By Laurence Miller, PhD
In Part I of this column, we examined the mutual contributions of military and police psychology to the demands of operational assistance. In Part II, we take a look at the role of police and military psychology in clinical services delivery.
In military and police psychology, clinical services encompass the behavioral and mental health strategies utilized to restore and improve the health and well-being of military or law enforcement service members. Unlike the more extensive scope and leisurely pace of many forms of civilian psychotherapy, the aims and purposes of military and law enforcement intervention strategies are typically short-term and targeted to restoring personnel to an optimum level of functioning in a minimum amount of time.
(AP Photo/Charles Rex Arbogast)
Combat and critical incident stress
Clearly, the most stressful aspect of both military service and police work is the prospect of being injured or killed, closely followed by the act of killing another. Other stresses have to do with enduring the loss of comrades and generally confronting the human cruelty and carnage of warfare or violent criminal activity. Both police and military psychologists have made important contributions to the assessment and amelioration of these traumatic stress syndromes.
History of the military and law enforcement stress concepts
Historically, the pendulum of interest in traumatic stress syndromes has swung back and forth between military and civilian traumas. The ancient Greeks and Romans wrote eloquently about the trials and travails that could afflict the warrior mind. One of the first modern conceptualizations of posttraumatic stress was put forth by the army surgeon Hoffer who, in 1678, developed the concept of nostalgia, defined as a deterioration in the physical and mental health of homesick soldiers, caused by the formation of abnormally vivid images in the battle-weary soldier’s brain by overexcitation of the “vital spirits.”
The American Civil War introduced a new level of industrialized killing and, with it, a dramatic increase in stress-related ailments. Further advances in weapons technology during the First World War resulted in new categories of battlefield casualties from machine guns, poison gas, and long-range artillery. The latter led to the widely applied concept of shell shock, initially believed to be caused by the brain-concussive effects of exploding shells, but later understood to be a form of psychological incapacitation resulting from the trauma of battle.
The experiences of the Second World War contributed surprisingly little to the development of new theories and treatments for wartime trauma, aside from its relabeling as battle fatigue. In fact, resistance to the very concept of battle fatigue, with it’s implications of mental weakness and lack of moral resolve, was widespread in both medical and military circles. There was a war on, plenty of good Joes were getting killed and wounded, and the army had little sympathy for the whinings of a few slackers and nervous nellies who couldn’t buck up and pull their weight.
However, it was becoming apparent that combat trauma and battle fatigue could take place in circumstances other than the actual battlefield. In World War II, then Korea and Vietnam, and later in the Persian Gulf Wars, clinicians began to learn about disabling stress syndromes associated with large-scale bombings of civilian populations, prisoner of war and concentration camps, “brainwashing” of POW’s, civilian atrocities, and terrorism. The 1991 Gulf War spawned a new traumatic stress syndrome, called Gulf War syndrome, which may reflect a combination of chemical exposure and psychophysiological anxiety. It has yet to be determined what the eventual psychological casualty rate from the current Afghanistan and Iraq wars will be.
In the civilian law enforcement and emergency services fields, the equivalent of combat stress has become known as critical incident stress.
By this definition, a critical incident is any event that has an unusually powerful, negative impact on police personnel because it is above and beyond the range of the ordinary stresses and hassles that come with the job. Major classes of critical incident include: an officer-involved shooting, line-of-duty death, serious injury to police personnel, serious multiple-casualty incident such as a multiple school shooting or workplace violence incident, suicide of a police officer, traumatic death of children, or an event with excessive media interest.
Recent times have expanded exponentially the range and scope of horrific law enforcement critical incidents to include acts of mass terror and destruction, involving multiple deaths of civilians, fellow officers, and other emergency personnel. Indeed, police psychologist John Violanti has characterized some aspects of police work as “civilian combat,”
Psychological interventions for military combat stress: PIE and BICEPS
Many of the principles of managing both combat stress and law enforcement critical incident stress incorporate the same basic elements. The primary goal is to depathologize these stress responses by framing them as normal responses of normal people to abnormal events. To this end, beginning in World War I, the military has relied on the PIE concept, where P = Proximity: provide care as close to the unit as possible; I = Immediacy: offer treatment as soon as possible; and E = Expectancy: convey the expectation of return to full duty.
