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PsychotherapyVolume 32/Winter 1995/Number 4
TOUGH GUYS:
PSYCHOTHERAPEUTIC STRATEGIES WITH LAW
ENFORCEMENT AND EMERGENCY SERVICES PERSONNEL
LAURENCE MILLER
Boca
Raton,
Florida
The men and women who work in law
enforcement and emergency
services—the "tough jobs"—are
exposed to special kinds of traumatic
events and daily pressures that sometimes
overwhelm defenses and result in
maladaptive psychological syndromes.
By dint of attitude, training, and social
norms, these "tough guys" are often
resistant to psychotherapy in its
traditional forms, and so special
therapeutic approaches are
required.
This article describes the types of stresses
and problems experienced by police
officers, firefighters, and paramedics,
and outlines the psychotherapeutic
strategies that may prove most effective
in helping the helpers.
Every time we dial 911, we expect that our
emergency will be taken seriously and handled
competently. The police will race to our burgled
office, the firefighters will speedily douse our
burning home, the ambulance crew will stabilize
our injured loved one and whisk him/her to the
nearest hospital. We take these expectations for
granted because of the dedication of the workers
who serve the needs of law enforcement, emer-
gency services, and public safety.
These "tough guys"—the term includes both
men and women—are routinely exposed to spe-
cial kinds of traumatic events and daily pressures
Correspondence
regarding
this article should be addressed
to Laurence Miller, Plaza Four, Suite 101, 399 W. Camino
Gardens Blvd., Boca Raton, FL 33432.
that require a certain adaptively defensive tough-
ness of attitude, temperment, and training. With-
out this resolve, they couldn't do their jobs effec-
tive.
Sometimes however, the stress is just too
much, and the very toughness that facilitates
smooth functioning in their daily duties now be-
comes an impediment to these helpers seeking
help for themselves.
This article describes the types of stresses and
problems experienced by police officers, fire-
fighters, and paramedics, and outlines the psy-
chotherapeutic strategies that may prove most ef-
fective in helping these professionals. Inasmuch
as an important component of any effective psy-
chotherapy, especially for nontraditional groups,
is an adequate understanding of the nature of the
therapist's clinical case material (Miller, 1990,
1991,
I993a,b,c, 1994fr,c), the experiences and
dynamics of this patient group will first be
described.
Stress and Coping in Law Enforcement and .
Emergency Services
Although there is some overlap in services—
for example, police sometimes have to perform
emergency medical first aid, and firefighters and
paramedics are often cross-trained—there are
some issues that are specific to each group, and
the present section will therefore consider each
of these groups separately.
Police Officers
Even people who do not like cops have to admit
that theirs is a difficult, dangerous, and often thank-
less
job.
Police officers regularly deal with the most
violent, impulsive, and predatory members of soci-
ety, put their lives on the
line,
and confront miseries
and honors that the test of us view from the sani-
tized distance of our newspapers and TV screens.
In addition to the daily grind, officers are frequently
the target of criticism and complaints by citizens,
592
Tough Guys
the media, the judicial system, hostile attorneys,
"do-gooder"
clinicians
and
social service personnel,
and their own administrators and law enforcement
agencies (Blau, 1994).
Police officers generally carry out their sworn
duties and responsibilities with dedication and
valor, but some stresses are too much to take, and
every officer has his breaking point. For some, it
may come in the form of a particular traumatic
experience, such as
a
gruesome accident
or
homi-
cide, a vicious crime against a child, a close per-
sonal brush with death, the death or serious injury
of a partner, a mistaken shooting of an innocent
civilian, or an especially grisly or large-scale
crime, leading, in some
cases,
to
the
development
of a full-scale post-traumatic stress disorder
(PTSD) (McCafferty, McCafferty, &
McCaf-
ferty, 1992). For other officers, there may be no
singular
major
trauma,
but the mental breakdown
caps the cumulative weight of a number of more
moderate stresses over the course of the officer's
career. Most police officers deal with both the
routine and exceptional stresses by a variety of
situationally adaptive coping and defense mecha-
nisms, such
as
repression, displacement, isolation
of feelings, humor—often seemingly callous or
crass humor—and generally toughing it out. Of-
ficers develop a closed society, an insular "cop
culture" centering around what they refer to as
"The Job." For many, "The Job" becomes their
life,
and crowds out other activities and relation-
ships (Blau, 1994).
