Sheehan syndrome

The combined tragedies of September 11, 2001, have merged into a significant American generational marker not experienced since the assassination of President John F. Kennedy. Nowhere have the cascading consequences of these watershed events impacted more than on the law enforcement profession. Critical incidents are a recognized part of the law enforcement experience. After all, it is a high-risk profession. Normally, critical incidents occur on a small scale, affect only a few people, and cause only short-term burdens on existing organizational resources. The events related to September 11th, however, clearly deviated from the norm. Protecting human resources within law enforcement always has been a challenge, but critical incidents, such as those experienced on September 11th, pose extraordinary difficulties requiring extreme responses. From such adversities invariably come innovations, lessons learned, and, ultimately, even greater response capabilities.

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Reviewing the evolving practices of uniquely experienced organizations, commonly referred to as an analysis of best practices, can prove informative. Therefore, the authors have undertaken such an analysis of some of America's uniquely experienced law enforcement organizations regarding their ongoing efforts to assist their personnel in coping with critical incidents, both small and large scale. As the first survey of its kind, this may represent a significant contribution to the profession.

BACKGROUND

The practice of providing critical incident stress management and support services to law enforcement personnel has a rich history, but the origins of such assistance actually can be traced to the military. Wars and conflicts have punctuated this country's history since its inception. Technological advances in weaponry beginning with the Civil War produced causalities of a type and scale previously not experienced by medical personnel. Out of sheer necessity in the face of incredible, large-scale suffering, they had to add newly constructed intervention principles to traditional treatment practices. In time, the recognition of the importance of immediate intervention led to the assimilation of corpsmen and medics into combat units. During the Korean Conflict, the military moved medical units forward to gain proximity to the battlefields. Hard-won experience produced expectancy about the types of injuries that medical personnel could treat successfully. By the time the armed forces were engaged in Vietnam, their medical units had instituted triage as a standard practice that systematically assigned a priority to the treatment of the wounded based on such factors as urgent need, the chance of survival, and the amount of resources available.

What affects the mind affects the body, and what affects the body affects the mind. (1) The two are inextricably intertwined and cannot be separated. The shell shock of World War I and the combat fatigue of World War II proved just as potentially debilitating to soldiers as many of their physical wounds. The military discovered that the principles established for treating physical traumas also applied to treating psychological ones. "Nothing could be more striking than the comparison between the cases treated near the front and those treated far behind the lines .... As soon as treatment near the front became possible, symptoms disappeared ... with the result that 60 percent with a diagnosis of psychoneurosis were returned to duty from the field hospital. War neuroses ... could be controlled by scientific management, rather than allowing nature to take its course." (2) "Those on field duty found it to be most advantageous to the soldier, and to the army, to recognize exhaustion and the fear but not to remove the soldier to the rear .... By and large, the prognosis ... varies directly with the time factor ... the great issue ... is not to permit the syndrome to become entrenched ... the most effective implement is to keep alive the [causal] relation between the symptoms and the traumatic event." (3)

These military observations became concretized as the three pillars of crisis intervention: proximity (the ability to provide psychological support wherever needed in the field), immediacy (the ability to provide rapid support), and expectancy (viewing adverse reactions to critical incidents as basically normal reactions of extreme stress and not as pathological reactions). The three became known collectively as the P.I.E. Principle (4) and formed the historical foundation of crisis intervention not only for the military but also for law enforcement. The type of trauma experienced by soldiers in combat is quite similar to that endured by law enforcement officers. In short, the law enforcement profession adopted the best practices of the military.

METHOD

The application of best practices can be a highly effective way to deal with complex problems. Law enforcement professionals do not have the luxury of sitting back and theorizing when confronted with catastrophes. They usually have to act immediately to establish public order in the wake of the disorder caused by large-scale critical incidents. Practical, logistical, and time constraints make it difficult to conduct the randomized controlled trial, which is the gold standard researchers use to compare the effectiveness of intervention. Therefore, copying the successful tactics of other agencies that have dealt with similar problems becomes an effective and efficient strategy. It saves valuable time and resources at the most critical point, the immediate aftermath of an incident.

