BUILDING RESILIENCY AMONG LAW ENFORCEMENT OFFICERS by Jordan Grebenc Law Enforcement Studies Diploma, Justice Institute of British Columbia 2015 Bachelor of Law Enforcement Studies, Justice Institute of British Columbia 2017 MAJOR PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS (CRIMINAL JUSTICE) In the School of Criminology and Criminal Justice © Jordan Grebenc 2019 UNIVERSITY OF THE FRASER VALLEY Winter 2019 All rights reserved. This work may not be reproduced in whole or in part, by photocopy or other means, without permission of the author. Approval Name: Jordan Grebenc Degree: Master of Arts (Criminal Justice) Title: Building Resiliency Among Law Enforcement Officers Examining Committee Zina Lee, Ph.D. Chair Associate Professor, School of Criminology and Criminal Justice ____________________________________________________________ Amanda McCormick, Ph.D. Senior Supervisor Associate Professor, School of Criminology and Criminal Justice ____________________________________________________________ Neil Dubord, Ph.D. External Examiner Chief Constable Delta Police Department ____________________________________________________________ Date Defended/Approved: April 23, 2019 i Abstract Law enforcement officers are frequently exposed to stressors such as organizational and operational stress. These sources of stress have the potential to manifest or cumulate over time and lead to various negative consequences for the officers. In addition to these sources of stress there are also critical incidents which can lead to trauma. Trauma also has several negative consequences for officers such as physical and mental health issues. If left untreated, these issues have the potential to manifest and develop into Post Traumatic Stress Disorder (PTSD). PTSD is a psychiatric disorder that can develop when individuals experience or witness a traumatic event (Parekh, 2017). PTSD can occur in any population or ethnicity and is prevalent in approximately 3.5% of adults in the United States according to Parekh (2017). The rate for law enforcement officers is much higher. Carleton, Afifi, Taillieu, Turner, Krakauer, Anderson, and McCreary (2019) found that approximately 44.5% of Canadian Public Safety Personnel screened positive for PTSD. Fortunately, there are several protective factors that can mitigate the negative effects of PTSD for law enforcement officers. These include Critical Incident Stress Management, Strong and Effective Leadership, Peer Support, Mindfulness, Road to Mental Readiness, and Employee Assistance Programs. ii Acknowledgements I would like to thank Dr. Amanda McCormick for her constant support and mentorship throughout this process. She has also spent a significant amount of time providing feedback and guidance throughout this entire process. My various professors throughout the Masters program have all played an important role in preparing me for this final paper. They always made themselves available for feedback and support if needed. I would also like to acknowledge my family and friends who were supportive throughout this program. It was not easy on them at times and their support was a motivator to push through the course work. I would also like to thank my employer who was willing to work with me and allow me to take the time off that I needed to travel to class every month and complete my course work. iii Table of Contents Abstract .................................................................................................................................................... ii Acknowledgements ............................................................................................................................. iii Introduction ............................................................................................................................................ 1 Occupational and Organizational Stressors ................................................................................ 2 Critical Incident ..................................................................................................................................... 4 Trauma...................................................................................................................................................... 6 Prevalence ............................................................................................................................................... 8 Post-Traumatic Stress Disorder (PTSD) ..................................................................................... 11 Correlates of PTSD .............................................................................................................................. 14 Physical Health .......................................................................................................................................................... 15 Gender and PTSD ...................................................................................................................................................... 15 Age and Experience ................................................................................................................................................. 16 Protective Factors for PTSD ............................................................................................................ 17 Suicide ..................................................................................................................................................... 18 Mental Health Stigma ......................................................................................................................... 19 Resiliency Strategies and Resources ............................................................................................ 20 Post-Incident Screening........................................................................................................................................ 21 Critical Incident Stress Management (CISM) ............................................................................................ 21 Strong, Effective Leadership .............................................................................................................................. 24 Peer Support ............................................................................................................................................................... 25 Mindfulness ................................................................................................................................................................. 26 Road to Mental Readiness ................................................................................................................................... 27 Employee Assistance Programs (EAPs) ....................................................................................................... 28 Recommendations .............................................................................................................................. 30 Conclusion ............................................................................................................................................. 33 References ............................................................................................................................................. 35 iv Introduction There has been extensive research conducted regarding the development of PostTraumatic Stress Disorder (PTSD) to date. Approximately 80% of first responders have reported experiencing a traumatic event while at work (Klimley et al., 2015). Research has consistently demonstrated that there is a significant correlation between the exposure to trauma and the subsequent development of PTSD in first responders (Carleton, Afifi, Taillieu, Turner, Krakauer, Anderson, & McCreary, 2019; Chopko & Schwartz, 2012; Hartley, 2013). Police officers are at an increased risk for developing psychological disorders such as PTSD due to their exposure to traumatic events throughout the duration of their career (Chopko 2018; Chopko, Palmieri, & Facemire, 2013; Hartley et al., 2016; Martin, Marchand, Boyer & Martin 2009; Violanti, 2006). According to Chopko (2017), nearly one third (30%) of officers display symptoms of PTSD following a traumatic incident exposure. This is a major issue because in the nature of their official duties, first responders are frequently exposed to traumatic events more often than members of the general public (Mumford, Taylor & Kubu, 2015). This increased exposure places them at a higher risk of developing PTSD. According to Chopko (2017), many police officers cope with traumatic and non-traumatic stressors by suppressing their thoughts and feelings and this is not an effective way to deal with the issue as it may lead to other issues, such as substance abuse, burnout, or suicidal ideation. Still, it is important to first understand what PTSD is and what the symptoms are before exploring various methods of prevention. 