Apparently, police pressures and their re-
sponses to them are remarkably similar in most
Western societies where these have been exam-
ined, including Australian police officers (Evans,
Coman, Stanley, & Burrows, 1993) and Scottish
constables (Alexander & Walker, 1994). Action-
oriented coping strategies, alternating with di-
placement and self-blame, appear to characterize
these officers' efforts to deal with job
stress.
In the
U.S., two-thirds of officers involved in shootings
suffer moderate or severe problems, and about 70
percent leave the force within seven years of the
incident. Police are admitted to general hospitals
at significantly higher rates, have significantly
higher rates of premature death, and rank third
among occupations in death rates (Sewell, El-
lison, & Hurrell, 1988). Interestingly, however,
despite the popular notion of rampantly disturbed
poh'ce marriages, the empirical evidence does not
support
a
higher-than-average divorce rate for
po-
lice officers (Borum & Philpot, 1993).
Perhaps the most tragic form of police casualty
is suicide (Hays, 1994; Seligmann, Holt, Chinni,
& Roberts, 1994). Twice as many officers, about
300 annually, die by their own hand as are killed
in the line of
duty.
In New York City, the suicide
rate of police officers is more than double the
rate for the population. In fact, these totals may
actually be even higher, since such deaths are
sometimes underreported by fellow cops to avoid
stigmatizing the deceased officers and to allow
the families to collect benefits. Most victims are
young patrolmen with no record of misconduct,
and most shoot themselves off-duty. Often prob-
lems involving alcohol or romantic problems are
the catalyst, and easy access to a lethal weapon
provides the ready
means;
indeed, physicians and
pharmacists, with access to potentially deadly
prescription drugs, have even higher suicide
rates.
Cops under
stress are
caught
in
the dilemma
of risking confiscation of their guns, transfer to
desk duty, or other career setbacks if they report
distress or request counseling.
Aside from the daily stresses of patrol cops,
special pressures
are
experienced by higher-rank-
ing officers, such as homicide detectives, who
are involved in the investigation of particularly
brutal crimes, such as multiple murders or serial
killings (Sewell, 1993). The societal protective
role of
the
police officer becomes even more pro-
nounced,
at
the same time as
their
responsibilities
as public servants who protect the rights of indi-
viduals become compounded by the pressures to
solve the crime.
Moreover, the sheer magnitude and shock ef-
fect of many mass murder scenes and the vio-
lence, mutilation,
and
sadistic brutality associated
with many serial killings, sometimes involving
children, often exceed the defense mechanisms
and coping abilities of even the most seasoned
officers. Revulsion may be tinged with rage, all
the more so when fellow officers have been killed
or injured. Finally, the cumulative effect of fa-
tigue results in case errors, poor work quality,
and
deterioration of home
and
workplace relation-
ships.
Fatigue also wears down the officer's nor-
mal defenses, rendering him/her even more vul-
nerable to stress and failure.
Firefighters
Every child hears the story about brave fire-
fighters rescuing citizens from burning buildings.
For the most part, firefighters display exceptional
skill and courage in the performance of their duties,
593
Laurence Miller
but as in any role which involves dealing with life-
threatening emergencies, stress can take its toll.
According to the National Commission on Hie Pre-
vention and Control, firefighting is the single most
hazardous occupation in the United States. Every-
day, approximately 280 firefighters are killed or
injured, and each year, over 650 are forced to retire
due to occupational illness, including psychological
disability (Hildebrand, \9Ua,b).
In addition to fires, crimes, suicides, accidents,
medical emergencies, toxic waste explosions, and
bombs are among the traumatic experiences that
firefighters must deal with. In a study of the To-
ronto Fire Department (DeAngelis, 1995), fire-
fighters confronted an average of
3.91
such expe-
riences per year. In the last year of the study,
these included rescuing people from an ammonia
cloud, dealing .With stabbings and suicides, and
recovering a woman's severed head in an indus-
trial accident. Compared to a one percent rate
for the general population, the prevalence rate
of diagnosable PTSD for firefighters was 16.5
percent—one percent higher than PTSD rates for
Vietnam veterans. Firefighters battling a huge
bushfire in Australia showed even higher rates of
PTSD (McFarlane, 1988).
