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Abstract

Canadian Public Safety Personnel (e.g., correctional workers, dispatchers, firefighters, paramedics, and police) are regularly exposed to potentially traumatic events, some of which are highlighted as critical incidents warranting additional resources. Unfortunately, available Canadian public safety personnel data measuring associations between potentially traumatic events and mental health remains sparse. The current research quantifies estimates for diverse event exposures within and between several categories of public safety personnel. Participants were 4,441 public safety personnel (31.7% women) in 1 of 6 categories (i.e., dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, and Royal Canadian Mounted Police). Participants reported exposures to diverse events including sudden violent (93.8%) or accidental deaths (93.7%), serious transportation accidents (93.2%), and physical assaults (90.6%), often 11+ times per event. There were significant relationships between potentially traumatic event exposures and all mental disorders. Sudden violent death and severe human suffering appeared particularly related to mental disorder symptoms, and therein potentially defensible as critical incidents. The current results offer initial evidence that (a) potentially traumatic event exposures are diverse and frequent among diverse Canadian public safety personnel; (b) many different types of exposure can be associated with mental disorders; (c) event exposures are associated with diverse mental disorders, including but not limited to posttraumatic stress disorder, and mental disorder screens would be substantially reduced in the absence of exposures; and (d) population attributable fractions indicated a substantial reduction in positive mental disorder screens (i.e., between 29.0 and 79.5%) if all traumatic event exposures were eliminated among Canadian public safety personnel.
Exposures to Potentially Traumatic Events Among Public Safety
Personnel in Canada
R. Nicholas Carleton
University of Regina
Tracie O. Afifi, Tamara Taillieu, and Sarah Turner
University of Manitoba
Rachel Krakauer
University of Regina
Gregory S. Anderson
Justice Institute of British Columbia
Renée S. MacPhee
Wilfrid Laurier University
Rosemary Ricciardelli
Memorial University of Newfoundland
Heidi A. Cramm and Dianne Groll
Queen’s University
Donald R. McCreary
Brock University
Canadian Public Safety Personnel (e.g., correctional workers, dispatchers, firefighters, paramedics, and
police) are regularly exposed to potentially traumatic events, some of which are highlighted as critical
incidents warranting additional resources. Unfortunately, available Canadian public safety personnel data
measuring associations between potentially traumatic events and mental health remains sparse. The
current research quantifies estimates for diverse event exposures within and between several categories
This article was published Online First December 10, 2018.
R. Nicholas Carleton, Anxiety and Illness Behaviours Laboratory, De-
partment of Psychology, University of Regina; Tracie O. Afifi, Tamara
Taillieu, and Sarah Turner, Rady Faculty of Health Sciences, University of
Manitoba; Rachel Krakauer, Anxiety and Illness Behaviours Laboratory,
Department of Psychology, University of Regina; Gregory S. Anderson,
Office of Applied Research & Graduate Studies, Justice Institute of British
Columbia; Renée S. MacPhee, Department of Kinesiology & Physical
Education, Health Sciences, Faculty of Science, Wilfrid Laurier Univer-
sity; Rosemary Ricciardelli, Department of Sociology, Faculty of Human-
ities and Social Sciences, Memorial University of Newfoundland; Heidi A.
Cramm, School of Rehabilitation Therapy, Queen’s University; Dianne
Groll, Department of Psychiatry, Faculty of Health Sciences, Queen’s
University; Donald R. McCreary, Department of Psychology, Brock Uni-
versity.
All authors made substantial contributions consistent with the Interna-
tional Committee of Medical Journal Editors. The details describing the
contributions are presented below alphabetically by last name. Initial
project design was a collaborative effort based on the following contribu-
tors, each of whom was responsible for overseeing their area-specific
domains for assessment, all of whom reviewed, revised as necessary, and
approved the final design in its entirety: Afifi, Anderson, Carleton, Cramm,
Groll, MacPhee, Ricciardelli. Implementation was a collaborative effort
primarily driven by: Afifi, Anderson, Carleton, Cramm, Groll, MacPhee,
Ricciardelli. Analysis for the current article was a collaborate effort pri-
marily driven by each of the following: Afifi, Carleton, Taillieu, Turner;
however, area-specific analytic information was provided by different
authors as required. Write up for the current article was a collaborate effort
primarily driven by each of the following: Afifi, Carleton, Taillieu, Turner,
with specific consultation efforts from Anderson and McCreary; however,
all authors reviewed the document and provided detailed feedback that was
ultimately integrated into the submitted manuscript. All authors also ap-
proved the submitted version of the manuscript.
