POST-TRAUMATIC STRESS DISORDER: An Introduction for Criminal

POST-TRAUMATIC STRESS DISORDER: An Introduction for Criminal Justice Officers from the Law Enforcement Families Partnership brought to you by

ACKNOWLEDGEMENTS Many people at Florida State University’s Institute for Family Violence Studies contributed to the development of this Training. They include: Haley Van Erem, MSW Annelise Martin, MSW Laura Summerlin, MSW Rachyl Smith, MSW Candidate Phyllis Stolc, MSW Candidate Mark Stern Denise Choppin Karen Oehme, J.D. THIS TRAINING IS DEDICATED TO THE BRAVE MEN AND WOMEN WHO KEEP OUR COMMUNITIES SAFE; THEY DESERVE TO GET HELP WHEN THEY NEED IT.

WHO SHOULD READ THIS TRAINING? All law enforcement supervisors and administrators, including those in State agencies, Police, Sheriff, and Highway Patrol agencies. All supervisors employed by Departments of Corrections or private correctional agencies. All certified criminal justice officers.

WHY IS PTSD TRAINING IMPORTANT? “PTSD is a greater cop killer than all the guns ever fired at police officers.” – Lt. James F. Devine, former director of NYPD Counseling Services About 300 officers kill themselves yearly, which is more than are murdered by felons. Many of these suicides are the result of failing to cope with PTSD.

WHAT IS PTSD? PTSD stands for Post-Traumatic Stress Disorder PTSD is a response to trauma that: may develop after an individual is exposed to: threatened death or severe injury, a threat to the physical integrity of oneself or another person, or death or injury to another person

EVENTS THAT MAY LEAD TO PTSD Combat in military service Ongoing exposure to community violence Terrorist attacks Sexual or physical abuse First-hand exposure to trauma such as crimes and serious accidents Witnessing the death of a loved one Ongoing violent relationships

COMMON SYMPTOMS OF PTSD Commonly reported symptoms associated with PTSD include: Intrusive Memories Avoidance Anxiety or Emotional Arousal

COMMON SYMPTOMS OF PTSD (CONTINUED) There are many immediate responses to trauma, including fluctuations in heart rate and blood pressure and other physiological responses. However, many symptoms of PTSD usually begin to develop three to twelve months after a traumatic event has occurred.

COMMON SYMPTOMS OF PTSD (CONTINUED) Intrusive Memories Examples: Flashbacks Dreams Reliving the event These events are often caused by triggers (e.g., the sound of a car backfiring or seeing a news story similar to the traumatic event)

COMMON SYMPTOMS OF PTSD (CONTINUED) Avoidance Examples: Feeling hopeless Reporting memory loss Avoiding once enjoyable activities Experiencing difficulty concentrating Having trouble maintaining close relationships Avoiding thoughts about the event Feeling emotionally numb

COMMON SYMPTOMS OF PTSD (CONTINUED) Anxiety or emotional arousal Examples: Anger Irritability Guilt or shame Trouble sleeping Trouble concentrating Being easily frightened Self-destructive behavior Hearing or seeing things that aren’t there

ADVERSE EFFECTS OF PTSD PTSD can cause: Personality change Issues with employment (e.g., disorganization, memory issues, and lack of concentration) Relationship problems (e.g., domestic violence and divorce) Physical Symptoms (e.g., increased heart rate or sweating)

ADVERSE EFFECTS OF PTSD (CONTINUED) PTSD is strongly associated with substance abuse. Alcohol abuse occurs in 60-80% of Vietnam veterans seeking PTSD treatment. 34.5% of men who have had a history of PTSD reported dependence on or abuse of drugs at some time in their lives; the rate is 15.1% for men in the general population. 26.9% of women with a history of PTSD reported dependence on or abuse of drugs at some time in their lives as opposed to 7.6% of women in the general population.

ADVERSE EFFECTS OF PTSD (CONTINUED) Domestic Violence is another concern that has been linked with PTSD. Veterans with PTSD have higher rates of domestic violence than do people in the general population. 33% of veterans with PTSD have been violent with their partner in the span of one year. Veterans who have PTSD are two to three times more likely to be violent with their partner than veterans who don’t have PTSD.

CASE SCENARIO #1 Lisa, Officer John Smith’s girlfriend, noticed that John seemed different after he was a first responder to a fatal car accident a month ago. The accident took the lives of two children. Officer Smith had worked hard to prevent the loss of their lives, but it was too late and he was unable to save them. Lisa noticed that in the last month John had been waking up in the middle of the night very frightened from his dreams. He had also become easily angered by Lisa and others and had stopped attending poker nights with his friends, which had once been the highlight of his week. Lisa encouraged John to seek treatment, and a counselor told John that he had symptoms of PTSD.