Currently, U.S. Department of Defense’s protocol for management of combat stress is based on the BICEPS model, where B = Brevity: treatment is short-term, addresses the problem at hand, and is focused on return to service. I = Immediacy: intervention begins as soon as possible, before symptoms have a chance to worsen. C = Centrality: psychological treatment is set apart from medical facilities to reduce the stigma soldiers might feel about seeking mental health services. E = Expectancy: a service member experiencing problems with combat stress is expected to return to full duty. P = Proximity: in order to enhance expectations of recovery, soldiers are treated as close to their units as possible and are not evacuated from the area of operations. S = Simplicity: besides formal therapy, the basics of a good meal, hot shower, and a comfortable place to sleep ensure that a soldier’s basic physical needs are met.
Psychological interventions for law enforcement critical incident stress: CISD/CISM
To address the special needs of law enforcement and emergency services personnel, the concept of critical incident stress management (CISM) has incorporated the basic philosophy and methodology of the PIE and BICEPS models and has expanded and refined the methodology, which has, in turn, been adopted back into the military. Critical incident stress debriefing (CISD) is a structured group intervention designed to promote the emotional processing of traumatic events through the ventilation and normalization of reactions, as well as to facilitate preparation for possible future crisis experiences.
A CISD debriefing is a peer-led, clinician-guided, group process. A typical debriefing takes place within 24 to 72 hours of the critical incident and consists of a single group meeting that lasts two to three hours, although shorter or longer meetings may be dictated by circumstances. The formal CISD process consists of seven key phases, designed to assist cognitive and emotional integration and mastery, beginning with more objective and descriptive levels of processing, progressing to the more personal and emotional, and back to the educative and integrative levels. These include: (1) Introduction: the team leader introduces the CISD process, encourages participation by the group, and sets the ground rules of confidentiality, attendance for the full session, unforced participation in the discussions, and the establishment of a noncritical atmosphere. (2) Fact phase: the group members are asked to briefly describe their activity during the critical incident and some facts about what happened; the basic question is: “What did you do?” (3) Thought phase: group members discuss their initial and subsequent thoughts during the critical incident: “What was going through your mind?” (4) Reaction phase: this begins to move the group from a predominantly cognitive mode of processing to a more expressive emotional level: “What was the worst part of the incident for you?” (5) Symptom phase: this continues the movement back from the predominantly emotional processing level toward the cognitive processing level. Participants are asked to describe their cognitive, physical, emotional, and behavioral signs of distress: “What have you been experiencing since the incident?” (6) Education phase: encouraging further progression toward intellectual processing and normalization of the experience, didactic information is provided about the nature of the stress response and the expected physiological and psychological reactions to critical incidents. (7) Re-entry phase: during this wrap-up, any additional questions or statements are addressed, referral for individual follow-ups are made, and general group bonding is reinforced: “What have you learned?”
Using this basic model, there have been a number of specialized adaptations of the CISD/CISM model for the military and law enforcement. These include the Navy’s special psychiatric response intervention teams (SPRINT); the Army’s special medical augmentation response team-stress management (SMART-SM); the Air Force’s critical incident stress teams (CIST); specialized law enforcement debriefing; integrative debriefing; line-of-duty death debriefing; individual debriefings; critical incident peer support seminars; salutogenic debriefing; California Peace Officer Commission Peer Counselor Training; Salt Lake City Police Department Traumatic Incident Corps; the FBI’s Critical Incident Stress Management Program; and the U.S. Secret Service’s Critical Incident Support Team. Whether explicitly or tacitly, all of these programs incorporate important elements of the military PIE/BICEPS and law enforcement CISD/CISM models.
Psychotherapy for police and military service members
Mental health services in law enforcement and the military are not limited to critical incident or combat stress. Police officers and soldiers can be affected by a wide variety of problems that include depression, suicidality, substance abuse, work stress, and relationship problems. Here again police and military psychologists can cross-contribute valuable therapeutic strategies for treating these specialized personnel. In general, the effectiveness of any therapeutic strategy will be determined by the timeliness, tone, style, and intent of the intervention.