R. Nicholas Carleton’s research is supported by the Canadian Insti-
tutes of Health Research (CIHR) through a New Investigator Award
(FRN: 285489). Tracie O. Afifi’s research is supported by a CIHR New
Investigator Award and Foundation Scheme Award. This research was
also funded in part by the Ministry of Public Safety and Emergency
Preparedness through the Policy Development Contribution Program.
Special thanks for recruitment support provided by the following (al-
phabetically): Badge of Life Canada, Behind the Red Serge, Canadian
Association for Police Governance (CAPG), Canadian Association of
Chiefs of Police (CACP), Canadian Association of Fire Chiefs (CAFC),
Canadian Institute for Military and Veteran Health Research (CIM-
VHR), Canadian Ministry of Public Safety and Emergency Prepared-
ness, Canadian Police Association (CPA), Community Safety Knowl-
edge Alliance, Correctional Service of Canada (CSC), Families of the
RCMP for PTSD Awareness, First Responder Mental Health Network
Collaboration, International Association of Firefighters (IAFF), Justice
Institute of British Columbia, Mental Health Commission of Canada,
Mood Disorders Society of Canada, Nova Scotia Operational Stress
Injury Clinic - Capital Health, Paramedic Association of Canada (PAC),
Paramedic Chiefs of Canada (PCC), Royal Canadian Mounted Police
(RCMP), Tema Conter Trust, Union of Solicitor General Employees
(USGE), and Wounded Warriors Canada. This research was funded in
part by the Ministry of Public Safety and Emergency Preparedness
through the Policy Development Contribution Program.
Correspondence concerning this article should be addressed to R. Nich-
olas Carleton, Anxiety and Illness Behaviours Laboratory, Department of
Psychology, University of Regina, Regina, SK, Canada S4S 0A2. E-mail:
nick.carleton@uregina.ca
Canadian Journal of Behavioural Science /
Revue canadienne des sciences du comportement
0008-400X/19/$12.00 2019, Vol. 51, No. 1, 37–52
© 2018 Canadian Psychological Association http://dx.doi.org/10.1037/cbs0000115
37
of public safety personnel. Participants were 4,441 public safety personnel (31.7% women) in 1 of 6
categories (i.e., dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics,
and Royal Canadian Mounted Police). Participants reported exposures to diverse events including sudden
violent (93.8%) or accidental deaths (93.7%), serious transportation accidents (93.2%), and physical
assaults (90.6%), often 11times per event. There were significant relationships between potentially
traumatic event exposures and all mental disorders. Sudden violent death and severe human suffering
appeared particularly related to mental disorder symptoms, and therein potentially defensible as critical
incidents. The current results offer initial evidence that (a) potentially traumatic event exposures are
diverse and frequent among diverse Canadian public safety personnel; (b) many different types of
exposure can be associated with mental disorders; (c) event exposures are associated with diverse mental
disorders, including but not limited to posttraumatic stress disorder, and mental disorder screens would
be substantially reduced in the absence of exposures; and (d) population attributable fractions indicated
a substantial reduction in positive mental disorder screens (i.e., between 29.0 and 79.5%) if all traumatic
event exposures were eliminated among Canadian public safety personnel.
Public Significance Statement
Growing evidence suggests that many first responders and other public safety personnel in Canada
may be experiencing substantial difficulties with symptoms of mental health disorders. There have
been suggestions that such difficulties may be associated with increased exposure to potentially
traumatic events as part of working in public safety, with some people suggesting specific types of
events may be particularly problematic. The current results support both suggestions and may be
important for informing the national action plan mandated by the Prime Minister of Canada.
Keywords: trauma, critical incidents, Public Safety Personnel, mental health disorders, operational stress
injuries
An event is considered potentially traumatic when exposure
includes direct or indirect experiences of actual or threatened
death, serious injury, or sexual violence (American Psychiatric
Association, 2013). Most of the North American general popula-
tion (i.e., 50 –90%) are exposed to one or more potentially trau-
matic events during their lifetime (Kilpatrick et al., 2013;Perrin et
al., 2014). Posttraumatic stress disorder (PTSD) is one potential
outcome from such exposures (American Psychiatric Association,
2013;Kilpatrick, Resnick, & Acierno, 2009); however, only
5–10% of persons in the general population develop PTSD as a
result of such exposures (Ozer, Best, Lipsey, & Weiss, 2003).