In recognition of this concept, Dr. Everly initiated a survey in the spring of 2003 to ascertain what various law enforcement agencies and organizations have done to support their personnel during extraordinary critical incidents. Sadly, New York, New Jersey, Washington, DC, and Pennsylvania were not the only locations affected by mass crisis. The jarring horror of losing so many children in Waco, Texas, and Oklahoma City, Oklahoma, stand as equally traumatic events. Regardless of geographic location or size, all law enforcement agencies face potential, large-scale incidents.

SURVEY PARTICIPANTS

The authors included 11 organizations based on accrued unique experience responding to the psychological demands associated with extraordinary critical incidents and mass disasters. They consulted federal, state, and city organizations to provide a balanced perspective for dealing with catastrophic events and obtained information from interviews with program directors and from written descriptions. Many of these programs not only are innovative but represent prime exemplars of a structured response to the unique psychological needs of those in the law enforcement profession.

Bureau of Alcohol, Tobacco, Firearms, and Explosives

The Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) initiated its Peer Support/Critical Incident Stress Management Program in 1989 out of concern for special agents involved in shootings and other critical incidents. Administered via the Office of the Ombudsman, a program manager, who is a mental health clinician, provides clinical oversight. The ATF program serves all 6,000 employees and their families, as well as state and. local law enforcement partners who represent 25 to 30 percent of the program workload.

The ATF Peer Support Program has four components: peer responders, mental health professionals, chaplains, and trainers. The 43 peer support personnel are not counselors but special agents, inspectors, and other key personnel with over 60 hours of specialized training. Mental health providers make referrals to the agency's employee assistance personnel or to community resources as necessary. Sixty chaplains provide spiritual support and critical incident stress management interventions. ATF professional development personnel conduct related training.

ATF uses a comprehensive, multicomponent critical incident stress management model that includes preincident education, assessment of need and management consultations, individual peer support, large-group crisis intervention, family support services, small-group crisis intervention, chaplain or pastoral care services, referral and follow up, and debrief-the-debriefer sessions. Based on the specifics of a particular incident, ATF has tailored its intervention plan to reach and accommodate those directly or indirectly impacted by a critical incident.

Cop 2 Cop

Cop 2 Cop serves 40,000 law enforcement officers, plus family members, in the New Jersey Port Authority Police, New York State Police, and the New Jersey Urban Search and Rescue Unit. Established in 1998, it became fully operational on November 1, 2000, through the use of a widely circulated, toll-free telephone number (1-866-COP-2COP). The staff consists of 4 retired clinicians with experience treating law enforcement officers, 4 mental health specialists, and 48 retired law enforcement officers who voluntarily answer the telephone hotline.

Following the terrorist attacks, Cop 2 Cop's role expanded to include all New Jersey firefighters and emergency medical service personnel. The program also provided intervention services to Secret Service and FBI agents residing in New Jersey. In the aftermath of September 11th, the program initiated acute traumatic stress leadership training and implemented a unique large-group "reentry program."

Cop 2 Cop employs an integrated, multicomponent emergency mental health continuum-of-care approach, including telephone hotlines, one-on-one crisis intervention, telephone assessments, group crisis intervention, and referrals to mental health resources. Since its inception, the program has received over 9,000 telephone calls and has conducted more than 450 critical incident stress management interventions.