In some cases, firefighters, police officers, par-
amedics, or other rescue personnel may appear
to emerge from a dangerous situation or series of
emergencies emotionally unscathed, only to later
break down and develop a full-blown PTSD reac-
tion following a relatively minor incident like a
traffic accident (Davis & Breslau, 1994). The
fender-bender, certainly far less traumatic than
the horrific scenes encountered in emergency
work, seems to have symbolized vividly the per-
sonal risk, sense of human fragility, and existen-
tial uncertainty that their job-related activities en-
tail,
but that they are unable to face directly if
they are to maintain their necessary defenses to
get the job done. The stifled affect may then be
projected onto the minor incident, which is a
"safer" target to blow up at. Unfortunately, this
may instigate a fear of losing control and going
crazy, further propelling the vicious cycle of in-
creased stress but greater reluctance to report it.
Paramedics
Within the medical field, the Emergency Medi-
cal Services (EMS) experience is somewhat
unique (Becknell, 1995). Whereas most other
branches of medicine practice in the controlled,
sterile environment of the hospital, clinic, office,
or even busy emergency room, paramedics find
their victims in their homes, on the street, under
wrecked cars, in demolished buildings. The
deaths they witness are not the neat, sedated pass-
ings of the hospital bed, but are typically sudden,
messy, noisy, agonized, and undignified. Al-
though capped by many heroic and lifesaving
events, for many paramedics the more common
succession of tragedies and occasional stark hor-
rors takes a grim psychological and existential
toll, especially if the incident resonates with
events from the worker's personal history (Beck-
nell, 1995).
In coping with death, paramedics use a number
of coping strategies reminiscent of those em-
ployed by other tough job workers (Palmer,
1983).
These include desensitization processes
that are an actual part of some paramedic training,
the use of dark humor and crass joking, overuse
of technical jargon and a special working lan-
guage, the ability to cognitively fragment scien-
tifically and escape into paramedical work, and
rationalization as to both the importance of the
emergency medical function and the condition of
the patient, that is, that the patient would have
died no matter what.
Once again, the strain sometimes becomes too
much, and, like police officers and firefighters,
some paramedics take their own lives, although
precise suicide statistics for this population are
unavailable. There are a number of reasons why
paramedics commit suicide (Mitchell, 1987), in-
cluding romantic troubles, major illness, death of
a close family member, economic problems, job
failure or failure to achieve career goals, humilia-
tion in the presence of
peers,
or boring retirement
after an active career. The stresses are usually
multiple, diverse, and cumulative, and only rarely
do job-related factors alone lead to suicide.
Again, there exists the dilemma that requesting
psychological help may lead to failed fitness-for-
duty ratings and other stigmatizing consequences.
Dispatchers and Support Personnel
In addition to the on-line police officers, fire-
fighters, and paramedics, a vital role in law en-
forcement and emergency services is played by
the workers who operate "behind the scenes,"
namely the dispatchers, complaint clerks, clerical
personnel, crime and fire scene evidence techni-
cians,
and other support personnel (Holt, 1989;
Sewell & Crew, 1984). Although rarely directly
exposed to actual danger or catastrophe (except
594
Tough Guys
where on-scene and behind-scene personnel alter-
nate shifts), several high-stress features character-
ize the job descriptions of these workers. These
include: 1) dealing with multiple, often simulta-
neous,
calls; 2) having to make time-pressured
life and death decisions, often with 3) low infor-
mation about, and control over, the emergency
situation; 4) intense, confusing, and sometimes
hostile contact with frantic and outraged citizens;
and S) and exclusion from the status and comara-
derie typically enjoyed by on-scene workers who
"get the credit."
After particularly difficult calls, dispatchers
may show many of the classic post-traumatic re-
actions and symptoms, including numbed respon-
siveness, impaired memory for the event alternat-
ing with intrusive, disturbing images of the
incident, irritability, hypervigilance, sleep distur-
bance, and interpersonal hypersensitivity. As
with other tough jobs, these individuals require
the proper treatment and support.
Intervention Services and Psychotherapeutic
Strategies
To avoid "shrinky" connotations, mental health
intervention services with tough job personnel are
often conceptualized in such terms as "stress man-
agement," and "critical incident debriefing"
(Belles & Norvell,
1990;
Mitchell & Bray, 1990).