Other mental disorders are also thought to be possible sequelae to
traumatic exposure (e.g., major depressive disorder, panic disor-
der; Nixon, Resick, & Griffin, 2004;O’Donnell, Creamer, &
Pattison, 2004;Perkonigg, Kessler, Storz, & Wittchen, 2000;Sha-
lev et al., 1998).
Revisions for the Diagnostic and Statistical Manual of Mental
Disorders-Fifth Edition (DSM–5) allow for cumulative exposures,
instead of singularly identifiable exposures, to meet criteria for and
contribute to mental health disorder symptoms (American Psychi-
atric Association, 2013;Kilpatrick et al., 2009). The DSM change
may be extremely important for persons exposed to multiple
traumatic events, such as those working to ensure the safety of our
communities. Public safety personnel include, but are not limited
to, persons working as correctional workers (security and nonse-
curity roles), dispatchers, firefighters, paramedics, and police of-
ficers (Oliphant, 2016).
There is broad international evidence that public safety person-
nel may have substantially more difficulties with mental disorders
than the general public (Berger et al., 2012;Faust & Ven, 2014;
Haugen, Evces, & Weiss, 2012;Neria, DiGrande, & Adams, 2011;
Oliphant, 2016;Stanley, Hom, & Joiner, 2016). Canadian public
safety personnel have also reported substantial difficulties with
clinically significant symptoms of one or more mental disorders
(e.g., PTSD, major depressive disorder, and panic disorder; As-
mundson & Stapleton, 2008;Carleton, Afifi, Turner, Taillieu,
Duranceau, et al., 2018;Corneil, Beaton, Murphy, Johnson, &
Pike, 1999;Haugen et al., 2012;Horswill, Jones, & Carleton,
2015;Oliphant, 2016). A recent study (Carleton, Afifi, Turner,
Taillieu, Duranceau, et al., 2018) assessed a large sample of
Canadian public safety personnel and found that approximately
44.5% screened positive for one or more mental health disorders,
primarily PTSD (23.2%) or major depressive disorder (26.4%).
There were also significant differences identified between public
safety personnel categories (e.g., municipal/provincial police rel-
ative to Royal Canadian Mounted Police) that imply potential
important differences in their experiences. In all cases, the screen-
ing rates starkly contrast the population diagnostic rates of one or
more current diagnostic mental health disorders (i.e., 10.1%; Sta-
tistics Canada, 2012).
The apparent differences between mental health disorders across
public safety personnel and between public safety personnel and
the general population may be due, in part, to diversity in expo-
sures to potentially traumatic events (Galatzer-Levy, Madan, Ney-
lan, Henn-Haase, & Marmar, 2011;Komarovskaya et al., 2011;
Turner, Taillieu, Carleton, Sareen, & Afifi, in press). There is an
anecdotally reasonable presumption that public safety personnel
experience higher exposure frequencies to potentially traumatic
events than the general public; however, the published empirical
data on such exposures using general population measures remains
sparse, particularly for Canadians. General population estimates
suggest as many as 50 –90% of people will be exposed to one or
38 CARLETON ET AL.
more potentially traumatic events during their lifetime, including
unexpected death of a loved one (Kilpatrick et al., 2013;Perrin et
al., 2014). The limited data available for public safety personnel
exposures to potentially traumatic events as assessed among the
general population suggests higher exposure frequencies. For ex-
ample, a study assessing Canadian and American firefighters
where the authors coded potentially traumatic events as being
critical evidenced most participants (90%) are exposed to at least
one potentially traumatic event within the past year, many involv-
ing encountering death by suicide, or graphic, deadly tragedies
(Corneil et al., 1999).