FBI

The FBI uses a two-pronged approach in delivering stress management services to approximately 28,000 employees and their families. The FBI Academy emphasizes training and research. It teaches stress management; examines stress-related issues, such as domestic violence and suicide, (5) in televised forums and publications; and is developing an early warning tool for detecting excessive stress reactions by law enforcement officers. (6)

The FBI's Employee Assistance Unit, consisting of several mental health professionals and support personnel, became self-contained in 1993. It coordinates delivery of four primary services and represents an integrated, multicomponent continuum-of-care model, including preincident training, assessment, triage, individual crisis intervention, small-group crisis intervention, psycho-educational seminars, family support services, and chaplain referrals. Specifically, 300 coordinators, positioned throughout the organization, provide assessment, short-term counseling, and referrals to employees experiencing a wide range of problems. Critical incident stress management--a peerbased, small-group crisis intervention--occurs subsequent to exposure to critical incidents. Peer support/post-critical incident seminars (residential group psycho-educational interventions) follow significant critical incidents, such as shootings and mass disasters. These last up to 4 days and began in 1983 in response to agent-involved shooting incidents. Over 100 experienced volunteer chaplains provide pastoral counseling, family support, death/bereavement services, and individual or small-group crisis intervention.

Federal Law Enforcement Training Center

The Office of Critical Incident Stress Management, Federal Law Enforcement Training Center (FLETC), Department of Homeland Security supports 40,000 students from approximately 76 federal law enforcement agencies each year. It also serves permanent and detailed staff, participating organizational personnel, employees, contractors, visitors, and their families.

FLETC formally established its Critical Incident Stress Management and Peer Support Program in 1999. Eight teams, comprised of 50 employees, provide services throughout the United States and abroad.

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The center integrates a multidisciplinary standard-of-care continuum with specific services, including precrisis education/inoculation; individual, team, mental health practice, and community basic and advanced training; triage/assessment/referral for initial/follow-up treatment; individual peer support; small- or large-group defusing; small-group debriefing or demobilization; individual traumatic stress reduction management; pastoral/bereavement counseling; employee assistance services; and a wellness program.

National Fraternal Order of Police

The National Fraternal Order of Police (FOP) originally established its Critical Incident Committee in 1996. But, in 2001, it reformulated this entity as the Critical Incident Stress Management Program to provide affected emergency service workers with services that mitigated or lessened the impact of the effects of critical incident stress and accelerated the recovery following a traumatic event. FOP designed the program to prevent or mitigate the adverse psychological reactions that so often accompany emergency services, public safety, and disaster response functions. Interventions in this program are directed toward the mitigation of post-traumatic stress reactions. Fundamental to the FOP approach is a philosophy and a belief in the importance and value of the human response, especially within the occupation of law enforcement.

Key services include consultation to local law enforcement, critical incident education programs, development of a national law enforcement emergency response strike team to assist wherever needed, and the establishment of a central repository for available law enforcement critical incident stress management programs nationwide. FOP uses an integrated, multicomponent crisis intervention system that includes precrisis education seminars, individual crisis intervention services, group crisis interventions, demobilizations, defusings, debriefings, chaplain services, family interventions, organizational consultation, follow-up resources, and referral to formal mental health services as indicated.

New Jersey Attorney General's Office and State Police

Established in 2003, New Jersey's Critical Incident Stress Response Program functions within a preexisting employee assistance program. In addition to traditional services, it sponsors a unique command staff leadership series that covers ethics-based leadership, law enforcement family dynamics, terrorism, and psychological counterterrorism. The New Jersey model offers an integrated, multicomponent crisis intervention system with a full spectrum of employee assistance services.

New York City: Police Organization Providing Peer Assistance

In 1994 and 1995, the 26 police officer suicides generated grave concerns throughout New York City. In response to this alarming phenomenon, the city created the Police Organization Providing Peer Assistance (POPPA), an autonomous, independent, confidential, and voluntary police assistance agency. Volunteer peer support personnel received training in crisis intervention and critical incident stress management and began staffing a 24-hour hotline in March 1996.