In general, one-time, incident-specific interven-
tions will be most appropriate for handling the
effects of overwhelming trauma on otherwise nor-
mal, well-functioning personnel. Where post-trau-
matic sequelae persist, or where the psychological
problems relate to a longer-term pattern of maladap-
tive functioning, more extensive individual psycho-
therapeutic approaches are called for. To have the
greatest impact, intervention services should be part
of an integrated program of services within the de-
partment and have full administrative commitment
and support from commanders and the department
(Blau, 1994; Sewell, 1986).
Critical Incident Stress Debriefing (CISD)
Although components of this approach com-
prise an important element of
all
therapeutic work
with traumatized patients, critical incident stress
debriefing, or CISD, has been organizationally
formalized for law enforcement and emergency
services by Mitchell
(1983,
1988; Mitchell &
Bray, 1990), and is now implemented in public
safety departments throughout the United States,
Britain, and other parts of the world (Dyregrov,
1989).
CISD is a structured intervention designed
to promote the emotional processing of traumatic
events through the ventilation and normalization
of reactions, as well as preparation for possible
future experiences. Although initially designed
for use in groups, it can also be used with individ-
uals,
couples, and families.
According to Mitchell & Bray (1990), after a
critical incident, there are a number of criteria
on which peer support and command staff might
decide to provide a CISD to personnel after a
critical incident: 1) many individuals within a
group appear to be distressed after a call; 2) the
signs of
stress
appear to be quite severe; 3) person-
nel demonstrate significant behavioral changes;
4) personnel make significant errors on calls oc-
curring after the critical incident; 5) personnel
request help; 6) the event is extraordinary.
The structure of a CISD debriefing usually con-
sists of the presence of one or more mental health
professionals and one or more peer debriefers,
that
is,
fellow police officers, firefighters, or para-
medics who have been trained in the CISD pro-
cess and who probably have been through critical
incidents and debriefings themselves. A typical
debriefing takes place within 24-72 hours after
the critical incident, and consists of
a
single group
meeting that lasts approximately 2-3 hours, al-
though shorter or longer meetings are determined
by circumstances.
The CISD process consists of several phases:
Introduction: The introduction phase of a de-
briefing is the time in which the team leader grad-
ually introduces the process, encourages partici-
pation by the group, and sets the ground rules
by which the debriefing will operate. Generally,
these involve confidentiality, attendance for the
full group, nonforced participation in discussions,
and the establishment of a noncritical atmosphere.
Fact phase: During this phase, the group is
asked to describe briefly their job or role during
the incident and, from their own perspective,
some facts regarding what happened. The basic
question is: "What did you do?"
Thought phase: The CISD leader asks the
group members to discuss their first thoughts dur-
ing the critical incident: "What went through
your mind?"
Reaction phase: This phase is designed to move
the group participants from the predominantly
cognitive level of intellectual processing into the
emotional level of processing: "What was the
worst part of the incident for you?"
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Laurence Miller
Symptom phase: This begins the movement
back from the predominantly emotional pro-
cessing level toward the cognitive processing
level. Participants are asked to describe their cog-
nitive, physical, emotional, and behavioral signs
and symptoms of distress which appeared 1) at
the scene or within 24 hours of the incident, 2) a
few days after the incident, and 3) are still being
experienced at the time of the debriefing: "What
have you been experiencing since the incident?"
Education phase: Information is exchanged
about the nature of the stress response and the
expected physiological and psychological reac-
tions to
critical
incidents.
This serves
to
normalize
the stress and coping response, and provides a
basis for questions and answers.
Re-entry phase: This is
a
wrap-up,
in which
any
additional questions or statements are addressed,
referral for individual follow-ups are made, and
general group bonding is
reinforced:
"What have
you learned?" "How can you help one another
from now on?" "Anything we left out?"
Despite the enthusiasm for this form of interven-
tion,
the QSD approach has come under criticism,
especially when used indiscriminately or regarded
as the only necessary and sufficient form of inter-
vention. Bissoo and Deahl (1994) have reviewed
the literature suggesting some of the limitations,
pitfalls,
and drawbacks
of
the
QSD
approach.
They
note that even Mitchell (1988) acknowledges mat
not everyone in every critical incident situation will
benefit
from
QSD. In some cases, more extensive,
individual intervention may be called for.