1 There are several strategies that can help officers after they are exposed to trauma or a critical incident. Critical Incident Stress Management (CISM), mindfulness, effective leadership and strong social support are strategies that can be implemented to assist individuals who are experiencing negative physical or psychological issues related to mental health. This paper will explore the various sources of stress and PTSD among law enforcement officers, will review the possible programs and strategies available to prevent and more effectively respond to the issues associated with them. Occupational and Organizational Stressors As reviewed by Cohen, McCormick, and Rich (2019), police officers experience a variety of stressors during their normal course of duty. Police officers are exposed to events that are likely to cause trauma or there is a threat of serious harm to the officer (Carleton et al., 2018). Occupational stressors may include constant exposure to fear inducing situations, dealing with difficult and contentious individuals, experiencing physical tiredness, working long shifts and spending many hours inside of a vehicle, and experiencing negative comments and criticism from the public (Cohen et al., 2019; Plecas et al., 2015; Rose & Unnithan, 2015; Stinchcomb, 2004). Chopko and Schwartz (2012) state that this also can include feeling that there is inadequate support from supervisors, being assigned an incompatible partner, being subjected to excessive discipline, and media scrutiny. Another broad type of stressor that officers are routinely exposed to is organizational stress. Organizational stressors can include shifting models, highperformance expectations, a lack of available resources, increasing paperwork demands, frequent policy changes, frustrations with the criminal justice system process, and the 2 police culture (Cohen et al., 2019; Rose & Unnithan, 2015; Stinchcomb, 2004). Further research also suggests that organizational stressors also include various structural arrangements, policies, and practices (Shane, 2010; Violanti et al., 2017). Exposure to both operational and organizational stressors can have a negative impact on police officers’ physical health.. Constant exposure to stressful situations can cause the body to release cortisol, which causes the body to prepare for fight, flight, or freeze response (Anderson et al., 2002; Cohen et al., 2019). Stressful situations also increase an officer’s heart rate and their blood pressure and such heightened levels can last for the duration of their shift after exposure to the incident. Anderson et al. (2002) found that officers’ heart rates would remain “nine beats per minute higher than those who did not experience a critical incident” (p. 414). This also creates a state of hypervigilance which can cause a crash when they reach the point of exhaustion. Exposure to such situations can contribute to traumatization because the body not able to effectively process the psychological response to the trauma, which leaves the officer in a state of hyperarousal and awareness (Rees & Smith, 2008). Furthermore, Violanti, Andrew, Burchfiel, Dorn, Hartley, and Miller (2006) stated that exposure to chronic stress such as organizational stressors, can lead to an increased cardiovascular disease risk among officers. Avoidance and hyperarousal are associated with depressing event exposure, such as death, whereas psychological distress is more associated with routine occupational stressors (Klimley, Hasselt, & Stripling, 2018). This highlights that different symptoms can come from different types of events, that every officer can have a different response to a situation and display different symptoms, no situation is the same, and different officers experience the same events differently. 3 Additionally, Carleton et al. found that women, public safety personnel with different years of service and experience, Royal Canadian Mounted Police and municipal officers all experience and respond to critical incidents and organizational stressors in seemingly different ways. For example, Carleton et al. (2018), highlights the potential difference between RCMP officer and municipal officers by stating that municipal officers potentially have a greater access to structural and social supports whereas RCMP officers frequently have to relocate to more remote areas. The very nature of the RCMP structure that requires frequent relocating, often times to different divisions or provinces, may also have a negative impact on social supports as the friendships and peer groups that take time to develop can be removed to a certain extent after a relocation. It is more likely that the remote areas do not offer the same level of structural or social supports. Another important detail to note is that Carleton et al. (2018) note that different public safety personnel serve different populations such as corrections who work with incarcerated people in a difficult environment or a single RCMP officer who encounters a difficult person when the closest backup is far away. Conditions such as these have the potential to increase the risk of developing a mental disorder. Critical Incident A critical incident can be defined as a situation where public safety personnel experience strong emotional reactions, which have the potential to interfere with their ability to function (Carleton, Afifi, Taillieu, Turner, Krakauer, Anderson, & McCreary, 2019). An event can also be considered a critical incident if a public safety personnel perceives an incident to be critical; this is important to note because it limits the objectivity and focuses on the individual’s subjective perception (Carleton et al., 2019). A crisis occurs when an 4 event effects an individuals’ ability to cope (Wuthnow, Elwell, Quillen, Ciancaglione & Wilmington, 2016). The event disturbs the individual’s normal level of functioning and their normal coping mechanisms do not restore the balance, which results in a degree of functional impairment (Wuthnow et al., 2016). The most commonly reported traumatic events experienced by public safety personnel include: being exposed to sudden violent death, exposed to sudden accidental death, exposure to a serious transportation accident, exposure to a physical assault, exposure to a fire or explosion and serious accident at work, home, or during a recreational activity (Carleton et al., 2019; Chopko & Schwartz, 2012). Montgomerie, Lawrence, Adam, LaMotte & Taft (2015) also state that there are increased rates of PTSD among individuals who experience firearm violence and more specifically mass shootings. More broadly, a traumatic event occurs when there is a direct or indirect experience of threatened or actual death, serious injury, or sexual violence (American Psychological Association, 2013). The event becomes traumatic when the body enters the fight, flight, or freeze response and the brain is unable to cope with this response (Anderson et al., 2002). Stress can also have a negative psychological effect on police officers. Violanti (2006) and Carleton et al. (2018) stated that approximately one third of officers are at a risk of developing PTSD and others may experience other symptoms such as depression, chronic fatigue, marital problems or other personal consequences. Carleton, Afifi, Taillieu, Turner, El-Gabalawy, Sareen and Asmundson (2018) further found that public safety personnel, which included Call Center Operators/Dispatchers, Correctional workers, Firefighters, Municipal/Provincial Police, Paramedics, and Royal Canadian Mounted Police, who reported experiencing chronic pain were significantly more likely to screen positive 5 for PTSD, major depressive disorder, generalized anxiety disorder, social anxiety disorder, and alcohol use disorder. This further shows that the relationship between the negative physical and psychological effect on public safety workers often appears in conjunction. According to Klimley et al. (2018), general routine work related stressors for officers can also negatively impact an officer’s ability to cope with a significant traumatic incident because repeated exposure to trauma can impede an individual’s ability to cope (Arter et al. 2018). This is important because normal work duties place an officer in a more vulnerable position to deal with a traumatic incident through simply doing their job. It also stresses the need to identify effective coping mechanisms for dealing with routine workrelated stressors effectively to prevent the likelihood of developing PTSD following an incident. Trauma Exposure to traumatic, violent, and horrific events may lead to an increased risk of an individual developing PTSD (Hartley, 2013; Violanti, 2006; Martin & Marchand, 2009). Officers also experience a high level of emotional stress, where stress triggers different strong emotions and the majority of which comes from occupational sources (Martin & Martin, 2017). There are four events which have been identified in research as being the four most major stressors for police (Martin & Martin, 2017). These include killing someone while on duty, witnessing another officer being killed, being physically attacked, and seeing a battered child (Martin & Martin, 2017). These incidents are the most stressful incidents; however, they occur relatively infrequently. Other potentially traumatic events may include police suicides, exposure to domestic violence, and dead bodies (Chopko & Schwartz, 2012). 