Currently, POPPA has an administrative staff consisting of a director, clinical director, peer liaison, consulting staff, and a case manager; a clinical panel of over 120 psychologists, psychiatrists, social workers, and addictions counselors trained and motivated to work with police officers; and 180 peer support officers. Available at all times, these individuals meet with distressed officers in neutral, private locations. They provide referrals only at face-to-face meetings. All meetings, referrals, and subsequent treatment remain strictly confidential. Since 1996, over 6,500 face-to-face meetings have taken place.

POPPA uses an integrated, multicomponent critical incident stress management intervention system adapted to best meet the needs of law enforcement personnel and the unique demands of each specific critical incident. It operates on the basis of a self-referral system. POPPA key interventions include assessment, triage, individual crisis intervention, demobilizations (large-group crisis intervention), defusings (small-group crisis intervention), debriefings (small-group format), and referral to subsequent psychological support if required.

Oklahoma City: Critical Incident Workshops

The April 19, 1995, terrorist bombing in Oklahoma City precipitated a series of critical incident workshops. Estimates indicated that 20 percent of the 12,384 rescue personnel involved would require some form of mental health care. As of October 2002, over 750 rescue personnel, survivors, volunteers, and family members have received direct service from 70 workshops, which use an intensive 4-day format. Intervention teams consist of a facilitator, psychologist, chaplain, and a trained crisis intervention peer support individual.

Workshops use key interventions, such as individual crisis intervention, small-group critical incident stress debriefing, family support, education, chaplain/pastoral services, referrals, and follow-up care. The workshops offer eye movement desensitization and reprocessing (EMDR), a highly controversial but effective technique, as an optional treatment.

U.S. Marshals Service

In 1991, the U.S. Marshals Service (USMS) initiated its Critical Incident Response Team (CIRT). Staffed by 3 mental health professionals and 51 peer support personnel, CIRT extends services to over 4,200 employees and their family members. Incident-specific response teams consist of an employee assistance representative and one or two peer support marshals. USMS uses an integrated, multicomponent intervention continuum-of-care approach consisting of assessment, triage, individual crisis intervention, small-group crisis intervention (defusings and debriefings), large-group crisis intervention, organizational development, family intervention services, and referral to psychotherapeutic resources.

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U.S. Secret Service

The U.S. Secret Service (USSS) implemented its Critical Incident Peer Support Team in 1985. Administered from its Employee Assistance Program (EAP), the peer support team has expanded to include agents, uniformed officers, and administrative support staff. It includes 4 EAP counselors and 86 peer support personnel, who receive specialized training in crisis intervention and critical incident debriefings. Designated peer support counselors assist EAP counselors with precrisis education seminars for new agents and uniformed officers. Field intervention teams consist of an EAP counselor and one or two peer support personnel. USSS uses an integrated, multicomponent intervention approach consisting of assessment, triage, individual crisis intervention, small-group debriefings, precrisis education seminars, family intervention services, follow-up resources, and referral to mental health professionals as needed.

World Trade Center--Rescuer Support Victim Program

Because first responders comprised approximately 400 of the 2,800 victims of the September 11th disasters, this program began in 2002 to serve law enforcement, firefighters, and emergency medical personnel. It has three primary components: 1) crisis intervention hotline help, 2) crisis intervention training programs, and 3) clinical intervention services. On a pro bono basis, the program provides peer counseling, individual crisis intervention, and individual therapy and uses a structured, six-session, group treatment model.

The program's main purpose is to give voice to the rescuers. The conceptual framework includes partnership with management, establishment of funding, consultation of nationally recognized experts, collaboration with clinicians, use of peer support, and reliance on logistical and planning flexibility.

KEY FINDINGS

Five best practices emerged from the many practical, empirically field-tested strategies used to deal with large-scale critical incidents. They almost are universal, and agencies should consider them in any organizational approach to effective critical incident stress management.

Early Intervention

The survey revealed that the law enforcement agencies sampled recognized the value of early psychological intervention for those officers responding to critical incidents. This echoed earlier military experience regarding the importance of immediate intervention in treating physical and psychological wounds.

