and phones are properly charged. This is significant given her daily social media focus. It is certain the FBI has received all cell server data from both phones. This has likely contributed to the warrant issuance and national search. The cellular data was added to toll highway data from Colorado and Texas while Laundrie was on his way to Florida from the murder scene in Wyoming. It is also likely now that the Bureau is encircling his parents who may have helped him escape. At least one of them will be convinced to tell the truth because I am certain they are now being interviewed separately. They now cannot lie to protect the killer since there is now a federal warrant on him. If they do, they are then arrested and charged with being complicit in Gabby’s death. This case requires careful analysis once the murderer has been officially charged or found dead. By not doing so Gabby Petito’s death became another invisible young woman who wrongly believed she was safe and with the love of her life. After seeing the body worn police encounter, Dr. Ziv Ezra Cohen, a clinical assistant professor of psychiatry at Weill Cornell Medical College of Cornell University and staff member of New York-Presbyterian Hospital, told Fox News Laundrie and Petito were ‘both minimizing their argument’ and said the footage suggested the couple may have been high and having ‘a bad trip.’ (Fox News story). The psychologist cast doubt on the couple’s efforts to explain away the fight as caused by Petito’s OCD, insisting that the condition is ‘not a risk factor for violence.’ Petito expressed anxiety through her tears perhaps with an impending sense of doom.  ‘People with OCD are not violent. OCD is not a risk factor for violence. If there was an altercation between them, certainly OCD would not be fodder for something that would lead her to hurt him,’ according to Ezra Cohen, MD. If anything having OCD is more apt to result in being victimized and not the aggressor. Park Ranger Melissa Hills told Petito that her and Laundrie’s relationship had the markings of a ‘toxic’ one as reported in the Daily Mail.  ‘I was imploring with her to reevaluate the relationship, asking her if she was happy in the relationship with him, and basically saying this was an opportunity for her to find another path, to make a change in her life,’ added Ranger Melissa Hulls in Moab according to writer Rachel Sharp published in the Daily Mail on 9-24-2021.  Domestic Violence Fatality Review Teams identify homicides, suicides, and other deaths caused by, related to, or somehow traceable to domestic violence and review them to develop preventive interventions (Dawson, 2017; Websdale, 2010; Websdale, 2012; Websdale et al., 2017). These frequently depend on careful communication among those who work within the field of intimate partner violence including members of judiciary, bail commissioners, district attorneys, law enforcement, and social services. Without definitive recommendations, review boards provide nothing to protect potential victims and do nothing to move the needle in the direction of improved safety plans and dangerousness assessments of potential murderers. Sadly, Gabby Petito will not grow old. She will not have children or grandchildren.  She will not have a career.  It is incumbent upon society to look at the similarities among cases of domestic violence homicide using case study data, aftermath review of facts, and structured interviews to intervene ahead of the secretive pattern of control, abuse, sexual violence, and murder that happens much too often and flies below law enforcement radar. By doing so, victims build new lives with safety plans and legal contingencies for those who violate those orders of protection.

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.

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. 

Cumulative exposure to stress: The stigma of being human

The impact of cumulative emotional reactions and Post traumatic Stress Disorder (PTSD) has significant negative impact on law enforcement heartiness, job satisfaction and career success (Polizoti, 2018). Police agencies across the country are looking for ways to mitigate the impact of accumulated stress associated with exposure to the worst of the worst of all human experience. “Arguably, everything from unattended death, domestic violence, child abuse, and a fatal motor vehicle crash may show up on the call board of any dispatcher on any day or night.” Sefton, 2014. There is no doubt that police officers and first responders are exposed to experiences that are well outside of normal human experience. On top of this requirement many officers do not feel supported by the people they serve and worse, the leadership hierarchy within the agency.

Law enforcement agencies are looking for ways to reduce the human cost of the stress and trauma LEO’s experience on the job but eliminating this all together is likely impossible. This “roller coaster” ride is often why we sign up for the police service where one can have hours of boredom sprinkled with seconds of shear terror and exposure to viral human suffering.

It has been said that LEO’s keep their internal conflict and emotions to themselves always in check and under control. Some fear being perceived as weak and feel intimidated by seeking support for the behavioral health needs resulting from the job. Strength in silence is the archaic mantra lurking behind the blue line and may be the underpinning stigma at work. This stereotype has a significant impact on family relationships, work performance, and career longevity. It has changed in the past decade but very slowly and too many officers are suffering.

Just as we have seen in a subset of the returning member’s of the armed forces, LEO’s are taking their own lives as a result of the accumulation of stressful calls year after year coupled with an erosion of coping skills rendering them vulnerable to becoming hopeless, embittered, and angry. On top of that and perhaps most dangerous is a growing mistrust and perceived lack of respect and support from community leaders, citizens, and sometimes department leaders.

Bias refers to having expectations about a class or subset of people based on unrecognized and unsubstantiated prejudice. Among law enforcement there is a perceived threat of reverse bias associated with having an emotional reaction to the law enforcement experience – at least as far as the front line troops are concerned. There is sometimes an negative attribution associated with being on stress-related leave so many officers who need support do not seek help. Over time this takes a toll on officer well-being. The health risks from years of maladaptive coping to on-the-job calls for service can be insurmountable for some leading to substance abuse, depression, heart disease, and PTSD.