Despite the limited empirical data on potentially traumatic
events experienced by public safety personnel, the anecdotal ex-
pectation of higher exposure frequencies has led to the creation of
a related category of events, called critical incidents, to distinguish
relatively common potentially traumatic event exposures from
exposures thought more likely to be problematic. Critical incidents
are situations that cause public safety personnel, “to experience
unusually strong emotional reactions which have the potential to
interfere with their ability to function either at the scene or later”
(Mitchell, 1983, p. 36) and can include “all physical custody
(arrests), all vehicle and foot pursuits, all dispatched code re-
sponses (emergency), all motor vehicle accidents that require
physical work and all calls which present an active threat to life
and/or property” (Anderson, Plecas, & Segger, 2001, p. 18). There
is no requirement for a critical incident to include direct or indirect
experiences of actual or threatened death, serious injury, or sexual
violence (American Psychiatric Association, 2013), but the context
suggests an inherent overlap with potentially traumatic events
experienced by public safety personnel.
A measure specifically assessing critical incidents among fire-
fighters and paramedics (n173) was developed with an Amer-
ican firefighter sample (Beaton, Murphy, Johnson, Pike, & Cor-
neil, 1998). The results suggested frequent exposures to potentially
traumatic events and that critical incidents typically involved one
or more of the following categories: (a) catastrophic injury to self
or coworker; (b) gruesome victim incidents, render aid to seriously
injured people; (c) vulnerable victims; (d) minor injury to self and
death; and (e) dying exposure as categories. In addition, research
using critical incident inventories with public safety personnel,
rather than potentially traumatic event inventories used with gen-
eral population measures, remains sparse and homogeneous. Cor-
neil and colleagues (1999) reported on data from a large sample of
Canadian firefighters wherein exposure to suicides (39%) and
persons dead on arrival because of other than natural causes (25%),
as the top two critical incidents based on the Beaton and col-
leagues’ (1999) critical incidents inventory. Another study allowed
participants to subjectively identify their own number of critical
incidents, but did not present the incident details (Brazil, 2017). A
more recent study with firefighters detailed the percentages of
exposure to each critical incident and suggested that 85% were
exposed to at least one critical incident in the past two months
(MacDermid et al., in press). A South African sample of diverse
public safety personnel reported critical event exposures averaged
from 4.55 to 20.59 times within the preceding 2 months alone
(Ward, Lombard, & Gwebushe, 2006). A small sample (n31) of
United Kingdom firefighters reported between 16 and 100% had
experienced each type of critical incident from a list of nine
adapted options (Haslam & Mallon, 2003). Among a sample of
American paramedic personnel, the five most common critical
incidents had significant overlap with the five most distressing
potentially traumatic events—seeing someone die, a recently dead
body, badly beaten adult, or a severely neglected child; completing
a death notification; and involving someone familiar to the crew
(Donnelly & Bennett, 2014).
Efforts at creating inventories of potentially traumatic events
and critical incidents that are specific to public safety personnel
(Beaton et al., 1998) remain extremely laudable and important;
however, understanding event exposure frequencies using general
population measures (e.g., the PTSD life events checklist; Blevins,
Weathers, Davis, Witte, & Domino, 2015;Weathers et al., 2013)
would provide important insights for researchers, public safety
personnel leaders, and policymakers who are trying understanding
the experiences of public safety personnel.
The presumed frequent exposure of public safety personnel to
diverse potentially traumatic critical incidents, coupled with the
apparent higher risk for mental health sequelae (Carleton, Afifi,
Turner, Taillieu, Duranceau, et al., 2018;Oliphant, 2016;J. D.
Richardson, Darte, Grenier, English, & Sharpe, 2008), led to the
development of strategies intended to minimise the impact of
critical incidents—specifically, critical incident stress management
programs and, therein, critical incident stress debriefing programs
(Canadian Institute for Public Safety Research and Treatment
[CIPSRT], 2016). The critical incident stress management pro-
grams were intended to bolster mental health before, during, and
after exposures to potentially traumatic critical incidents. Critical
incident stress debriefing programs are intended to be components
of critical incident stress management programs that follow a
specific event designated as a critical incident (CIPSRT, 2016;
Mitchell, 1983). There remains a great deal of debate about critical
incident stress management and critical incident stress debriefing
(CIPSRT, 2016); nevertheless, identifying the most common po-
tentially traumatic events experienced by public safety personnel
as the “worst event,” whether or not those events would be
considered critical incidents, would be important for understanding
public safety personnel experiences and for determining when to
engage additional mental health resources. In addition, understand-
ing the relationships between different potentially traumatic events
and different mental health disorders may also help to inform when
additional resources should be engaged and with what kinds of
symptom focus.