Complete Care

All of the organizations sampled recommended the use of a phase-sensitive, multicomponent crisis intervention system as part of an overall continuum of care. Such a system underscores the necessity of employing strategic planning prior to implementation.

Peer Support

Each participant emphasized the importance of peer support and saw it as a virtual imperative to a successful law enforcement program. Consistent with this tactical formulation, not one of the organizations viewed crisis intervention as psychotherapy nor as a substitute for it.

Specialized Training

All of the organizations acknowledged the importance of receiving specialized training in crisis intervention/emergency mental health (for both peer interventionists, as well as mental health clinicians) prior to implementing such programs. Well-meaning intentions are not enough. Officers exposed to traumatic events need focused assistance by trained practitioners at all levels of care, ranging from hotline assistance to therapeutic treatment.

Tactical Intervention

Tactical interventions, in most programs, included the ability to perform one-on-one small- and large-group crisis interventions and family support services, as well as the ability to access spiritual support assistance and treatment resources. The word tactical refers to adroit maneuvering used to achieve a desired objective. The military connotation is highly appropriate in any discussion of psychological trauma induced by critical incidents. Much of the psychological assistance given to public safety and emergency personnel in the domestic terrorism of Oklahoma City and in the international terrorism of New York City was based on lessons learned during conventional wars.

CORE COMPETENCIES

Five core competencies appeared as features of a best practices model. These elements offer law enforcement agencies an effective way to help their personnel deal with critical incidents.

Assessment and Triage

Agencies need to rapidly evaluate affected officers and provide them with assistance consistent with the resources at hand. Integral to the process of assessment, however, is knowing when not to interfere with natural coping mechanisms. Simply said, law enforcement often can be a stressful profession, but formal crisis intervention always should yield to the individual's natural coping mechanisms and resources as long as these function effectively.

Crisis Intervention with Individuals

Officers differ in their responses, and their agencies must remember that mass critical incident care is not a one-size-fits-all proposition. Crisis intervention skills applied to one individual at a time (face-to-face or telephonically) represent the bedrock of all emergency mental health techniques and always begin with the assessment of their suitability.

Small-Group Crisis Intervention

Peers supporting each other in a group setting can be highly effective and efficient. The small-group crisis intervention format (e.g., debriefings) can be a useful intervention mechanism. (7) Care must be taken, however, to ensure that vicarious traumatization does not occur. This is best achieved by using homogeneous functional groups of individuals who have experienced the same level of psychological toxicity via their exposure. Similarly, care must be taken so as not to encourage excessive ventilation, coercive group pressure, or scapegoating (targeting individuals or organizational policy).

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Large-Group Crisis Intervention

A town meeting provides another way for people to process the tumultuous events engulfing them. Typically employed with large groups, this type of crisis intervention is largely a psycho-educational process designed to enhance cohesion, control rumors, improve self-assessment, and make individuals aware of coping techniques and resources. (8) Agencies may apply this method many different ways, including in the format of roll call.

Strategic Planning

"The process is strategic because it involves preparing the best way to respond to the circumstances of the organization's environment, whether or not its circumstances are known in advance .... The process is about planning because it involves intentionally setting goals ... and developing an approach to achieving those goals." (9) Thus, strategic planning allows operational planners to best combine and sequence multiple interventions within an integrated Incident Command System. All strategic planning, as well as tactical intervention, must be predicated upon on-going assessment.

FUTURE DIRECTIONS

Large-scale critical incidents spring from all manner of causes. Some result from upheaval and disruption of the natural order. The air, earth, fire, and water that normally sustain people become the hurricanes, earthquakes, wildfires, and floods that destroy them. Other major critical incidents result from human activity, such as war and terrorism. Both types of critical incidents impact everyone. No group is more affected than those who impose order upon the chaos resulting from major critical incidents. In response to the acute mental health needs of those in crisis, the field of crisis intervention was born.