6 Exposure to such events may cause a traumatic response by an officer when they are overwhelmed, and this can disrupt their emotional equilibrium in turn causing their normal coping mechanisms to fail (Chopko & Schwartz, 2012). Trauma can be much more damaging than stress as it can develop into PTSD much faster; stress is dealt with on a daily basis and is not always negative, but trauma is experienced far less frequently (Martin & Martin, 2017). Stress that can be considered positive may include deadlines or incentives for preforming certain tasks. This kind of stress acts as a motivation force or an incentive to complete a task or goal. A certain amount of stress in the work place is natural and healthy. Martin and Martin (2017) differentiate the relationship between stress and trauma as “[u]nlike stress, trauma can cause actual damage to the brain and can result in PTSD. Trauma not only injures one’s feelings, it causes havoc to the brain emotionally and can actually cause physical damage the brain” (Martin & Martin, p 33, 2017). Shucard, Cox, Shucard, Fetter, Chung, Ramasamy, and Violanti (2012) identified that traumatic experiences and symptoms of PTSD affects the brain structure and function. Stress does not lead to PTSD. Trauma leads to PTSD. Trauma is not caused by stress, but it is rather a psychological injury that can lead to the development of PTSD (Martin & Martin, 2017). The effects of trauma can depend on the frequency, intensity, and repetitiveness of exposure and repeated trauma hinders an individual’s ability to cope (Arter et al., 2018). Trauma can therefore be classified into two categories: cumulative trauma, which occurs over several years of repeated exposure, and acute trauma which is caused by a single critical incident (Martin & Martin, 2017; Arter et al. 2018; Rose & Unnithan, 2015). Acute stressors can be viewed as a precursor to PTSD but they are sudden and disruptive whereas routine stress, such as from organizational 7 sources, can build up over time (Violanti et al., 2018). The two different paths can lead to the same mental health issues. The critical incident or acute instances are for the most part rather rare and not frequently experienced where as the organizational stressors have the potential to be an every day issues for officers at work because of the environment that they work in. Prevalence Nearly a decade ago, Martin, Boyer, and Martin (2009) conducted a study of 132 Canadian police officers and discovered that approximately eight percent of them had lifetime PTSD which means that they had received an official diagnosis at some point in their life. It was also discovered that an additional seven percent of the participants had lifetime-partial PTSD where some symptoms existed. Again, PTSD is a spectrum disorder. However, this study was conducted through self-administered questionnaires. Reliance solely on self-reporting can be problematic due to errors in reporting from perceived stigma, under reporting of symptoms, and inaccurate self-reflections. Further, a positive screen does not necessarily equate to a diagnosis. While these results suggest that fifteen percent of police officers have some degree of PTSD, this is lower than other studies on this topic. Fox et al. (2012) conducted a study with 150 police officers in Connecticut and found that 24% of participants screened positive for PTSD. It was also discovered that the most common symptoms associated with the positive screening included: intrusive thoughts or nightmares (30%); avoidance of situations that could remind them of a traumatic event (22%); and depression (9%). These are common symptoms associated with PTSD. Chopko (2010) obtained similar results with a sample of United States police 8 officers, where of the 183 participants were administered a questionnaire at roll call. The results were that 9% had indicators of PTSD, while 18% most likely had PTSD but it had not been diagnosed. Additionally, 27% of the 183 participants displayed what Chopko identified as significant PTSD symptoms. For comparison, the rate of PTSD in the general public is approximately 3.5% according to Parekh (2017) and the rate for law enforcement officers is significantly higher. Chopko (2010) used the Impact of Events Scale-Revised to measure the level of subjective distress among participants following exposure to a traumatic event. When a point score of 24 is reached out of a total possible score of 88, the symptoms are considered to be significant. The rates of PTSD symptoms and poor coping skills appear to be higher in first responder populations than in the general public. In a recent Canadian study, Carleton et al. (2018) identified that 44.5% of Canadian public safety personnel had a positive screening, which is significantly higher than the general public (Carleton et al., 2018). The results with the public safety personnel are only positive screenings and not a definitive diagnosis, meaning that a direct comparison of the results would not be accurate or appropriate. However, this still shows a potentially statistically significant difference between the public safety personnel and the general public that could be directly related to the frequent exposure to potentially traumatic events throughout their general work duties and functions. Carleton et al. (2018) discussed that the differences amongst Canadian public safety personnel could possibly be attributed to a number of diverse factors, such as that municipal and provincial officers may have increased access to various structured and social supports because they are more typically deployed in a more urban setting versus an 9 officer with the Royal Canadian Mounted Police, who may be more likely to be stationed in a rural or remote setting and who may therefore have less access to the same type of supports. Rural officers also often work alone while urban officers are more likely to be partnered up with another officer. Carleton et al. (2018) additionally point out that provincial or municipal officers are more likely to have a partner assigned with them during their shift and an RCMP officer is more likely to be alone whilst on duty. This can cause added stress to situations knowing that backup is much farther away if a critical incident was to occur. These studies commonly also identify poor coping skills as a factor among those with symptoms of PTSD. Carleton et al., (2018) found that the rate of alcohol use disorder among Canadian public safety personnel was approximately 6% and this was screened for by self-reporting surveys. The collection self-reporting survey may impact the rate of alcohol use reporting and it is likely higher. Fox et al.’s (2012) study revealed that 19% of participants had abused alcohol, although there is no timeframe noted with regards to the diagnosis, and a further 14% of participants indicated that they believed they needed to reduce their alcohol consumption in the overall study. Overall, of the 150 participants in Fox e al.’s (2012) study, it was discovered that 40% either had any mental health condition, approximately 25% had PTSD, approximately 8% had depression and approximately 18% had alcohol abuse. Similarly, Meffert (2008) conducted a study with 180 officers from several urban police departments across the United States. The results showed that 21% of the officers had indicators