Overall, the previously published results represent important,
but very preliminary, data elucidating public safety personnel
experiences, as well as providing some direction for public safety
personnel leaders regarding when to engage additional mental
health services. However, there are currently no empirical assess-
ments using general population measures to inventory the fre-
quency or diversity of potentially traumatic events, or which event
types public safety personnel perceive as the worst event, in large
heterogenous samples of Canadian public safety personnel. There
is also no currently available evidence assessing the relationships
between different potentially traumatic event types and different
mental health disorders in large heterogenous samples of Canadian
public safety personnel. The current research was designed to (a)
better understand the relative frequencies of potentially traumatic
events encountered by diverse Canadian public safety personnel;
(b) better understand which potentially traumatic events are most
likely to be considered worst and therein potentially critical inci-
39
TRAUMATIC EXPOSURES AMONG PUBLIC SAFETY PERSONNEL
dents; (c) assess for differences between categories of public safety
personnel; (d) assess for relationships across public safety person-
nel categories between potentially traumatic events and positive
screenings for diverse mental disorders; and (e) assess the popu-
lation attributable fractions associated with different potentially
traumatic event exposures among public safety personnel. Doing
so is critical for educating the general public and informing public
safety personnel leadership at all levels about the experiences of
Canadian public safety personnel.
Method
Data and Sample
The current data were collected using a Web-based self-report
survey made available to public safety personnel participants in
English or French as part of a larger study (Carleton, Afifi, Turner,
Taillieu, Duranceau, et al., 2018). The research followed estab-
lished guidelines for Web-based surveys (Ashbaugh, Herbert, But-
ler, & Brunet, 2010). Participation was solicited through emails
sent to actively working public safety personnel, including civilian
members working for police and volunteer firefighters. A total of
N8,520 began the survey (Carleton, Afifi, Turner, Taillieu,
Duranceau, et al., 2018), of whom N4,441 public safety
personnel participants could be definitively placed into one of the
six public safety personnel categories of interest in this study (i.e.,
municipal/provincial police; Royal Canadian Mounted Police
(RCMP); corrections workers; firefighters; paramedics; and call
centre operators/dispatchers) and responded to the traumas and
stressors module in the survey, producing a completion rate of
52.1%. The study was approved by R. Nicholas Carleton’s Uni-
versity of Regina institutional research ethics board (File #2016
107).
Sample representativeness was determined by comparing the
demographic proportions for sex, age, and provincial region in the
current sample to data provided by Statistics Canada for public
safety personnel using the 2011 National Household Survey and
the National Occupational Classification (Statistics Canada, 2012).
The results demonstrated that the sex distribution was similar
among firefighters, municipal/provincial police, paramedics,
Royal Canadian Mounted Police; that the age distribution was
similar with regard to municipal/provincial police, paramedics,
Royal Canadian Mounted Police; and that the provincial distribu-
tion was similar for correctional officers, firefighters, municipal/
provincial police, Royal Canadian Mounted Police. Further details
are available in previous studies (i.e., Carleton, Afifi, Turner,
Taillieu, Duranceau, et al., 2018,Carleton, Afifi, Turner, Taillieu,
LeBouthillier, et al., 2018).
Traumatic Exposures
The Life Events Checklist for the DSM–5 (LEC-5; Blevins et
al., 2015;Weathers et al., 2013) was used to assess participants’
lifetime exposure to any of the 16 different potentially traumatic
events (see Table 1 for specific traumatic events). There were two
items from the LEC-5 that were modified slightly to differentiate
experiences that are relatively more common for public safety
personnel—specifically, “natural disaster” was revised to “a life-
threatening natural disaster” and “transportation accident” was
revised to “a serious transportation accident.” Participant re-
sponses were coded as having been exposed to a specific traumatic
event if they reported that: (a) it happened to them personally, (b)
they witnessed it happen to someone else, (c) they learned about it
happening to a close family member or close friend, and/or (d)
they were exposed to it as part of their jobs as public safety
personnel. Respondents could select all that applied, left blank, or
checked off “does not apply” for events to which they were not
exposed. The total number of different traumatic exposures was
also computed by summing exposures across the 16 items. Al-
though the percentage of missing responses on each individual
potentially traumatic event item was small (range from 1.4 to
11.0%), cumulatively missing values compromised computation of
the exact number of different traumatic exposures for several
participants. Therefore, we allowed up to two missing values in the
calculation of the total number of different traumatic exposures
variables. An additional 721 respondents, or 16.2% of the final
sample, were excluded from the total number of traumatic expo-
sures variable because of three or more missing values. These
analytic choices likely resulted in a slightly more conservative
estimate of the total number of different traumatic exposures for
this sample. Cronbach’s for the scale assessing the total number
of traumatic events was 0.81.