The majority of law enforcement officers exposed to a traumatic event will not need formal psychological intervention, but that does not negate the obligation to respond to the needs of those who will require acute psychological support. Information regarding critical incidents, common reactions, and sources of support could benefit everyone.

An observation about firefighters applies equally well to law enforcement officers. "In all the controversy, criticism, and research debate on the merits of debriefing [i.e., early psychological intervention], certain constants are emerging. The most effective methods for mitigating the effects of exposure to trauma ... those, which will help keep our people healthy and in service, are those, which use early intervention, are multimodal and multicomponent. That is, they use different 'active ingredients' ..., and these components are used at the appropriate time with the right target group." (10)

Most of the emphasis of existing programs is on managing the reactions to mass critical incidents after they occur. This direct approach, while practical and goal oriented, does not encompass the full range of options available. The key to optimizing existing programs is to focus on preincident strategies.

Preincident Training

The study of the current and historical military response to psychological trauma has become quite useful in developing an effective and efficient law enforcement model for mass critical incident stress management. For example, a British military psychiatrist and his colleagues found that debriefing techniques even reduced alcohol use after stressful assignments. (11) However, one lesson remains from the military that the law enforcement profession has not sufficiently incorporated into its programs, the principle of expectancy. Two Israeli psychologists investigated roles of immediacy, proximity, and expectancy. (12) Results indicated that all three early intervention principles contributed to therapeutic outcome, with expectancy supplying the most to positive outcome. As earlier research noted, to a significant degree, the soldier's expectation of outcome predicted recovery from war neurosis. (13) The military experience demonstrated that the law enforcement profession must do a better job of managing the expectations of officers to ensure their psychological well-being after a major critical incident.

To illustrate the apparent importance of expectation management for new and experienced law enforcement professionals, the authors present some real-life examples. Approximately every 2 weeks, 50 agent trainees arrive at the FBI Academy on a Sunday afternoon. On the following Wednesday morning, they are issued the handguns they will carry throughout their law enforcement careers. For 5 years, on the afternoon after they received their weapons, Special Agent Sheehan taught the trainees a block of instruction called Stress Management in Law Enforcement. He always started the 7-hour course by asking how many of them would be surprised if they actually had to use their service weapon. Virtually everyone said it would be a surprise. He then would point out some hard facts. First, while at the academy, they will fire thousands of rounds until they can quickly and accurately fire 50 rounds at targets 25 to 5 yards away. Next, they must qualify with a minimum score of 80 percent four times a year during their employment. Also, every day that they are on duty for those 20 to 30 years, they will have to carry their weapon. In addition, every year, the FBI holds critical incident seminars, and many agents who are shooters or shootees attend. Following a shooting, approximately 79 percent of involved officers have reported time distortion and 52 percent have indicated memory loss for part of the event. (14) And, finally, estimates have indicated that the career of a law enforcement officer is shortened significantly after a shooting incident. Under these circumstances, new employees need to change their expectations about what could happen to them.

This change in expectations is necessary for the more experienced members of the law enforcement community as well. Several years ago, Special Agent Sheehan went to Belfast, Northern Ireland, at the request of the Royal Irish Constabulary to address the Association of Chief Police Officers of England, Scotland, Wales, and Northern Ireland about violence in the United States. He asked these experienced and highly accomplished officers what shocked them the most about the events that had occurred at Columbine High School in Colorado. Their answers ranged from gun violence to sudden death. They were partially right, of course, but, in the authors' view, the aspect that ultimately bothers most people about that event was the brutal violation of what their expectation of the school experience should be. Children should be able to go to school in safety without the fear of immediate death.