Timing and clinical appropriateness are im-
portant. There is a general consensus that de-
briefing is most effective if carried out sooner
rather than later, and clinical experience supports
the holding of debriefing sessions toward the ear-
lier end
of the recommended 24-72 hour window
(Bordow & Porritt, 1979; Solomon & Benbe-
nishty, 1988). Although all involved personnel
should participate in a debriefing, mandatory or
enforced CISD can lead to passive participation
and
resentment
among workers (Bisson & Deahl,
1994;
Flannery, Fulton, & Tausch, 1991), and
the QSD process may quickly become a boring
routine if used indiscriminately after every inci-
dent, no matter how
"critical,"
thereby diluting its
effectiveness for those situations where it really
could have helped.
There may also be some negative side-effects
of inappropriate QSD. In the Australian bushfire
study, McFarlane (1988) found that, while fire-
fighters who received QSD shortly after the inci-
dent were less likely to develop acute post-trau-
matic stress
reactions
than nondebriefed workers,
they were more likely to develop delayed PTSD.
McFarlane (1989) expressed the concern that
overreliance on quick-fix, primary prevention
methods may delay the diagnosis and effective
treatment of those workers who suffer more seri-
ous psychological sequelae and require more ex-
tensive follow-up treatment.
As is the case for any wholesale application
of
a
promising psychological treatment modality,
further research and clinical experience typically
narrow and
refine
the appropriate therapeutic ap-
plications, and point up certain limitations and
even potentially deleterious side-effects. This has
been the case, for example, with cognitive reha-
bilitation (Hall & Cope, 1995; Miller, 1992), re-
laxation training (Lazarus & Mayne, 1990), bio-
feedback (Silver & Blanchard, 1978), and
behavioral medicine approaches (Miller, 1994a).
It is therefore the responsibility departmental ad-
ministrators and the mental health clinicians who
advise them to ensure that debriefing modalities
are used responsibly, and that workers who re-
quire more extensive psychotherapeutic interven-
tion will have these available.
Tough Guy Psychotherapy
Tough job personnel, cops especially, have a
reputation for shunning mental health services,
perceiving its practitioners as softies
and
bleeding
hearts who help rotten criminals go free with
wussy excuses
or
overcomplicated psychobabble.
Other tough guys fear being "shrunk," having a
notion of the psychotherapy experience as akin
to brain-washing, a humiliating, infantilizing ex-
perience in which they lie on a couch and sob
about their toilet training. More commonly, the
idea of needing "mental
help"
implies weakness,
cowardice, and lack of ability
to do
the
job.
In
the
environment of
many
departments, some workers
realistically fear
censure,
stigmatization, ridicule,
impaired career advancement, and alienation
from coworkers if they are perceived as the type
who "folds
under
pressure."
Finally, others in the
department who have something to hide may fear
a colleague "spilling his guts" to the shrink and
blowing the malfeasor's cover.
Administrative Issues
There is some debate about whether psycholog-
ical services, especially therapy-type services,
596
Tough Guys
should be provided by a psychologist within the
department, even a psychologist who is a sworn
officer
or
active-duty emergency services worker,
or whether such matters are best handled by out-
side therapists who are less answerable to depart-
mental politics and less likely to be in the gossip
loop (Blau, 1994; Silva, 1991).
On the one
hand,
the
departmental shrink is likely
to have more knowledge of and experience with
the direct pressures faced by the personnel he/she
serves; this is especially true if the psychologist is
also a sworn officer or active-duty worker, or has
had formal training and ride-along experience. On
the
other
hand,
in addition
to
providing psychother-
apy services,
the
departmental psychologist is likely
to also be involved in performing work-status and
fitness-for-duty evaluations, as well as other assess-
ment or legal roles which may conflict with mat of
the effective psychotherapist. An outside therapist
may have less direct experience with departmental
pressures, but may have more therapeutic freedom
of movement.
My own experience has been that the tough
job personnel who come for help—especially if
they haven't been "forced" into treatment—are
usually less concerned with the therapist's exten-
sive technical knowledge of
"The
Job,"
and more
interested that he/she demonstrate a basic trust
and a willingness to understand the worker's situ-
ation—they'll be happy to provide the details.