Effective psychological interventions with military and law enforcement personnel share in common the following elements, which are already familiar from the PIES/BICEPS model discussed above:
Briefness: utilize only as much therapeutic contact as necessary to address the present problem; the service member does not want to become a “professional patient.” Limited focus: the goal is not to solve all the service member’s problems, but to assist in restabilization and provide stress-inoculation for future crises. Directness: therapeutic efforts are focused on resolving the current conflict or problem to reach a satisfactory short-term conclusion, while planning for the future if necessary.
[For more information on this topic, see: Critical incidents: Myths and realities & Law Enforcement Traumatic Stress: Clinical Syndromes and Intervention Strategies]
Suicide prevention and intervention
Arguably, the single most devastating personal mental health crisis is suicide. Considering that both military service and law enforcement are high-demand, high-stress fields that attract personnel that tend to have high expectations of themselves, little tolerance for weakness, and a black-and-white, all-or-nothing view of success and failure, it is perhaps not surprising that self-perceived failure may lead to depression and suicidality, often commingled with alcohol abuse. Police officers and military service members may become despondent and suicidal for a variety of reasons related to their service or their family life.
One of the persisting problems in dealing with police officer suicide is the pervasive code of silence that characterizes these personnel. Officers are reluctant to report depression or other problems for fear of being seen as weak or, worse, of having restrictions placed on their activities (e.g. weapon carrying). Fellow officers are equally reluctant to “rat out” a distressed comrade, even though they may strongly suspect he or she needs help. Thus, there is a need for every law enforcement agency to have an efficient, nonstigmatized referral system for dealing with officers in psychological distress, so that any problems noted can receive appropriate treatment in a supportive atmosphere.
In this regard, police psychologists can learn from their military colleagues, who have been proactive in education and training around mental health issues such as depression and suicide. One advantage of military organizations is that programs generated by the Department of Defense, or even within an individual service branch, can achieve rapid, wide dissemination among service personnel, whereas the fragmented nature of literally thousands of municipal, county, regional, state, and federal law enforcement agencies in the U.S. makes such information-sharing a daunting task.
One example of a military program to counteract service member suicide is the Air Force’s LINK, which stands for: L = Look for possible concerns or signs of distress. I = Inquire about those concerns. N = Note the level of risk. K = Know the appropriate referral sources and strategies.
Similarly, the Navy and Marine Corps have adopted a program called AID LIFE, which stands for: A = Ask, “Are you thinking of hurting yourself?” or “Are you thinking about suicide?” Remember that asking a suicidal person about his or her thoughts will not impel them to do it, and may in fact save their life. I = Intervene immediately. Don’t wait to take action. Let the person know that he or she is not alone and that someone cares enough to do something. D = Don’t keep it secret. Silence can only lead to increasing isolation and deterioration. L = Locate help. Seek out a superior officer, chaplain, medical or mental health corpsman, crisis line worker, or other person who can intervene. I = Inform the chain of command, so that they can arrange for long-term assistance, if necessary. E = Expedite. Get help now. You may save someone’s life.
In turn, one area where the military can learn from law enforcement is in the development and implementation of specific protocols for prevention, response, and follow-up treatment of service members in distress.
If the warning signs have been missed, the first chance a clinician or peer may get to intervene with a depressed, suicidal service member may be when the crisis is already peaking. The task now is to keep him or her alive long enough to get appropriate follow-up care, and this can be accomplished by adapting and applying some fundamental principles of crisis intervention.
Define the problem. By helping the person clarify what’s disturbing him, nonlethal options and coping resources may be explored. It also shows that you’re listening and trying to understand.
Ensure safety. Try to encourage the individual to put even a few short steps between the thought of a self-destructive action and it’s implementation. For example, if he has a gun, ask him to unload it or decock it. If he’s got a knife to his throat, see if he’ll put in on the table or at least lower it to his lap. If he’s holding a bottle of pills, encourage him to keep the cap on while you’re talking. If he’s standing on a building ledge or on a curb beside heavy traffic, maybe you can get him to take a step or two back. And so on.