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Everyone has expectations. Sometimes, these get violated. In the law enforcement profession, expectations can be destroyed in an abrupt and massive way. In an era of incipient terrorism, agencies must provide proactive training. In 2003, the Institute of Medicine stated, "The committee finds that terrorism and the threat of terrorism will have psychological consequences for a major portion of the population, not merely a small minority .... The stress associated with the direct impact and lingering threat of terrorism raises obvious psychological concerns, particularly for ... first responders ...." (15)

Conducting more preincident education offers the best way to change expectations. Some training is taking place, but not enough. For example, although the FBI provides agent trainees with some preincident training, it offers no such regularly scheduled training for journeymen agents in the field. Even flu vaccines are administered on a yearly basis. Critical incident education provides one of the best inoculations available to law enforcement officers facing toxic situations. If they expect something, they are better able to cope with it. The military has firmly established that expectation management saves lives. Universally, the law enforcement community must do a more thorough job of creating realistic expectations through preincident training.

Early Warning Screening

People differ in their responses to critical incidents. Some officers adjust rapidly, whereas others adapt gradually. A small number adjust poorly and develop an extreme reaction called post-traumatic stress disorder (PTSD). A 2002 study revealed that 13 percent of rescue personnel developed PTSD, (16) a significantly higher rate than the 1 to 3 percent in the general population. This suggested that rescue workers, like law enforcement officers, face elevated risk due to increased exposure to traumatic events. According to the military principle of immediacy, these people need to be identified early. Immediate identification of acute problems allows for the mobilization of higher-ordered interventions, which work best before problems become habitual and fully assimilated. (17) Training peers and managers to recognize the first signs of maladaptive responses must occur. When managing critical incident stress, law enforcement agencies need to remember that the sooner they intervene, the better.

CONCLUSION

A number of occupations are at high risk for psychological distress and morbidity. Law enforcement constitutes one such profession. The corpses of fellow citizens, the ruins of buildings, and the wreckage of all types of conveyances scorch the senses and poison the memories of law enforcement officers. If society exposes them to these harsh aspects of life, it is morally bound to give them the best possible psychological support. Current state-of-the-art early psychological intervention programs within the law enforcement profession emphasize post-incident intervention. Expansion of early intervention services to include precrisis expectation training and early warning screening could move existing programs to the cutting edge of mass critical incident management. No agency has created a perfect model, but a number of organizations have developed workable programs for dealing with acutely stressful events. Regardless of the size of the department, the men and women who have dedicated themselves to protecting their communities will benefit from adopting these best practices.

The authors offer a special thanks to the survey contributors who made this article possible. Law enforcement officers in their respective organizations benefit from the daily efforts of these dedicated professionals. Now, because of their willingness to share such hard-won experience, all law enforcement officers and their supporters can benefit as well.

Endnotes

(1) G. S. Everly, Jr and J. M. Lating, A Clinical Guide to the Treatment of the Human Stress Response (New York, NY: Kluwer/Plenum, 2002); and D.C Sheehan, "Stress Management in the Federal Bureau of Investigation: Principles for Program Development," International Journal of Emergency Mental Health 1 (1999): 39-42.

(2) T. S. Salmon, "War Neuroses and Their Lesson," New York Medical Journal 108 (1919): 993-994.

(3) A. Kardiner, "The Traumatic Neuroses of War," Psychosomatic Medicine Monographs 11 (1941): 11-111.

(4) K. Artiss, "Human Behavior Under Stress: From Combat to Social Psychiatry," Military Medicine 128 (1963): 1011-1015.

(5) D.C. Sheehan, ed., U.S. Department of Justice, Federal Bureau of Investigation, Domestic Violence by Police Officers (Washington, DC, 2000); and D.C. Sheehan and J.J. Warren, eds., U.S. Department of Justice, Federal Bureau of Investigation, Suicide and Law Enforcement (Washington, DC, 2001).

(6) For additional information, see D.C. Sheehan and V.B. Van Hasselt, "Identifying Law Enforcement Stress Reactions Early," FBI Law Enforcement Bulletin, September 2003, 12-17.