CASE SCENARIO #1 (CONTINUED) Question 1 What symptoms, if any, does Officer Smith have that indicated to his counselor he could be suffering from PTSD? Question 2 If Officer Smith had continued without counseling, what could some potential risks have been?

CASE SCENARIO #2 Officer Carol Stewart, a member of the Florida National Guard, has been behaving differently since she returned from her second tour of duty in Afghanistan, where she witnessed severe trauma and the death of a close friend and fellow soldier. She returned to her unit and began street patrol again. Carol has been startled easily by nonthreatening events that occur on the street, and she has been unable to concentrate while on patrol. Her partner asked about her time overseas, and Carol became angry and would not talk about it. She has started going to get many drinks at a neighborhood bar after each shift. Her colleagues have said she seems “ready to explode.”

CASE SCENARIO #2 (CONTINUED) Question 1 What symptoms, if any, might Officer Stewart have that could be indicative of PTSD? Question 2 What event may have led to the onset of these symptoms?

PREVALENCE OF PTSD PTSD affects between two and nine percent of people in the general population. There is a greater likelihood of developing the disorder if a person has been exposed to: Trauma in early life Long-term trauma Recurring trauma

PREVALENCE OF PTSD (CONTINUED) PTSD Prevalence Among Military Veterans Between 15-30% of the armed forces who served in Vietnam are thought to suffer from PTSD. One out of six (around 17%) veterans who served in Iraq and Afghanistan are thought to suffer from PTSD. Some estimates are higher. 38% of soldiers, 31% of Marines, and 49% of National Guard members report psychological concerns like PTSD and traumatic brain injury. Does your agency employ returning soldiers who might need help with PTSD?

PREVALENCE OF PTSD (CONTINUED) PTSD Prevalence Among Law Enforcement Officers Law Enforcement Officers are often exposed to dangerous situations. The rate of police officers with duty-related PTSD is estimated at 7-19%. REMEMBER, IGNORING THE PROBLEM WON’T MAKE IT GO AWAY. HELP YOUR OFFICERS GET THE HELP THEY NEED!

PREVALENCE OF PTSD (CONTINUED) PTSD Prevalence Among Law Enforcement Officers (continued) Many daily activities and events in the lives of law enforcement officers can be precipitating factors to PTSD. The following events can cause PTSD in police officers: A violent crime The aftermath of a car accident A natural disaster A homicide Being threatened or assaulted by a criminal offender.

PREVALENCE OF PTSD (CONTINUED) PTSD Prevalence Among Law Enforcement Officers (continued) Sometimes personal experiences in the lives of law enforcement officers can also trigger PTSD. For example: Witnessing crimes or their aftermath Witnessing victim trauma Military service A fire or accident in their home Being a victim of domestic violence

PREVALENCE OF PTSD (CONTINUED) PTSD Prevalence Among Women Women are vulnerable to developing PTSD because they are more likely to be victims of domestic violence Women can also have symptoms of PTSD from their duty as police officers, an experience of physical or sexual assault, domestic violence, or other traumatic events. Women are increasingly being affected by PTSD due in part to deployment to overseas wars Women have had about the same rates of mental illness as male veterans

PREVALENCE OF PTSD (CONTINUED) PTSD Prevalence Among Women (continued) Women in the military are often more likely to be isolated because they: May not be seen as “real soldiers” by family members and friends and may therefore suffer alone with unacknowledged feelings and experiences. Still comprise a minority of the military and veteran population in the US despite growing numbers. Have few veteran-oriented resources to access that will help to decrease isolation and increase help-seeking behaviors.

PREVALENCE OF PTSD (CONTINUED) PTSD and Domestic Violence Domestic violence is considered by the United States Department of Veterans Affairs (2009) as a type of trauma that may be related to PTSD. In one study, 35% of people who had experienced domestic violence were found to have the disorder. PTSD is the most common anxiety disorder associated with domestic violence.

PTSD & DOMESTIC VIOLENCE Several symptoms can heighten the negative experiences of PTSD: The length of time someone is exposed to domestic violence. The severity of the violence. The violence beginning at an early age. The woman’s assessment of the violence (for example, her perception of threat).This threat to self is constant, recurring, and unpredictable, which may contribute to PTSD symptoms.