These workers expect us mental health profes-
sionals
to
give
"110
percent"
to the
psychotherapy
process,
just
as
the workers do
in their
own fields,
and for the most part, they do not want us to be
another cop or firefighter, they want us to be a
skilled therapist—that is why they are talking to
us and not their colleagues. Many are actually
glad to find a secure haven outside the fishbowl
atmosphere of the department and relieved that
the therapeutic sessions provide a respite from
shop talk. This is especially true where the refer-
ral problem has less to do with direct job-related
issues and more with outside pressures, such as
family or alcohol problems, that may impinge on
job performance. In any case, the therapist, the
patient, and the department should be clear about
issues relating
to
confidentiality
and chain
of com-
mand at the outset, and any changes in the
"ground rules" should be clarified as needed.
Trust and the
Therapeutic
Relationship
As is obvious from the above discussion, trust
is
a
crucial element
in
doing effective psychother-
apy with police officers (Silva, 1991), a lesson
that can be applied to clinical work with all tough
job personnel. Difficulty with trust appears to be
an occupational hazard for workers in public
safety with a strong sense of self-sufficiency and
insistence on solving then' own problems, and
therapists may find themselves frequently
"tested," especially at the beginning of the treat-
ment process. As the therapeutic alliance begins
to solidify, the patient will begin to feel more at
ease with the therapist and finds comfort and a
sense of predictability from the psychotherapy
session. Following Egan (1975), Silva (1991)
outlines the following requirements for the estab-
lishment of therapeutic mutual trust:
Accurate empathy: The therapist conveys his/
her
understanding of
the
patient's background
and
experience (but beware of premature false famil-
iarity and phony "bonding").
Genuineness:
The therapist is spontaneous yet
tactful, flexible yet impulsive, and tries to be as
nondefensive as possible.
Availability: The therapist is available, within
reason, whenever needed, and avoids making
promises and commitments he/she cannot keep.
Respect: This is both tough-minded and gra-
cious,
and seeks to preserve the patient's sense
of autonomy, control, and self-respect within the
therapeutic relationship. It is manifested by the
therapist's overall attitude, as well as by certain
specific actions, such
as
indicating
regard
for
rank
or job
role by initially using formal departmental
forms of address, such as "officer," "detective,"
"lieutenant," until trust and mutual respect allow
the patient to ease formality. Here it is important
to avoid the dual traps of overfamiliarity, pa-
tronizing, and talking down to the worker on the
one hand,
and
trying to "play
cop"
or force bogus
comraderie by assuming the role of a colleague
or field commander.
Conceretness: Therapy with
tough
job person-
nel should, at least initially, be goal-oriented and
have a problem-solving focus. These workers are
into action, and to the extent that it is clinically
realistic, the therapeutic approach should empha-
size active, problem-solving approaches.
Therapeutic
Strategies and
Techniques
Since most law enforcement and emergency
services personnel come under psychotherapeutic
care in
the
context of
some
form of post-traumatic
stress reaction, the clinical literature reflects this
emphasis (Blau, 1994; Fullerton, McCarroll, Ur-
597
Laurence Miller
sano,
& Wright, 1992). In general, the effective-
ness of any intervention technique will be deter-
mined by the timeliness, tone, style, and intent
of the intervention. Effective interventions share
in common the elements of briefness, focus on
specific symptomatology or conflict issues, and
direct operational efforts to resolve the conflict
or to reach a satisfactory conclusion.
In working with police officers, Blau (1994)
recommends that the first meeting between the
therapist and the officer establish a safe and com-
fortable working atmosphere by the therapist's
articulating: 1) a positive regard for the officer's
decision to seek
help;
2) a clear description of
the
therapist's responsibilities
and
limitations
with
re-
spect to confidentiality and priviledge; and 3) an
invitation to state the officer's concerns. A
straightforward, goal-directed, problem-solving
therapeutic intervention approach for this patient
group
includes
the
following
elements:
1)
creating
a sanctuary; 2) focusing on critical areas of con-
cern;
3) identifying desired outcomes; 4) re-
viewing assets; 5) developing a general plan;
6) identifying practical initial implementations;
7) reviewing self-efficacy; 8) setting appoint-
ments for review, reassurance, and further
implementation.
Blau (1994) delineates a number of effective
individual intervention techniques for police of-
ficers
that can be
adapted
to
therapeutic work with
all tough job personnel. These include the fol-
lowing.
Attentive
listening:
This includes good eye con-
tact,
an
occasional nod,
and
genuine interest
with-
out inappropriate comment or interruption.
Being there with
empathy:
This therapeutic atti-
tude
conveys availability, concern,
and
awareness
of the turbulent emotions being experienced by
the traumatized
patient.