(7) M. Arendt and E. Elklit, "Effectiveness of Psychological Debriefing," Acta Psychiatrica Scandinavica 104 (2001): 423-437; A Dyregrov, "Psychological Debriefing: An Effective Method?" Traumatoloy vol. 4, issue 2 (1998), see http://www.fsu.edu/~trauma; and M. Deahl, M. Srinivasan, N. Jones, J. Thomas, C. Neblett, and A. Jolly, "Preventing Psychological Trauma in Soldiers: The Role of Operational Stress Training and Psychological Debriefing," British Journal of Medical Psychology 73 (2000): 77-85.

(8) G.S. Everly, Jr., "Crisis Management Briefings," International Journal of Emergency Mental Health 2 (2000): 53-57.

(9) "What Is Strategic Planning?"; retrieved on April 6, 2004, from http://www.nonprofits.org/npofaq/03/22.html.

(10) H. Duggan, International Association of Fire Chiefs, "CISM at the World Trade Center: Lessons Learned," IAFC On Scene, January 2002; retrieved on April 7, 2004, from http://www.iafc.org.

(11) M. Deahl, M. Srinivasan, N. Jones, J. Thomas, C. Neblett, and A. Jolly, "Preventing Psychological Trauma in Soldiers: The Role of Operational Stress Training and Psychological Debriefing," British Journal of Medical Psychology 73 (2000): 77-85.

(12) Z. Solomon and Z. and R. Benbenishty, "The Role of Proximity, Immediacy, and Expectancy in Frontline Treatment of Combat Stress Reaction Among Israelis in the Lebanon War," American Journal of Psychiatry 143 (1986): 613-617.

(13) Supra note 3.

(14) A. Artwohl, "Perceptual and Memory Distortion During Officer-Involved Shootings," FBI Law Enforcement Bulletin, October 2002, 18-24.

(15) Institute of Medicine, Preparing for the Psychological Consequences of Terrorism (Washington, DC: National Academies Press, 2003).

(16) C. S. North, L. Tivis, et al., "Psychiatric Disorders in Rescue Workers After the Oklahoma City Bombing," American Journal of Psychiatry 159 (2002): 857-859.

(17) The Law Enforcement Officer Stress Survey identified areas officers find most troubling; supra note 6.

By DONALD C. SHEEHAN, GEORGE S. EVERLY, Jr., and ALAN LANGLIEB

Compiling Authors

Donald C. Sheehan, George S. Everly, Jr., and Alan Langlieb, from the law enforcement and academic communities of the FBI, Loyola College in Maryland, and Johns Hopkins University, formed an alliance with the contributing authors to honor the valiant law enforcement professionals who gave their lives in the performance of their duties during the terrorist attacks of September 11, 2001, and to offer assistance to those who survived, yet carry not only the physical scars but the psychological traumas as well.

Contributing Authors

Ralph Biase, U.S. Secret Service

Cherie Castellano, Cop 2 Cop and World Trade Center Rescuer Support Victim Program

Bill Genet, Gene Moynihan, and Frank Dowling, New York City Police Organization Providing Peer Assistance

Mike Haley, National Fraternal Order of Police

Jim Horn and Kathy Thomas, Oklahoma City Critical Incident Project

Laura Kelso, U.S. Marshals Service

Jeffrey Lating, Loyola College, Baltimore, Maryland

Gail London, Paul Susenbach, Cindy Newbern, Pat Joyner, and Sartaj Khan, Federal Law Enforcement Training Center, Department of Homeland Security

Alexandra Mahr, Bureau of Alcohol, Tobacco, Firearms, and Explosives

James Nestor, New Jersey Attorney General's Office and State Police

Research and Coordinating Assistance

Heidi Joseph and Julia Finkel, Johns Hopkins University, Baltimore, Maryland

COPYRIGHT 2004 Federal Bureau of Investigation
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