of alcohol abuse and 7% had indicators of alcohol dependence. This study also discovered that 19% of participants were also suffering from depression. The rates of depression and alcohol usage is therefore comparatively high amongst officers 10 and could be attributed to officers self-medicating their symptoms of trauma (Donnelly Valentine & Oehme, 2015). These statistics illustrate that there is often at least one negative condition among officers and there is also a potential to have multiple conditions at the same time, although this was not specifically addressed in these studies. Post-Traumatic Stress Disorder (PTSD) PTSD can develop from a single incident or from multiple exposures to a critical incident (Klimley et al., 2018; Martin & Martin, 2017). Approximately 80% of first responders have reported experiencing a traumatic event while at work (Klimley et al., 2015). Consequently, first responders are more at risk than the general public of developing symptoms of PTSD (Carleton, 2018). PTSD is estimated to vary from 5% to 32% of individuals after exposure to a traumatic event (Klimley et al., 2018). First responders therefore experience PTSD at a higher rate than the general public because of their high rate of exposure to occupational traumatic events, their increased work demands, as well as routine exposure to physical and psychological stressors (Carleton et al., 2018; Donnelly et al., 2015; Klimley et al., 2018). Not all PTSD diagnoses are the same, as PTSD can be described as a spectrum disorder with varying symptomology; it can be thought of on a continuum or spectrum where an individual can be placed somewhere along it (Fox et al., 2009; Becker et al., 2009; Klimley et al., 2018). PTSD is a significant mental health problem and the symptoms can have a number of negative effects. Several risk factors have been identified in research for officers and the development of PTSD. These include the severity of the traumatic incident, the degree of exposure to an incident, the amount of personal losses experienced by the officer, and the 11 officer’s role in the incident (Klimley et al., 2018). Furthermore, the officer’s level of proximity to an incident also is important and can be directly related to the development of symptoms (Klimley et al., 2018). Approximately one-third of police officers suffer from PTSD or post-traumatic stress responses that can seriously negatively affect their physical and mental health (Klimley et al., 2018). For instance, a study of Dutch police officers found that 34% of officers exposed to a single traumatic event suffered from PTSD symptoms (Klimley et al., 2018). Carleton et al. (2018) estimated this figure to be between 10% to 35% among Public Safety Personnel. Violanti (2006) also found that in his study, approximately 30% of participants suffered from PTSD symptoms. Research seems to consistently demonstrate that the prevalence rate for PTSD symptoms is approximately 30%. This statistic is important because this is only resulting from exposure to a single incident, whereas on average police officers are exposed to three traumatic events every six months (Klimley et al., 2018). There are indications that the risk of developing either partial or full PTSD can also depend on a number of factors. These factors include; the nature of the traumatic incident, the individual’s developmental history, personality characteristics and the level of social support (Klimley et al., 2018; Carleton et al., 2018). Furthermore, each occupation within the first responder community experiences traumatic events differently as they respond to different types of calls for service and perform different essential functions. Each occupation has a different job function which includes different tasks and involvements at various stages of an event. This can be seen when comparing and contrasting the different job functions of occupations such as corrections, sheriffs, police officers, and other groups 12 that fall under the umbrella term of law enforcement. In addition to this, members within the same occupation can experience events differently (Klimley et al., 2018). PTSD can also develop as a result of exposure to cumulative events (Arter et al., 2018; Martin & Martin, 2017). Cumulative events can include constant exposure to death, struggles associated with making routine arrests, high risk pursuits to both the officers and the public, and screams of victims and the reactions of family members during next of kin notifications (Martin & Martin, 2017). Several duty-related traumatic incidents are strongly linked to the development of PTSD. These incidents include; killing in the line of duty, the death of another officer and being physically assaulted (Klimley et al., 2018). Martin and Martin (2017) explained that cumulative PTSD is often second to acute PTSD because it can go unnoticed until an illness or another tragedy occurs. The Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition has been revised to allow for the recognition of cumulative exposures rather than just a single incident exposure to meet the criteria for a mental health disorder; this is also important because the symptoms of PTSD are the same, but the pathway of developing it can be different (Carleton et al., 2019). This is important because it allows for public safety personnel who work dealing with trauma for years to have their cumulative damage recognized. This is also important because it allows for the inclusion of repeated exposure of organizational stressors to be a recognized pathway to the development of PTSD. Prior to this change, only single incident or acute trauma could result in the diagnosis of a mental health disorder because the cause was more noticeable and identifiable. Symptoms of PTSD may include re-experiencing the precipitating event in an intrusive way both at work and during their personal life, avoiding situations that are likely 13 to trigger memories of the precipitating event, which can negatively affect work performance; having intrusive flashbacks of the traumatic incident and hyperarousal, which can cause difficulty sleeping and which can lead to other negative health issues and decreased work performance; and difficulty in concentration, which can be an officer safety concern (Hartley, 3013; Shucard et al., 2012; Chopko & Schwartz, 2012). Officers may experience nightmares, functional impairment, and avoidance of stimuli and again, this can negatively impact their work performance and their personal life (Martin & Martin, 2017). When these symptoms last longer than one month, PTSD can be diagnosed. In addition to stressors and traumatic incident exposure, research has also identified personal characteristics that can increase the risk for PTSD development. Characteristics such as family psychiatric history, difficulty expressing emotions, anxiety sensitivity and hypersensitivity to threat factors can increase the risk of developing PTSD (Klimley et al., 2018). Correlates of PTSD Many police officers who are diagnosed with PTSD also suffer from mental health problems, such as: psychological distress and bereavement; anxiety; depression; sleeping difficulties; and substance abuse problems (Klimley et al., 2018; Arter et al., 2018). These mental health issues can also be linked to many of the physical health issues that exist, such as cardiovascular disease and gastrointestinal issues (Violanti et al.,2008; Hartley et al., 2016; Klimley et al., 2018). One of the more common problems that exists when an individual has PTSD is substance abuse (Klimley et al., 2018; Arter et al., 2018). There are a large number of first responders who have issues with alcohol and substance abuse, particularly with males 14 (Carleton et al., 2018; Waters and Userry, 2007; Fox, 2012; Klimley et al., 2018). In addition to the negative physical and psychological issues that are present with substance abuse, other negative consequences can include relationship conflict. These consequences only further place an officer’s life out of balance and can negatively impact both their professional and personal lives (Chopko et al., 2014; Klimley et al., 2018). Physical Health There is a relationship between traumatic incident exposure and poor health among police officers. PTSD symptoms can be linked to increased health problems, which can include poor physical health and quality of life; greater severity of pain and arthritis; gastrointestinal issues; and even cardiovascular issues (Hartley et al., 2016; Violanti et al., 2008). Research also suggests that officers continuously have high levels of stress, even