Participants were also asked to identify which traumatic event
was, for them, the worst or most distressing event. That is, if more
than one of the events happened, the participant was asked to
identify the one event that currently causes them the most distress
(i.e., “Please think about the events that you have experienced in
your lifetime and consider which event from the list was the worst,
most distressing event. If more than one of these events happened
to you, select the one event that currently causes you the most
distress”). The potentially traumatic events most frequently iden-
tified as the worst, most distressing events can reasonably be
considered for inclusion in a list of critical incidents.
Mental Disorder Symptoms
Current mental disorder symptoms were assessed using several
reliable, validated self-report mental disorder screening measures.
PTSD was assessed with the PTSD Check List 5 (PCL-5; Ash-
baugh, Houle-Johnson, Herbert, El-Hage, & Brunet, 2016;Blevins
et al., 2015;Bovin et al., 2016;MacIntosh, Séguin, Abdul-Ramen,
& Randy, 2015;Weathers et al., 2013) based on a past-month
timeframe. A positive screen for PTSD was indicated if the par-
ticipant reported at least one traumatic exposure on the LEC-5
(PTSD follow up questions based on single worst traumatic event,
most distressing event, or event that was currently causing the
most distress), met minimum criteria on each PTSD cluster, and
had a total score 32 on the PCL-5 (Weathers et al., 2013).
Depression was assessed with the 9-item Patient Health Question-
naire (PHQ-9; Beard, Hsu, Rifkin, Busch, & Björgvinsson, 2016;
Kroenke, Spitzer, & Williams, 2001;Kroenke, Spitzer, Williams,
& Löwe, 2010;Löwe et al., 2004) based on a past 14-day time-
frame and was indicated by a total score 9(Manea, Gilbody, &
McMillan, 2015). Generalised anxiety was assessed with the
7-item Generalised Anxiety Disorder scale (GAD-7; Beard &
Björgvinsson, 2014;Kroenke et al., 2010;Spitzer, Kroenke, Wil-
liams, & Löwe, 2006) based on a past 14-day timeframe and was
indicated by a total score 9(Swinson, 2006). Social anxiety was
40 CARLETON ET AL.
Table 1
Prevalence of Potentially Traumatic Exposure Types Across Canadian Public Safety Personnel Categories
Type of exposure
Total
Municipal/provincial
police
a
RCMP
b
Correctional
workers
c
Firefighters
d
Paramedics
e
Call centre operators/
dispatchers
f
2
Significant differences
between public safety
personnel categories%(n)%(n)%(n)%(n)%(n)%(n)%(n)
Life threatening natural disaster 66.4 (2,832) 61.2 (676) 70.2 (804) 51.0 (276) 71.4 (484) 74.9 (445) 73.1 (147) 109.08
ⴱⴱⴱ
ab, d, e, f b eca,
b, d, e, f
Fire or explosion 86.0 (3,727) 85.8 (965) 88.4 (1,026) 61.8 (337) 98.0 (687) 89.2 (534) 86.8 (178) 357.76