PTSD: IMPORTANT NOTE Not all people who see trauma have PTSD or have symptoms of the disorder. However, everyone who is suffering from PTSD can benefit from treatment.

DEVELOPMENT OF PTSD It is not the fault of the person suffering In past years, the symptoms of PTSD were discussed as the “fault“ of the sufferer Contrary to this notion, recent research has revealed that Exposure to trauma can alter brain chemistry PTSD is probably caused by a mix of factors, including an individual’s brain chemistry and hormones, inherited personality traits, inherited predisposition to mental illness, and life experiences A person suffering from PTSD is not to blame for the development of the disorder

DEVELOPMENT OF PTSD (CONTINUED) Risk Factors for PTSD Apart from brain chemistry, there are other risk factors for the development of PTSD. These factors include: Being hurt in the traumatic event. Seeing someone else killed or hurt. Having a history of mental illness. Feeling extreme fear or hopelessness. Dealing with extra stress after the event. Having little social support after the event.

DEVELOPMENT OF PTSD (CONTINUED) Protective Factors of PTSD Just as there are many factors that increase the risk of development of PTSD, Protective Factors can reduce the risk of experiencing PTSD. These factors include: Seeking support from others, such as friends and family. Having a coping strategy. Attending a support group.

IGNORING PTSD WILL NOT MAKE IT GO AWAY Someone who suspects that a colleague or employee has symptoms that may be related to PTSD should try to help him/her.

THE GOOD NEWS ABOUT PTSD The good news about PTSD is that it can be treated. But first the person suffering needs help!

TREATMENT OF PTSD Importance of Treatment for PTSD There is treatment that can work very well for PTSD. What works for some people may not work for others. The absence of accessible and effective treatment may lead to: An increased likelihood of self-medication with alcohol and drugs. A higher risk of suicide.

TREATMENT OF PTSD (CONTINUED) Often people suffering from PTSD are treated with therapy, medications, or some combination of the two. Therapy as treatment for PTSD: Should be conducted by trained professionals who are skilled in PTSD treatment. Can be individual counseling or group therapy Can be a place where those struggling with PTSD can meet and learn that their experiences and feelings are shared by others.

TREATMENT OF PTSD (CONTINUED) Medications as Treatment for PTSD Some medications also work for PTSD. People who believe they are suffering from PTSD should always speak to a physician regarding their symptoms and possible treatments.

IF SYMPTOMS OF PTSD ARE PRESENT Anyone experiencing symptoms of PTSD and who may be suffering from the disorder should talk to his/her doctor or someone at a community health center about symptoms and possibilities for treatment.

IF SYMPTOMS OF PTSD ARE PRESENT (CONTINUED) After talking to a medical professional, the person can also do the following: Utilize other support systems like family and friends. Learn more about PTSD. Talk to others who have been through trauma. Practice relaxation methods. Start an exercise program. Realize that symptoms will most likely go away gradually, not immediately, with treatment from a professional.

IF SYMPTOMS OF PTSD ARE PRESENT (CONTINUED) Anyone who may be considering harming him/herself should contact the 24-hour hotline of the National Suicide Prevention Lifeline at 1–800–273–TALK (1–800–273–8255); TTY: 1–800–799–4TTY (4889). Veterans should press “1” after dialing. This will connect the caller with a trained counselor.

IF SYMPTOMS OF PTSD ARE PRESENT (CONTINUED) Anyone experiencing suicidal thoughts should also call 911 or go to a hospital emergency room immediately. The website below lists crisis telephone numbers for different cities and counties across the country. http://suicidehotlines.com

CASE SCENARIO # 3 Officer Scott Rogers is concerned because he often feels scared from non-threatening situations. At home, when he hears a car back-firing, and at work, when he is alone in the break room and someone startles him by coming in the door, he becomes frightened and has intrusive memories of six months ago, when he had a gun pulled on him at a crime scene. He had been responding to a domestic violence call, and when he entered the home, the perpetrator who was holding a gun on his wife turned it to Officer Rogers. Unable to reach his weapon, Officer Rogers was sure that he would die. However, he was able to talk the offender down, and backup arrived quickly. Months later Officer Rogers remains scared. He tries to avoid any domestic violence calls and often calls in sick to work. When at work, he does whatever possible to remain alone and not interact with others in the agency. He often feels physically sick with stomach cramps and headaches. Some coworkers expressed concern. Officer Rogers feels like he cannot get away from his memories of the incident, but he does not know what to do.