when they are off duty as there is a perpetual need for vigilance (Waters & Ussery, 2007). The adverse development of PTSD after a traumatic incident exposure could be the primary reason for the negative health outcomes (Klimley et al., 2018). Further research also suggests that the relationship between PTSD and adverse health outcomes is potentially cumulative as it builds up over time (Klimley et al., 2018). It is also troubling that when officers are exposed to trauma, even without the development of PTSD symptoms, the officers can suffer the same physical health issues. This means that trauma, even without the development of a mental health issue, is detrimental to the physical health and wellbeing of officers (Klimley et al., 2018). Gender and PTSD Females are more likely to interpret events to be traumatic compared with male officers (Violanti, 2008; Klimley et al., 2018) and in the Carleton et al. (2018) study, women were also more likely to screen positive for a mental disorder in general than men are. 15 Arter et al. (2018) state that females can experience unique stressors, which may include “sexism, lack of role models and mentoring, demands to prove themselves, lack of acceptance by the police sub culture, and even stress from their own friends and family” (p. 31) which can reduce their ability to cope with exposure to trauma in the field. In addition to the frequency of exposure, Klimley et al. (2018) stated that the development of PTSD might also depend on the level which the officer is able to identify with the victim of crime. If an officer can relate on a more personal level, they may become more emotionally attached and this has the potential for them to also feel their traumatization to a certain extent. Age and Experience Research has shown that there may also be a relationship between age and experience when it comes to the development of PTSD (Arter et al., 2018; Klimley et al., 2018). Older officers with more years of service are typically at an increased risk of developing PTSD than newer, younger officers. Klimley et al. (2018) attributes this to newer officers going through a period of enthusiasm and excitement during the beginning of their career, which could be a protective factor against PTSD. Arter et al. (2018) however, attributes this to older officer have had more time to be indoctrinated into the police subculture and place more emphasis on the negative stigma. Officers who are 50 years of age or older have the highest rates of PTSD and have a 40% higher rate of PTSD than officers who are under the age of 40 (Klimley et al., 2018). This could be attributed to the length of service and increased or prolonged exposure to traumatic events (Arter et al., 2018). When a violent incident occurs, although it may not be frequent, can lead to severe PTSD symptoms being developed by the officer (Klimley et al., 2018). This suggests that it 16 is not only the frequency to which officers are exposed to trauma, it is also the severity of the trauma they experience that matters (Arter et al., 2018; Martin & Martin, 2017). Similarly, Carleton et al. (2018) reported that younger public safety personnel with fewer years of experience are less likely to report symptoms of a mental disorder. This could be due to the less frequent exposure to traumatic events over time. A newer officer can still be exposed to single traumatic events; however, they may not necessarily have the same amount of compounded or cumulative exposure over time as a more senior officer. Protective Factors for PTSD Fortunately, there have also been many protective factors that have been identified in research to protect an individual from the negative effects of trauma. Protective factors increase an individual’s resiliency and can mitigate or protect them from negative aspects of trauma to a certain extent. Such protective factors include individual resilience, satisfaction with life, gratitude, and posttraumatic growth. The strongest protective factor identified is social support (Klimley et al., 2018). Public safety personnel who are single or divorced were also more likely to show symptoms of a mental disorder than those who were married or in a common law relationship (Carleton et al., 2018). This could be attributed to having a constant positive social support relationship. Carleton et al. (2018) state that such relationships can serve as resiliency factor or a protective factor from mental health issues. Carleton et al. (2018) found that individuals who were married or in a common law relationship were significantly less likely to report suicidal behaviours. This finding was also supported by Violanti, Fekedulegn, Charles, Andrew, Hartley, Mnatsakanova and Burchfiel (2009). 17 Fostering an environment that creates a positive attitude from peers and superiors about emotional expression can also be beneficial to officers (Klimley et al., 2018). When there is a perceived availability of support mechanisms in place by an employee and there is also a satisfaction with the support this can further act as a protective factor for an individual. This could create a more positive police culture. Education also appears to increase resilience. Participants with a bachelor’s degree or four years of college in Carleton et al.’s (2018) study, were less likely than those who had finished high school or who were less educated to report symptoms of a mental disorder (Carleton et al., 2018). This suggests that a higher level of education might be a protective factor from mental health disorders. Carleton et al. (2018) state that this might also be associated with other factors, such as access to wealth. Suicide There is a strong relationship between suicidality and PTSD among police officers (Klimley et al., 2018; Arter et al., 2018; Violanti, 2006; Carleton et al., 2018). This relationship has been thoroughly researched and well established. Police suicide deaths often outnumber line of duty deaths for officers in the United States (Martin & Martin, 2017). The suicide rate for police officers is greater than the number of officers who are killed while on duty by firearms and accidents combined (Martin & Martin, 2017). This is certainly problematic and needs to be addressed with proper intervention. The number of police suicides are estimated to range from 125 to 150 annually (Martin & Martin, 2017). However, according to Martin and Martin (2017), police suicide statistics are difficult to gather, for several reasons. There is a lack of records because not all law enforcement agencies keep statistics about officer suicide and the cause of death can be 18 mislabeled (Martin & Martin, 2017). Another important point is that various departments across the United States have different organizational intervention programs that could account for different rates of suicides among different departments (Martin & Martin, 2017). Although it is difficult to accurately capture these statistics, it appears that police officers are at an increased risk of suicide as compared to the general public (Violanti, 2006; Carleton et al., 2018; Arter et al., 2018). An individual can be drawn to suicide as a solution to what they perceive as an insolvable problem (Violanti, 2016). Violanti (2016) stated that there is a strong correlation between hopelessness and suicide and that levels of individual hopelessness are at their highest when there is a lack of organizational support for that individual. The individual can feel alone and hopeless when there are no support systems in place for them and the fear of feeling stuck with no perceived way out can lead to suicidal ideation, and in some instances, suicide. In addition to this, Violanti (2016) also stated that this relationship was strongest when there were PTSD symptoms being exhibited by the individual. Mental Health Stigma As previously noted, due to a police culture that emphasizes strength and invulnerability, police officers do not typically seek out professional help when they are experiencing the negative impact of trauma (Arter et al., 2018). The police sub-culture has historically viewed exposure to trauma as part of the job, and help-seeking as being weak, expecting officers to tough it out (Arter et al., 2018). This police culture prevents officers from seeking out services and help when they believe it is needed; such barriers only allow 19 the underlying issues to fester and potentially become worse with time (Rose & Unnithan, 2015). Officers who do seek help fear being labeled as troubled (Arter et al., 2018). This attitude has unfortunately caused a lack of discussion surrounding