The upwelling of professional disdain toward the police and outright lack of support from the public arising from use of force and incidence of fatal officer involved shootings adds to the LEO “disidentification” with the police service. Once an officer has disidentified with the job he or she is vulnerable to a host of professional challenges associated with becoming at risk for career burn out and embittered.

“Pain is lessened by ceasing to identify with the part of life in which the pain occurs. This withdrawal of psychic investment may be supported by other members of the stereotype-threatened group—even to the point of its becoming a group norm. But not caring can mean not being motivated. And this can have real costs.” according to Steele (1999) who studied achievement in African American college students.

Whether one is speaking about academic achievement or career satisfaction and job performance in the police service “disidentification is a high price to pay for psychic comfort” according to Steele (1999).

The reason for this falls back to deeply held bias toward mental illness that cuts across all segments of society. But it hits particularly hard among law enforcement and first responders. This is especially true when a brother officer is silently suffering.

Elevated mental health distress includes suicidal ideation, anxiety, and depressive symptoms. Some LEO’s preferred to seek help from a chiropractor or physiotherapist rather than a clinician or mental health provider” which reveals the true extent of underlying stigma and bias (Berg et al., 2006).


Polizoti, L. (2018) Career resilience and hardiness. LEO presentation. Worcester, MA.
Steele, Claude (1999) Thin ice: Stereotype threat and black college students. The Atlantic Magazine.

Berg et al. (2006). Fighting Police Trauma: Practical Approaches to Addressing Psychological Needs of Officers

Predicting the next mass shooting: do people just “snap”?

bigstock-Mental-illness-in-word-collage-072313WESTBOROUGH, MA January 21, 2018  Do people just “snap”? Rarely according to most literature I have read and published. The expression of violence is elicited slowly following a prolonged period of marginalized aloneness along with underlying resentment and anger according to Michael Sefton, Ph.D. This takes a great toll on relationships, loss of trust and a growing persecutory narrative that may become delusional.  The gunman in the Las Vegas mass homicide was described as narcissistic – a personality disorder vulnerable perceived rejection or disrespect often resulting in sudden rage, denial, decreased rational thinking, accusatory blaming, and often marked denial of responsibility. In the Las Vegas shooting it has been learned that the gunman had recently sustained a significant financial loss although its link to the people he killed remains a mystery.  There is typically some specific event that may trigger a violent event that could have been planned over months or years and evolve like the expression of some genetic permutation.

“People do not just “snap.” When something horrible happens, like a murder or violent attack, we naturally look for a cause. “Snapping” is an easy way to describe what is actually a complex, yet understandable chain of events. Research into violent attacks and the behavior of the attackers can shed some light on how one moves down a pathway toward violence.” Swink, 2010

The capacity for behavioral science to predict when the next mass shooting will occur remains unrefined. Yet, by studying the cases of mass murder that have occurred in the past 5 years there are important pre-incident behaviors that may foreshadow a coming terminal event. Often there are people who know precisely what is going to happen.  In our study of a domestic violence homicide that took place in Maine, 2011 we were told by the aunt of the murderer that she expected her nephew to kill himself but expect that he would do it in front of his wife and children.  What ultimately happened was a murder suicide.  Steven Lake killed his wife and 2 children and made an attempt to incinerate their bodies before local police arrived.  At that point he made himself comfortable and ended his life and the Lake family timeline.


Swink, J (2010) The Pentagon Shooting: They Don’t “Just Snap” Posted Mar 06, 2010 Taken Jan 4, 2018

Officer resilience and career success with less burnout

Mike Sefton photo
Michael Sefton, Ph.D. in Guangzhou, China

WESTBOROUGH, MA December 9, 2017 Resilience in police training is an added lesson designed to enhance the careers of officers-in-training. According to Leo Polizotti, Ph.D. resilience refers to professional hardiness that is protective against career burnout and raises both professionalism and job satisfaction.

It is essential to help individual officers through the tough times and enhances job satisfaction.  In the case of traumatic events – officer resilience is essential for a healthy response to a critical incident.  In the long run, physical health and well-being are the underpinnings of an emotionally resilient professional who will be there over and again – when called upon for those once in a lifetime calls that most of us will never have to answer.

Emotional resilience is defined as the 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. In its absence a police officer experiences irritability, brooding, anger and sometimes resentment toward his own agency and “the system” for all its failures.  The lack of emotional resilience leads to officer burn-out.