ⴱⴱⴱ
ad,ebdca, b, d,
e,fedfd
Serious transportation accident 93.2 (4,084) 94.7 (1,071) 95.9 (1,129) 74.1 (409) 98.3 (693) 97.2 (590) 92.3 (192) 382.36
ⴱⴱⴱ
ad,ebdca, b, d,
e,ffb, d, e
Serious accident at work, home,
or during recreational activity 81.6 (3,430) 81.0 (878) 79.2 (882) 75.0 (408) 87.0 (587) 88.4 (520) 77.9 (155) 53.44
ⴱⴱⴱ
ad,ebd,eca, d,
efd, e
Exposure to toxic substance 67.4 (2,664) 61.7 (623) 67.3 (705) 49.6 (247) 89.6 (592) 73.1 (396) 52.1 (101) 262.99
ⴱⴱⴱ
ab, d, e b d,eca,
b, d, e e dfa, b, e,
d
Physical assault 90.6 (3,931) 95.3 (1,082) 95.4 (1,120) 88.7 (496) 75.7 (504) 93.7 (564) 80.5 (165) 268.26
ⴱⴱⴱ
ca, b, e d a, b, c, e
fa, b, c, e
Assault with a weapon 83.9 (3,639) 90.2 (1,017) 91.7 (1,078) 78.8 (439) 64.6 (437) 83.2 (496) 82.3 (172) 283.12
ⴱⴱⴱ
ca,bda, b, c, e, f
ea,bfa, b
Sexual assault 71.2 (3,035) 75.6 (849) 80.7 (939) 65.9 (355) 44.5 (287) 75.4 (445) 78.1 (160) 303.58
ⴱⴱⴱ
abca, b, e, f d a,
b, c, e, f e b
Other unwanted or uncomfortable
sexual experience 67.3 (2,803) 69.5 (765) 75.0 (852) 69.3 (368) 39.2 (246) 73.6 (416) 76.5 (156) 276.51
ⴱⴱⴱ
ab,fcbda, b, c,
e, f
Combat 18.8 (791) 19.0 (207) 20.6 (231) 19.8 (106) 13.1 (87) 21.8 (129) 15.4 (31) 21.77
ⴱⴱⴱ
da, b, c, e
Captivity 30.5 (1,279) 33.8 (370) 36.5 (416) 42.2 (225) 8.9 (58) 20.6 (117) 46.7 (93) 254.27
ⴱⴱⴱ
ac,fbc,fda, b,
c, e, f e a, b, c, f
Life threatening illness or injury 76.7 (3,301) 73.9 (828) 75.5 (870) 77.9 (430) 74.0 (502) 83.8 (498) 84.0 (173) 31.91
ⴱⴱⴱ
ae,fbe,fced
e, f
Severe human suffering 79.1 (3,234) 79.7 (844) 79.4 (859) 71.2 (371) 80.5 (528) 85.5 (502) 70.7 (130) 43.23
ⴱⴱⴱ
aebeca, b, d, e
defa, b, d, e
Sudden violent death 93.8 (4,101) 95.2 (1,080) 95.7 (1,126) 85.6 (475) 93.2 (647) 95.7 (578) 93.8 (195) 79.79
ⴱⴱⴱ
ca, b, d, e, f d b
Sudden accidental death 93.7 (4,063) 95.0 (1,070) 95.1 (1,113) 80.6 (435) 96.7 (669) 97.0 (585) 92.3 (191) 186.68
ⴱⴱⴱ
ca, b, d, e, f f d, e
Serious injury, harm, or death
you caused to someone else 36.2 (1,485) 48.1 (511) 43.1 (479) 29.0 (154) 20.1 (129) 30.3 (169) 21.7 (43) 198.15
ⴱⴱⴱ
baca,bda, b, c,
eea,bfa, b, c, e
Total number of different types
of potentially traumatic
exposures, M(SD) 11.08 (3.23) 11.36 (3.16) 11.64 (3.04) 9.88 (3.88) 10.22 (2.84) 11.59 (2.86) 10.96 (3.56) F32.76
ⴱⴱⴱ
ca, b, e, f d a, b, e, f
fb, e
Note. RCMP Royal Canadian Mounted Police. Different lettered superscripts indicate public safety officer categories than differ from one another at p.05. Differences in prevalence estimates
across categories were tested by changing the reference group in logistic regression models. Differences in mean scores across public safety personnel categories were tested by changing the reference
group in linear regression models.
ⴱⴱⴱ
p.001.