this issue (Martin & Martin, 2017). Fox (2012) stated that only 47% of the participants in their study had reportedly used mental health services. In addition to this alarming statistic, 35% of these officers sought care exclusively outside of their employee assistance program, which was attributed to a number of factors such as stigma and trust (Arter et al., 2018). The majority of officers who did this were for PTSD (45%) and alcohol abuse (40%). Fox (2012) states that the main reason for this was concerns with confidentiality because the employee assistance program was tied to the employer, a potential negative impact on their career and the stigma associated with the use of mental health services. Arter et al. (2018) further state that the three main reasons that acted as barriers to treatment are the negative stigma associated with mental health, a perceived lack of confidentiality with the services provided and a lack of trust with their organizational administration. These three barriers need to be eliminated to ensure those who need help are able to get help. Faust (2014) suggests that research should examine the military and their destigmatization strategies because many of the strategies that they have used can be adapted for use in police forces as they have a similar hierarchical structure. One example of a military strategy that was adapted for use with police is the Royal Canadian Mounted police’s Road to Mental Readiness, which will be discussed later in this paper. Resiliency Strategies and Resources It is difficult for police officers to get treatment if they are experiencing issues (Klimley et al., 2018). Mental health stigma, long hours and shift work, and fear of negative 20 repercussions on their career act as barriers for treatment (Klimley et al., 2018). These barriers need to be broken down so that officers can seek the help they need, if the resources exist for it. A review of the literature suggests that there are several management programs created to manage PTSD amongst front-line officers. Post-Incident Screening Early intervention after a traumatic event or critical incident is essential and it can be more effective than delayed follow up at a later point in time. Gates (2012) stated that screening can be utilized to identify individuals who have been exposed to trauma and could potentially have undiagnosed PTSD. The screening can also be used on individuals who are at an increased risk of developing PTSD. The screening can be done to identify issues and intervene earlier on to stop the progression of PTSD. The early intervention may result in a slower progression of the disorder and this could mean fewer symptoms or negative outcomes that are associated with PTSD (Gates, 2012). According to Gates (2012), there are some limitations to the screening. Selfreporting tools are open to participant and possibly researcher bias. Furthermore, there is the potential for participants to also be concerned about stigma and this could possibly lead to the under or over disclosure of symptoms that they might be experiencing. Gates (2012) outlined these issues with relying on only one measurement tool as this could lead to a false conclusion. It is therefore the standard screening practice to use multiple screening tools to get a more accurate and valid screening result. Critical Incident Stress Management (CISM) Critical Incident Stress Management (CISM) is a term that encompasses a variety of strategies that can be used to lessen psychological distress resulting from exposure to a traumatic incident (Klimley et al., 2018). CISM is preventative of post-traumatic stress and 21 it is also responsive to incidents. CISM is also used to mitigate the potential adverse post traumatic symptoms that an individual may experience. There are four goals of CISM which include: educating the individual with regards to stress and coping mechanisms, informing the individual of normal reactions to stress and validating their reactions, encouraging the emotional processing of the event that occurred and to provide information about available resources if they are needed (Klimley et al., 2018). There are seven core components of CISM. They include: 1. Pre-crisis preparation which includes education and other resiliency training for both individuals and organizations. 2. Demobilization/informal briefing which in preformed at a scene and during an event. This could include first responder or other community support groups. 3. Defusing which is a three-phase small group discussion that occurs within 12 hours of the incident. This allows for assessment and to provide information about critical incident stress. This is also an opportunity to identify individuals who are at risk and to triage them. 4. Critical Incident Stress Debriefing which involves a structured group discussion and this is usually provided between 1-10 days after the incident. The aim of this is to limit acute symptoms and provide some post crisis closure. 5. Facilitate one on one crisis intervention along the entire crisis spectrum. 6. Family Crisis Intervention which can also include organizational consultation. 7. Follow up and referral mechanisms for further assessment and treatment if it is needed. (Wuthnow et al., 2016, p. 476) 22 The first three steps consist of CISM and Crisis Intervention Stress Debriefings (CISD) begins at step 4 as noted above. CISM occurs before exposure to an incident and is a more comprehensive program than CISD, as it prepares individuals for exposure to trauma and also provides intervention after exposure, as well as follow up care when necessary. CISDs are conducted after exposure to a critical incident and consists of debriefings or diffusing (Klimley et al., 2018). During this process, the individual who was exposed to a critical incident is made aware that their normal coping mechanisms could be overwhelmed and what the various consequences of that are. These include; constricted thinking, being in a state of fear, and experiencing anxiety and or depression (Klimley et al., 2018). Unfortunately, the efficacy of CISM is not generally agreed upon in the literature. Some research supports the use of CISM and states that individuals who have used CISM report experiencing less depression, anger and fewer PTSD symptoms when compared to individuals who did not receive CISM (Klimley et al., 2018). Other research states that a single CISD does not prevent the development of PTSD (Bisson et al., 2009). Yet, Wuthnow et al. (2016) state that CISM has been used effectively over the past two decades with first responders. Although, there is not a lot of research regarding CISM in policing as it is mostly used in the health fiend and social work environments. A CISD on its own is not definitively agreed upon as being effective in the literature but this does not take into account any follow up that may occur as a result of the CISD. CISM alone is criticized as not being effective, however, CISD by design is not intended to be a solution to the various symptoms that are being experienced and that is what proper follow up with a mental health professional is for. This process aims to inform the 23 individual that what they are experiencing is normal following exposure to a critical incident and to let that individual know that they are not alone, there are resources available to assist them. There may also be issues with program fidelity because when a program is taken and implemented in different jurisdictions it may not always be implemented in the most effective way. This is important because the program transferability may not always work as one rigid approach may not work for all situations. Still, CISM is perceived as contributing to the wellbeing of individuals, creating destigmatization of mental health related issues, and increasing access to mental health care (Cohen et al., 2019). Strong, Effective Leadership Police leadership plays a pivotal role in reducing the negative stigma that surrounds mental health issues in policing (Arter et al., 2018). Donnelly et al. (2015) also stressed the need for leaders and supervisors to set the tone for their respective agencies. Cohen et al. (2019) stated that senior police leaders have an essential role in establishing the acceptance of occupational stress injuries as a work place injury and in reducing the stigma that is attached to help seeking for mental health issues. Leaders need to effectively communicate that everyone needs assistance dealing with issues that are outside of the norm (Arter et al., 2018) Cohen et al. (2019) further highlighted that leadership in