It is also helpful to let the
patient know
what
he/she is likely
to
experience in
the days and weeks to follow.
Reassurance: This is valuable if it is reality-
oriented, and should take the form of reassuring
the patient that routine matters will be handled,
premises and property will be secured, deferred
responsibilities will be handled by others, and
that he/she has organizational and command
support.
Supportive
counseling:
This includes effective
listening, restatement of content, clarification of
feelings, and reassurance, as well as community
referral and networking with liaison agencies,
as necessary.
Interpretive
counseling:
This type of interven-
tion should be used when the patient's emotional
reaction is significantly greater than
the.
circum-
stances of the critical incident seem to warrant.
In appropriate cases, this therapeutic strategy can
stimulate
the
patient
to search
for underlying emo-
tional stresses that intensify a naturally stressful
traumatic event. In some cases, this may lead to
ongoing psychotherapy.
Not
to
be neglected is
the
use of humor. Humor
has its place in many forms of psychotherapy (Fry
& Salameh, 1987), but may especially be useful
in working with law enforcement and emergency
services personnel (Fullerton et al., 1992; Silva,
1991).
In general, if
the
therapist and patient can
laugh together, this may lead to the sharing of
more intimate feelings. Humor serves to bring a
sense of balance and proportion to those circum-
stances in which the emotional world seems cha-
otic, stunted, or warped by horror. Humor, even
sarcastic, callous, or crass humor—if handled
appropriately and used constructively—may
allow
the
venting of anger, frustration, and resent-
ment and lead to productive reintegrative thera-
peutic work.
Departmental Support
Even in the absence of formal psychotherapeu-
tic intervention, following a department-wide
critical incident, such as the death of a worker,
or
a
particularly stressful rescue event, the mental
health professional can advise and guide law en-
forcement and emergency service departments in
encouraging and implementing several organiza-
tional response measures, based on the available
literature on individual and group coping strate-
gies for these groups (Alexander, 1993; Alex-
ander &
Walker,
1994;
Alexander
&
Wells,
1991;
DeAngelis, 1995; Fullerton et al., 1992; Palmer,
1983).
Many of these measures are applicable
proactively, that is, as part of training before a
disaster or critical incident occurs, as a means
of preparation. Some specific measures include
the following:
• Encourage mutual support among peers and
supervisors. The former typically happens any-
way, the latter may need some explicit reinforce-
ment. Public safety workers often work as "part-
ners"
and find that the shared decision-making
and mutual reassurance actually enhances effec-
tive job performance.
• Utilize
humor as a
coping mechanism to facil-
itate
emotional insulation
and group
bonding.
The
598
Tough Guys
first forestalls excessive identification with
vic-
tims,
the second encourages mutual group support
via a shared language. Of course, the
line
between
adaptive crass humor
and
maladaptive nastiness
may need
to be
monitored.
• Make use
of
appropriate rituals to give mean-
ing and dignity
to an
otherwise horrific and exis-
tentially disorienting experience. This need
not
include only religious rites related
to
mourning,
but such things
as a
military-style honor guard
to
attend bodies before disposition,
and the
formal
acknowledgment
of
actions above and beyond the
call
of
duty. Important here
is the
role
of
"grief
leadership," that
is,
the supervisor's or command-
ing officer's demonstrating
by
example that
it is
okay
to
express grief
and
mourn
the
death
of
fallen comrades
or
civilians,
and
that
the
appro-
priate expression
of
one's feelings about the inci-
dent will
be
supported,
not
denigrated.
Conclusion
Psychotherapy with
law
enforcement
and
emergency personnel typically entails
its
share
of frustration
as
well
as
satisfaction.
A
certain
flexibility is required
in
adapting traditional
psy-
chotherapeutic models
and
techniques
for use
with this group,
and
clinical work frequently
re-
quires both firm professional grounding and seat-
of-the-pants therapeutic maneuverability. Incom-
plete closures
and
partial successes
are to be ex-
pected,
but in a
few instances, the impact
of
suc-
cessful intervention can have profound effects
on
morale and job effectiveness that may be felt depart-
ment-wide.
In
sum, working with these tough guys
takes skill, dedication,
and
sometimes
a
strong
stomach,
but for
therapists
who are not
afraid
to
tough
it out
themselves, this
can be a
fascinating
and rewarding aspect
of
clinical practice.
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