Provide support. Keep the conversation focused on resolving the present crisis, perhaps gently suggesting that the larger issues can be dealt with later – which subtly implies that there will indeed be a “later.”
Examine alternatives. Typically, this takes one of two forms: (1) accessing practical supports: persons or groups immediately available to help the service member through the crisis until he or she can obtain follow-up care; and (2) coping mechanisms: cognitive strategies, distracting activities, positive images and memories of family, religious faith, or review of successful handling of crises in the past, that show the service member that hope is at least possible.
Make a plan and obtain commitment. Again, this involves a combination of both practical supports and coping mechanisms, as well as both short-term and longer-term plans. Clarify what the service member will do in the next minutes, hours, and days, and what role other people will play. Confirm that he or she agrees with the plan and set up a system to monitor and ensure its implementation.
Arrange for follow-up. When the acute crisis has passed, referral to a mental health clinician is crucial for two reasons. First, the military or police psychologist may have to perform a fitness-for-duty evaluation to determine if the officer is able to return to work; and if not, what treatment or other measures will be required. Second, specialized psychotherapeutic techniques may be applied, that involve a combination of emotional exploration, realistic confidence-building, and practical problem-solving approaches, often combined with medication.
[For more information on this topic, see: Police officer suicide: Recognizing the signs and helping our colleagues in distress]
Many professionals undertake dirty, demanding, and/or dangerous work – firefighters, paramedics, rescue workers, airline pilots, and so on. But only police officers and soldiers share the distinction of having the ability, authority, responsibility, and in many cases the direct order to kill other human beings as part of their job description. One difference is that while police officers may have to fire their weapon in the line of duty, killing another person is perceived as a last resort and the emphasis is usually on maintaining order without the use of deadly force. Military service members, however, know that they are trained precisely to kill the enemy and may have to do so on a regular basis. Even for highly trained soldiers, the taking of human life can be a profound experience that can contribute to combat stress and adjustment problems. Thus, there may be much that law enforcement and the military can learn from each other in dealing with the effects of killing as a vocation.
Psychological Effects of Killing
The stages of response that both soldiers and police officers go through following a service-related killing are similar. In his book, On Killing: The Psychological Cost of Learning to Kill in War and Society, Dave Grossman describes five basic phases often seen in response to killing in combat, which is quite similar to the reactions reported by police officers in civilian law enforcement shootings.
The first phase occurs prior to the shooting and consists of concern about being actually able to pull the trigger when the time comes, of not freezing up and letting one’s comrades down. The second phase is the actual killing experience, which is often done reflexively, the solider describing him/herself as “going on automatic.” Elated at having survived the deadly encounter, and having proven to himself that he can do the deed, there is a third stage of exhilaration that comes from having “popped my cherry” and from having been able to put one’s training into action. This exhilaration, fueled by the release of large amounts of adrenalin, can create a high or rush, which in some cases can give rise to combat addiction.
Remorse and nausea, Grossman’s fourth phase – or what police psychologists have called the recoil and remorse phase – follows the rush of exhilaration and is often associated with a close-range kill; this may be the more common type of response experienced by police officers who tend to confront their adversaries in close quarters, than many soldiers who often fire from a distance. A sense of identification and empathy for the victim may set in, especially if the slain combatant was a fellow enemy soldier “just doing his job like I was,” as opposed to an insurgent bomber or assassin, for whom there may be far less sympathy and less identification. Conversely, the service member may be creeped out by his own initial response: “I enjoyed killing that guy too much – is there something wrong with me?”
For police officers, feelings of guilt or self-recrimination may be especially likely in cases where the decision to shoot was less than clear-cut or where the suspect’s actions essentially forced the hand of the officer into using deadly force, such as in botched robberies, domestic disputes, or suicide-by-cop scenarios. Military service members may be able to feel more justification in killing on a traditional battlefield, but may experience many of the same kinds of self-recriminations in the nontraditional fighting arenas that have characterized most wars since the Vietnam era, in which targets are often elusive and ambiguous, with blurred lines between combatants and civilians.