policing sets the tone for the organization, but it is more importantly responsible for creating the opportunity and platform for reform. Change is slowly making progress throughout the policing culture regarding the effects of trauma and other occupational stress injuries (Cohen et al., 2019). Furthermore, police leaders must be willing to examine the available research to make evidence-based 24 decisions, speak with experts both within and outside of their organization, learn about the specifics of their issues, and develop strategies to both prevent and respond to such issues (Cohen et al., 2019). This is a large undertaking and it requires the commitment and dedication of leadership as they will be both personally and professionally vested in the success or failure of such change efforts. It is also important to create a shared vision and have all members of the organization believe in the organizational vision (Cohen et al., 2019). Peer Support Another available resource for officers to utilize is peer support groups. Peer support groups seek to provide social and emotional support for officers who are in distress in either their professional or personal lives (Martin et al., 2009; Klimley et al., 2018). Peer support groups also aim to assist officers with the psychological difficulties associated with their jobs (Klimley et al., 2018). The group also aims to normalize traumatic experiences that officers face at work (Klimley et al., 2018). Peer support has been identified as a protective factor and, when used properly, can assist officers who are having various issues experienced after exposure to a traumatic incident. Peer support groups allow for officers to share their experiences and feelings with anonymity and confidentiality with those who understand the field. Peer support groups are generally available to officers around the clock and can also include co-workers who have received specialized training (Klimley et al., 2018). If a co-worker gets the training to become a peer support counsellor then they are also able to further understand the issues that their peers are going through because they are doing the same job. Peer support 25 programs are also aimed to provide a level of comfort and security for officers (Martin et al., 2009). There are numerous peer support hotlines that are set up around the United States for officers to utilize. These hotlines are generally operated by volunteers who are trained to recognize the symptoms associated with PTSD, substance abuse and relationship difficulties (Klimley et al., 2018). Martin and Martin (2017) reference Safe Call Now which provides assistance to public safety employees who are experiencing a crisis. Safe Call Now is free to use and a confidential service which is staffed by former and current police officers. Safe Call Now can also make mental health or behavioral issue referrals when needed. Safe Call Now also focuses on educating public safety agencies on organizational resilience and wellness programs (Martin & Martin, 2017). Mindfulness Mindfulness based interventions are intended to create internal awareness about symptoms of stress and to encourage utilization of mindful practices to mitigate the effects (Cohen et al., 2019). There are several techniques that may be used, such as: a full body scan, where an individual reflects on how their body is reacting to stress; using meditation to regain a sense of calm; and taking mindful moments where an individual can focus on their thoughts and feelings and journaling (Christopher et al., 2016 ). This increased awareness has been shown in several studies to reduce feelings of stress, burnout, anger and sleeplessness (Williams et al., 2010; Chopko and Schwartz, 2013; Christopher et al., 2016). Mindfulness has the potential to assist officers in their ability to cope with the negative consequences of stress and the physical and psychological toll that they can have on an individual (Arter et al., 2018). With the proper training and promoting positive 26 coping skills within an organization, the impact has the potential be mitigated to a certain extent (Arter et al., 2018). Mindfulness practices are a way to both increase resilience beforehand and deal with the symptoms after the fact. Road to Mental Readiness The Royal Canadian Mounted Police (RCMP) has recognized the issues surrounding mental health and has responded as an organization to assist their employees with the struggles that they were experiencing (Beaubien, 2015). In 2015 the RCMP launched their Road to Mental Readiness (R2MR) program, which is now mandatory training for all employees of the RCMP (Beaubien, 2015). This program was a Department of Defence program and was adopted by the RCMP to educate officers and raise awareness about mental health and how to maintain mental resilience. The R2MR is a prevention tool that aims to reduce stigma before one experience a critical incident and this will presumably increase the likelihood of help seeking when one recognizes that they are having problems or struggling. R2MR also assists officers to help them recognize issues when their peers or colleagues are struggling. Another goal is to reduce the stigma that was associated with mental health issues among police. The R2MR has a colour coded scale that outlines behaviors for people in four stages: • Healthy (Green) which includes “normal mood fluctuations, good attitude, good performance, physical and social activity; • Reacting (Yellow) which includes “irritability, teariness, sleeplessness, decreased activity, regular but controlled substance use”; • Injured (Orange) which includes “anger, hopelessness, negativity, withdrawal, hard to control substance use; and 27 • Ill (Red) which includes “depression, suicidal thoughts, inability to perform duties or concentrate, isolation at home, substance addiction.” (Beaubien, 2015, RCMP webpage) The R2MR training is conducted through a workshop by a peer facilitator and a mental health professional. Beaubien (2015) explains that the R2MR workshop consists of four modules which include mental health in the RCMP, stress reaction, resilience skills, and resources that are available through work. This is a proactive program that is employee focused, similar to CISM. It is a good example of a large police organization taking steps to not only reduce stigma surrounding mental health but to also provide their employees with effective coping strategies to increase resilience. The RCMP has also implemented an internal Peer to Peer program to supplement their Employee Assistance Program (Government of Canada RCMP, 2018). This program provides officers access to a peer coordinator who can assist with work related issues or personal issues. Early findings suggest that there may be a short-term benefit in reducing the stigma and increasing resiliency (Cohen et al., 2019; Dobson et al., 2018). Future research must be conducted to fully understand the long-term impact of the R2MR and Peer to Peer programs. Employee Assistance Programs (EAPs) Employee Assistance Programs (EAPs) exist for the benefit of employees which in turn keeps their attendance and productivity up at work. EAPs provide resources to employees who experience issues that affect their work performance (Donnelly et al., 2015). Various EAPs offer psychological services, including assessments, counselling and if required, further referrals (Klimley et al., 2018). Unfortunately, Arter et al. (2018) found 28 that only 60% of employees would utilize EAPs through their employer. EAPs are not always properly utilized due to a perceived confidentiality issue (Arter et al., 2018). Often employees believe that their information will not remain private and could be shared with members of their department, which may also negatively impact their career progression or perceived fitness for duty (Arter et al., 2018). This shows that the negative stigma surrounding mental health issues is still strong in the policing culture. Stigma was the number one reason that employees chose to not access EAPs (Arter et al., 2018). There could also be a perceived conflict of interest for the EAP providers who may have a duty to notify the employer if there is a risk to the agency (Klimley et al., 2018). From the point of view of the employee, this can be perceived as a major disincentive to use the services and may result in the employee seeking independent care or worse, none at all. Martin and Martin (2017) state that this is a myth however, and that the results of the utilized EAP are bound by complete confidentiality, this may vary by jurisdiction. For example, in Nevada, everything you tell a provider will remain confidential unless one makes any suicidal, homicidal or child abuse/neglect statements as they are mandatory reporters. If there are still concerns with confidentiality, there is also the option to seek other treatment through the officer’s health insurance provider for options outside of the EAP. Unfortunately, most police officers remain suspicious and mistrustful of mental health professionals (Levenson Jr., 2007). Other reasons for not utilizing EAPs, according to officers, may include; a lack of trust with supervisors and administrators in an organization, a belief that mental health services are not needed as they could manage issues on their own, and the services being provided are not effective or of poor quality (Arter et al., 2018). 