CASE SCENARIO #3 (CONTINUED) Question 1 What symptoms of PTSD is Officer Rogers exhibiting? Question 2 What options are available to Officer Rogers for treatment?

IF SOMEONE YOU KNOW HAS SYMPTOMS THAT MIGHT INDICATE PTSD It is important that you help him or her to Talk to a doctor, Get the right diagnosis, and Receive treatment.

IF SOMEONE YOU KNOW HAS PTSD (CONTINUED) It is very important to pay attention to any statements the person makes about harming him/herself. If you hear any of these statements, it is necessary to report them to the individual’s doctor or therapist or assist them in calling: The National Suicide Prevention Lifeline at 1–800–273–TALK (1–800–273–8255); TTY: 1–800–799–4TTY (4889)

IF SOMEONE YOU KNOW HAS PTSD (CONTINUED) While the person is receiving treatment, other suggestions to help might include: Encouraging him or her to stay in treatment. Providing empathy and support. Learning about PTSD. Listening to the individual. Inviting him or her to positive outings.

CASE SCENARIO # 4 Officer Judy Cunningham has noticed that her friend and co-worker Officer Jose Medina, an army reservist, has been acting strangely following his return from active duty in Iraq. Officer Medina has seemed numb. When other officers ask him any questions, he responds with one-word answers. He also does not exhibit emotions like he did before his tour of duty. He very rarely appears happy or sad, even when a situation warrants such an emotion. Whenever he sees a news story about war, he appears ashamed and tries to avoid discussion about the issue. Officer Cunningham is particularly worried about Officer Medina because he lives alone and does not have many close friends or family.

CASE SCENARIO #4 (CONTINUED) Question 1 What symptoms of PTSD might Officer Medina experiencing? Question 2 What should Officer Cunningham do to help Officer Medina?

REVIEW: MYTHS & FACTS ABOUT PTSD Myth: PTSD is caused by a weakness of character. Fact: PTSD is caused by many factors beyond the control of the person suffering from it. Myth: Once a person develops PTSD, he/she will never recover. Fact: PTSD is curable. This means that everyone who is suffering from it should get help. Myth: PTSD is “all in your head.” Fact: PTSD is real, diagnosable, and painful. Myth: PTSD always happens immediately after a traumatic event. Fact: Sometimes weeks or months go by after the event before the person begins to suffer from PTSD. Myth: An individual’s alcohol and drug use can cure PTSD. Fact: These are depressants which can make PTSD worse.

ONLINE TRAININGS There are several online trainings where anyone can get more information about PTSD. The following offer training programs may be of interest: The United States Department of Veterans Affairs offers a free online training in PTSD with continuing education credits available. The training focuses on assessment, treatment, specific trauma, and special populations. To start viewing the modules, go to this website: http://www.ptsd.va.gov/professional/ptsd101/cour se-modules/course-modules.asp .

ONLINE TRAININGS (CONTINUED) The National Library of Medicine and National Institutes of Health have a fact sheet with many references to more information about PTSD. http://www.nlm.nih.gov/medlineplus/posttraumaticstressdisorder.h tml Toward the bottom, there is a link to a tutorial, which you can watch to learn more about PTSD. Here is the link to the tutorial: http://www.nlm.nih.gov/medlineplus/tutorials/ptsd/htm/index.htm .

ONLINE TRAININGS (CONTINUED) The Center for Deployment Psychology has several tutorial programs that have no fee. There may be information about continuing education credits for these courses at a later date: http://deploymentpsych.org/ The following are training programs this center offers: Working with Service Members and Veterans with PTSD: http://www.essentiallearning.net/student/content/sections/lectora/VeteransPTSD/index.htm l Prolonged Exposure Therapy for PTSD: http://www.essentiallearning.net/student/content/sections/lectora/ProlongedExposureTherapyVets/index.html Cognitive Processing Therapy for PTSD in Veterans and Military Personnel: http://www.essentiallearning.net/Student/content/sections/Lectora/CognitiveProcessingTherapyforPTSDinVet eransandMilitaryPersonnel/index.html Also please refer to the references if you are interested in more information about PTSD.