“Your biggest risk of burnout is the near constant exposure to the “flight or fight response” inherent to the job (running code, engaging and managing the agitated, angry, and irrational, or any other of your responsibilities that can cause you to become hypervigilant). Add the very real tension of the politics and stresses inside the office and a dangerous mix is formed. The pressures and demands of your job can take a toll on your emotional wellbeing and quality of life and burnout will often follow.” Olsen & Wasilewski, 2014

It is well documented that flooding the body with stress hormones like adrenaline and cortisol play a role in police officer health and well-being. “Stress and grief are problems that are not easily detected or easily resolved. Severe depression, heart attacks, and the high rates of divorce, addiction, and suicide in the fire and EMS services proves this” according to Peggy Rainone who provides seminars in grief and surviving in EMS. (Sefton, 2013). There are various treatments for stress-related burnout including peer support, biofeedback for reduced sympathetic dysfunction, and professional psychotherapy. “Being exposed to repetitive stress leads to changes in the brain chemistry and density that affect emotional and physical health.” (Olsen, 2014)  Improved training and early career support and resilience is essential for long term health of first responders including the brave men and women in blue.


Polizotti, L. (2017) Psychological Resilience: From Surviving to Thriving in a Law
Enforcement Career. Presentation. Direct Decision Institute

Olsen, A and Wasilewski, M. Police One.com (2014) Blog post: https://www.policeone.com/health-fitness/articles/7119431-6-ways-to-beat-burnout-in-a-police-officer/ Taken December 9, 2017

Rainone, P. (2013) Emergency workers at risk. (website) http://www.emsvilliage.com/articles/article.cfm?ID=176. Taken 12-1-2013

Sefton, M. Domestic Violence Homicide: What role does exposure to trauma play in terminal rage? Blog Post: https://wordpress.com/post/msefton.wordpress.com/505 Taken December 9, 2017.

Discretion, Treatment and Alternatives to Jail

WESTBOROUGH, MA July 16, 2017 In last weeks publication I introduced the problem of mental health and co-occurring substance abuse with some ideas about alternative restitution and treatment. These involve greater discretionary awareness among police officers.  More importantly options to jail require viable alternatives that will end the revolving door of minor criminality coupled with treatment for the breadth of addiction seen on a daily basis by law enforcement.

Mental and Physical Health Screening

At time of arrest the individual must have some level of mental health assessment if mental illness is suspected or documented. When I was a police officer prior to 2015 we often asked the D.A. to provide a court clinic assessment of the suspect to rule out suicidal ideation or delusional thinking. This must also include a screening for dangerousness especially when a subject is arrested for intimate partner abuse. Next a health history questionnaire should be undertaken to screen for co-occurring illness – both physical and mental. If a diabetic suspect is held without access to his insulin he is at great risk of death from stroke. Similarly, a person arrested for assault who suffers from paranoid ideation is at greater risk of acting violently without access to psychiatric medication. Finally, an alcoholic brought to the jail with a blood alcohol level greater than 250 is at great risk for seizures and cardiac arrhythmias when delirium tremens begin 6-8 hours after his last drink. The risk to personal health in each of the scenarios above must be taken seriously and the obtained data should be factually corroborated. Police departments across the United States are pairing up with private agencies to provide in-house evaluation and follow-up of individuals who fall on the borderline and may not be easily discerned by the officer in the field.

Diversion Safety Plan

Next, the probation and parole department must obtain an accurate legal history prior to consideration for bail. A nationwide screen for warrants and criminal history based on previous addresses is essential. In many places these are being done routinely. In the case of someone being arrested for domestic violence he may have no convictions thus no finding of criminal history. For these individuals the dangerousness assessment may bring forth red flag data needed for greater public safety resulting in protection from abuse orders, mandated psychotherapy, and in some cases, no bail confinement when indicated. Releasing the person arrested for domestic violence without a viable safety plan increases the risk to the victim and her family, as well as the general public – including members of law enforcement.

Bail, Confinement, Mandated Treatment

There is some thinking that higher amounts of bail may lessen the proclivity of some offenders to breach the orders of protection drafted to protect victims and should result in revocation of bail and immediate incarceration when these occur. I have proposed a mandatory DV Abuse Registry that may be accessed by law enforcement to uncover the secret past of men who would control and abuse their intimate partners. This database would also include information on the number of active restraining orders and the expected offender’s response to the “stay away” order. In cases where the victim decides to drop charges there should be a mandatory waiting period of 90 days. During this waiting period the couple may cohabitate but the perpetrator must be attending a weekly program of restorative justice therapy and substance abuse education. Violations of these court ordered services are tantamount to violation of the original protection order (still in place) and victim safety plan and may result in revocation of bail. If the waiting period passes and the perpetrator has met the conditions of his bail than he may undergo an “exit” interview to determine whether or not the protection order / jail diversion plan may be extended.

Guardianship

In many jurisdictions the mentally ill cannot be forced to take medication nor can they be forced into treatment. Adherents to this belief advocate on the behalf of the chronically mentally ill for the right to make these individual choices – treatment or no treatment. Ostensibly advocates seem unconcerned for the public health risks associated with ongoing drug addiction and major mental illness. There needs to be an active system in place to provide guardianship to individuals with repeated failed treatment that mandates treatment for those who cannot remain in a program of sobriety and psychotherapy in lieu of incarceration. In many cases a family member may be appointed temporary guardian for up to 180 days that allows decisions to be made about patient care up to the guardian not the patient himself who may be unable to stay on track.