29 Recommendations There are several recommendations that either individual officers or police organizations can implement to assist officers. The literature is rather consistent with peer support being the best protective factor for officers. Strong social and organizational support systems can reduce the occurrences of PTSD and PTSD symptoms with officers following exposure to trauma (Martin et al., 2009). Police officers should build strong social and support networks with their family, friends and police organizations to foster a supportive environment for their officers. Such social networks allow for inclusion and provide meaningful relationships. It is also important to maintain non law enforcement friendships to allow officers to get away from policing for a short period of time. Strong leadership is needed to change the negativity of the police culture regarding mental health. Leaders need to be aware of the state of their organization to be aware of the nature and quantity of occupational stress injuries within their organization (Cohen et al., 2019). A leader must also have the skills to bring about change when it is necessary (Arter et al., 2018). Leaders must foster an environment that encourages people to express their thoughts and feel heard and supported by management. Cohen et al. (2019) and Rose and Unnithan (2015) define organizational culture as the shared beliefs, values and norms within an organization and this also includes the various sub-cultures that can be present within the organization, such as across units. There must be open communication to accomplish this transformational change (Arter et al., 2018). This can be done by having leaders who are approachable and have an open-door policy where employees can speak with them when they feel the need to. This goes further than just sending out emails and memos. 30 Cohen et al., (2019) outline steps that organizations can take to begin to make the necessary changes. Firstly, organizations must develop and implement and mandate a wellness vison. The next step is to have an assessment conducted to determine the amount, level, types and causes of occupational stress injuries within their organization (Cohen et al., 2019). This assessment should be a self-administered and anonymous survey that uses validated measurement scales (Cohen et al., 2019). Such a survey could give leaders valuable information about the health of their officers and can be re-administered at a later date to see if any progress has been made. Measuring and recording the results and collecting the data is important to see if problems are improving, getting worse, or staying the same. Further research into the efficacy of proactive strategies such as the R2MR should be conducted. The program was created with the assistance of the Department of Defense and has been used on a national level. A program evaluation can be conducted to check if there is a significant change in PTSD among RCMP officers. This would also measure if any significant change in stigma occurred about mental wellness and other symptoms of mental health issues, such as depression and chronic stress. Critical incident management programs, such as CISM, have also shown to be effective in the short term for officers. CISM educates officers on what emotions or symptoms they may experience (Klimley et al., 2018). Perhaps the most useful part of CISM is that proper mental health referrals can be made if needed. This allows for further longterm care to deal with any lingering symptoms. CISM has become a common practice for most police organizations and should be made available to all police agencies. CISM may work at the onset of an incident but when it gets implemented in other jurisdictions it may 31 stray from the original program’s methods and intent. It is also important to note that a single intervention will have a different effect than multiple interventions. Research has clearly demonstrated that there is still a significant amount of stigma surrounding mental health and police officers. This stigma therefore acts as a barrier to effective treatment and symptoms that are left untreated can become worse over time. Police organizations need to proactively encourage their officers to speak up if they are having problems. Officers who are experiencing mental health issues associated with PTSD should be encouraged to self-report to get the help that they need early on. Early intervention is important and often more effective than late intervention. Furthermore, police organizations should also provide in-service training for their officers to recognize the symptoms of PTSD. Education is important and it also eliminates some of the stigma. Education on effective coping strategies for stress and traumatic exposure should be made available to officers. In addition, education can also be provided on early warning signs of suicide. Educating all members of an organization on resilience can result in an improvement of personal wellbeing, work performance and psychosocial functioning (Cohen et al., 2019; Robertson et al., 2015; Arter et al., 2018). Programs such as R2MR can be implemented and all members of the organization can receive the training. Education can be provided to officers’ families, which could also provide stronger social support at home. Another recommendation is to provide annual mental health checks for officers. Cohen et al., (2019) recommend annual psychological checkups for all members and further suggests that this should become a common practice. This could assist with the identification of any PTSD symptoms associated with single incident trauma and 32 cumulative PTSD. Identifying these issues before they have further time to develop and lead to other symptoms such as substance abuse or suicide ideation is important. Annual mental health checks should at the very least be implemented for officers who are more susceptible to traumatic incident exposure due to their job assignment, such as child abuse or sex crimes. This screening could take place using a clinical interview where participants have the opportunity to self-report and also be used in conjunction with an authentic, validated screening measurement. Police organizations also need to provide adequate employee assistance programs and communicate clearly about the extent that confidentiality will apply to their employees. They also need to equip their employees with the resources that they need if they encounter issues. It is important for organizations to educate their employees on what resources are available to them as well as how to access them (Donnelley et al., 2015). This education needs to be more than hand out brochures and done on a continuing basis, not just during their onboard after hiring. Donnelly et al., (2015) also suggests publishing and maintain an available resources list for all employees. Such education will also assist in reducing the negative stigma of speaking out about mental health issues. Further research can also be conducted into the different types of peer support programs and groups that are available. This will allow organizations to formulate their resources and time into the most effective peer support methods. This will benefit the officers and organizations with an evidence-based solution. Conclusion The rate of PTSD and other mental health issues among police officers is high and there are many negative consequences as a result. PTSD can affect an individual in many 33 aspects that include both physically and psychologically. Occupational stress injuries may also be a contributing factor to various physical and psychological issues. Extensive research has been conducted to break down the causes of PTSD and various mitigation strategies. 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