REFERENCES Cave, D. (2009). A combat role, and anguish, too. The New York Times. Retrieved from http://www.nytimes.com/2009/11/01/us/01trauma.html?pagewanted 1&sq ptsd&st cse &scp 1 . Duxbury, F. (2006). Recognising domestic violence in clinical practice using the diagnoses of posttraumatic stress disorder, depression and low self-esteem. The British Journal of General Practice, 56(525): 294-300. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1832239/ . Flannery, Jr., R.B. (2001). The employee victim of violence: Recognizing the impact of untreated psychological trauma. American Journal of Alzheimer’s Disease and Other Dimentias, 16, 230-233. Retrieved from http://aja.sagepub.com/cgi/reprint/16/4/230 . Florida Guard Online (n.d.) About us. Retrieved from http://www.floridaguard.army.mil/aboutus/default.aspx . Gajilan, A.C. (2008). Iraq vets and post-traumatic stress: No easy answers. CNN. Retrieved from http://www.cnn.com/2008/HEALTH/conditions/10/24/ptsd.struggle/index.html . Hughes, M.J. & Jones, L. (2000). Women, domestic violence, and posttraumatic stress disorder (PTSD). Retrieved from http://www.csus.edu/calst/government affairs/reports/ffp32.pdf . Job Accommodation Network (2008). Accommodation and compliance series: Employees with Post Traumatic Stress Disorder. Retrieved from http://www.jan.wvu.edu/media/ptsd.html . Kipp-Casati, C. & Chait, R. (2008). ‘Copshock’: The secret cop killer. The Epoch Times. Retrieved from http://www.theepochtimes.com/n2/arts-entertainment/copshock-police-ptsd-posttraumaticstress-disord-4373.html .

REFERENCES (CONTINUED) Lawford, B.R., Young, R., Noble, E.P., Kann, B., & Ritchie, T. (2005). The D2 dopamine receptor gene is associated with co-morbid depression, anxiety and social dysfunction in veterans with post-traumatic stress disorder. European Psychiatry, 21(3), 180-185. Marmar, C.R., McCaslin, S.E., Metzler, T.J., Best, S., Weiss, D.S., Fagan, J., . . . Neylan, T. (2006). Predictors of posttraumatic stress in police and other first responders. Annals of the New York Academy of Sciences, 1071, 1-18. Mayo Clinic (2009). Post-traumatic stress disorder. Retrieved from http://www.mayoclinic.com/health/post-traumatic-stress-disorder/DS00246/DSECTIO N symptoms . Minnick, F. (2007). Higher anxiety. National Guard Association of the United States. Retrieved from http://www.ngaus.org/NGAUS/files/ccLibraryFiles/Filename/000000002627/ptsd06072 .pdf . National Alliance on Mental Illness (2003). Post-traumatic stress disorder. Retrieved from http://www.nami.org/Template.cfm?Section By Illness&Template /TaggedPage/Tagg edPageDisplay.cfm&TPLID 54&ContentID 68642 . National Institute of Mental Health (2009). Post-traumatic stress disorder. Retrieved from http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/com plete-index.shtml .

REFERENCES (CONTINUED) National Institute on Drug Abuse (n.d.). Stress and substance abuse: A special report after the 9/11 terrorist attacks. Retrieved from http://www.drugabuse.gov/stressanddrugabuse.html . Riggs, D.S. (n.d.). Posttraumatic stress disorder and domestic violence. Center for Deployment Psychology. Retrieved from http://www.familyofavet.com/PTSD domestic violence.html . Shalev, A.Yl, Sahar, T., Freedman, S., Peri, T., Glick, N., Brandes, D., Orr, S.P, & Pitman, R.K. (1998). A prospective study of heart rate response following trauma and the subsequent development of Posttraumatic Stress Disorder. Archive of General Psychiatry.1998;55(6):553-559. Sherman, M.D., Sautter, F., Jackson, M.H., Lyons, J.A., & Han, X. (2006). Domestic violence in veterans with posttraumatic stress disorder who seek couples therapy. Journal of Marital and Family Therapy, 32(4), 479-90. Spradling, J. (n.d.). The cycle of violence. Retrieved from http://www.ksag.org/files/shared/Cycle.of.Violence.pdf . United States Department of Veterans Affairs (2009). National Center for PTSD. Retrieved from http://www.ptsd.va.gov/index.asp . Yeager, K.R. and Roberts, A.R. (2005). Differentiating Among Stress, Acute Stress Disorder, Acute Crisis Episodes, Trauma, and PTSD: Paradigm and Treatment Goals. In A.R. Roberts. Crisis Intervention Handbook: Assessment, Treatment, and Research. New York: Oxford University Press.

TO CONTACT THE INSTITUTE The Institute for Family Violence Studies can be reached at: Florida State University College of Social Work Institute for Family Violence Studies 296 Champions Way University Center C 2306 Tallahassee FL 850-644-6303 http://familyvio.csw.fsu.edu/lef