During this recoil/remorse phase, the military or law enforcement service member may seem detached and preoccupied, spacily going through the motions of his job duties, and operating on behavioral autopilot. A variety of posttraumatic symptoms may be seen, most of which will resolve in a few days or weeks. Physical symptoms may include headaches, stomach upset, nausea, weakness and fatigue, muscle tension and twitches, and changes in appetite and sexual functioning. Sleep is typically impaired, with frequent awakenings and often nightmares. Typical posttraumatic reactions of intrusive imagery and flashbacks may occur, along with premonitions, distorted memories, and feelings of déjà vu. Some degree of anxiety and depression is common, often accompanied by panic attacks. There may be unnatural and disorienting feelings of helplessness, fearfulness, and vulnerability, along with self-second-guessing and guilt feelings. Service members may desire support but at the same time reject helping efforts, leading to what law enforcement trainer Michael McMains calls a control-alienation syndrome which is offputting and irritating to everyone concerned. Substance abuse may be a risk.
Grossman’s (1996) final phase, rationalization and acceptance, can be a long process and many veterans wrestle with their wartime experiences for a lifetime. Similarly, in law enforcement, as the officer begins to come to terms with the shooting episode, a similar resolution or acceptance phase may be ensue, wherein he or she assimilates the fact that the use-force-action was necessary and justified in this particular instance of the battle for survival that often characterizes law enforcement deadly encounters. Even under the best of circumstances, resolution may be partial rather than total, and psychological remnants of the experience may continue to haunt the officer periodically, especially during future times of crisis. But overall, most officers are eventually able to return to work with a reasonable sense of confidence.
Post-Killing Psychological Intervention Strategies
Where problems persist, officers deserve to have access to proper psychological intervention. Psychotherapeutic strategies in these cases will typically follow the short-term intervention model described above. Some specific principles apply to law enforcement post-shooting stress, which can, in turn, be productively adapted to the military setting.
First, review the facts of the case with the service member. This allows for a relatively nonemotional narrative of the traumatic event. But in the case of a shooting episode, it serves a further, specific function. Precisely because of the cognitive and perceptual distortions that commonly occur in these kinds of incidents, what may be particularly disturbing to the service member is the lack of clarity in his or her own mind as to the actual nature and sequence of events. Just being able to review what is known about the facts of the case in a relatively safe and nonadversarial environment may provide a needed dose of mental clarity and sanity to the situation.
Next, review the service member’s thoughts and feelings about the shooting incident. This resembles the thought and reaction phases of a critical incident debriefing, but may not be as cut-and-dried as with a typical group debriefing. One of the most important things the military or police psychologist can do at this stage is to help modulate emotional expression so that it comes as a relief, not as an added burden.
Provide authoritative and factual information about psychological reactions to a shooting incident. The kinds of cognitive and perceptual distortions that take place during the incident, the posttraumatic symptoms and disturbances, and the sometimes offputting and distressing reactions of colleagues and family members, are likely to be quite alien to the service member’s ordinary experience, and might be interpreted by him or her as signs of going soft or crazy. Normalize these responses for the service member.
Finally, provide for follow-up services, which may include additional individual sessions, group or family therapy, referral to support services, possible medication referral, and so on. For both military and law enforcement personnel, the seeking of psychological services must be destigmatized and supported at all levels. In addition, both police and military psychologists can utilize the powerful social bonding forces of unit cohesion and morale to bolster stress-resilience and aid in recovery from deadly force encounters and other traumatic incidents.
[For more information on this topic, see: Shots Fired! A special PoliceOne series & Shots Fired! Final in a special PoliceOne series]
The siblings of military and police psychology need to be reintroduced and reunited, along with their firefighter, paramedic, and other emergency service cousins, to form a comprehensive system of clinical and operational psychology for personnel in high-danger, high-demand professions. These columns have offered a glimpse into that collaboration and cross-fertilization which will hopefully spur further research into the art and science of helping our men and women in uniform, whatever their stripes and colors may be.
To learn more about these topics