41
TRAUMATIC EXPOSURES AMONG PUBLIC SAFETY PERSONNEL
assessed with the 14-item Social Interaction Phobias scale (SIPS;
Carleton et al., 2009,2014;Duranceau, Peluso, Collimore, As-
mundson, & Carleton, 2014;Menatti et al., 2015;Reilly, Carleton,
& Weeks, 2012) based on current symptoms and was indicated by
a total score 20 (Carleton et al., 2009). Panic disorder was
assessed with the 7-item Panic Disorder Symptoms Severity scale
(PDSS; Furukawa et al., 2009;Shear et al., 1997,2001) based on
a past 7-day timeframe and was indicated by a total score 7
(Shear et al., 1997). Alcohol use disorder was assessed with the
Alcohol Use Disorders Identification Test (AUDIT; Gache et al.,
2005;Saunders, Aasland, Babor, de la Fuente, & Grant, 1993)
based on a past 12-month timeframe and was indicated by a total
score 15 (Gache et al., 2005). Participants were also asked
whether they had been diagnosed with several other mental disor-
ders including obsessive– compulsive disorder, persistent depres-
sive disorder, bipolar I, bipolar II, and cyclothymic disorder. The
low prevalence of these disorders precluded the examination of
each specific self-reported mental disorder with traumatic events.
As such, these mental disorders were only included in the any
positive mental disorder screen variable. A dichotomous any pos-
itive mental disorder screen was computed based on whether the
participant had a positive screen on one or more screening mea-
sures and/or self-reported mental disorders.
Sociodemographic Covariates
Sociodemographic covariates included sex (male or female), age
(19 to 29 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, or
60 years and older), marital status (married/common-law, remar-
ried, separated/divorced/widowed, or single), race/ethnicity (White
or other), education (high school or less, some postsecondary less
than 4 year college/university program, or university degree/4-year
college or higher), urban versus rural work location (urban or
rural), province of residence (Western Canada, Eastern Canada,
Atlantic Canada, Northern Territories), and total years of service
(less than 4 years, 4 to 9 years, 10 to 15 years, or more than 15
years).
Statistical Analyses
First, cross tabulations with
2
tests for associations were com-
puted to examine the distribution of traumatic exposures, the
frequency of different traumatic exposures, and the worst trau-
matic exposures across the six public safety personnel categories.
Differences across public safety personnel categories were tested
by changing reference groups in a logistic regression model. Dif-
ferences in mean scores on the total number of different traumatic
exposures across public safety personnel categories were calcu-
lated using a one-way analysis of variance (ANOVA), and differ-
ences across categories were tested using coefficients derived from
a linear regression model. We also present the reported frequency
of lifetime exposure for each different potentially traumatic event
type among respondents who reported having ever been exposed to
that specific trauma. The frequency options ranged from 1 to 10,
and then included an 11option; however, the results were
grouped from 1 to 5, 6 to 10, and 11to facilitate analytic
comparisons.
Second, a series of multivariate logistic regression models were
run to examine the association of each type of traumatic exposure
with positive mental disorder screens. The models were adjusted
for sociodemographic covariates (i.e., sex, age, marital status race/
ethnicity, education, urban/rural work location, province of resi-
dence, and total years of service) and public safety personnel
category.
Third, there is a statistical procedure called population attribut-
able fractions that can be used to estimate the proportion of the
mental health disorders that might be decreased if the potentially
traumatic event exposure had not occurred (Last, 2001). The
population attributable fraction size depends on the relationship
strength between the potentially traumatic event exposure and
mental health disorders (Young, 1998). Researchers have used
population attributable fractions in previous research with civilian
and military populations to understand the impact of childhood
abuse on mental health and suicide (Cougle, Resnick, & Kilpat-
rick, 2009;Najavits & Capezza, 2014;O’Donnell et al., 2004;
Stein & Kennedy, 2001). Population attributable fractions were
computed from estimates derived from the multivariate logistic
regression models to estimate the extent to which positive mental
disorder screens might be reduced if traumatic exposures were
eliminated. All population attributable fraction analyses were con-
ducted using the punaf module in Stata Version 15. Results at p
.05 were considered statistically significant.
Results
Exposure Frequencies to Potentially Traumatic Events
Details of exposure frequencies to potentially traumatic events
as self-reported by participants are provided in Table 1. There were
significant differences identified across many, but not all, of the
public safety personnel category comparisons. The most com-
monly reported potentially traumatic event types across the public
safety personnel categories were: sudden violent death (93.8%),
sudden accidental death (93.7%), serious transportation accident
(93.2%), physical assault (90.6%), fire or explosion (86.0%), as-
sault with a weapon (83.9%), and serious accident at work, home,
or during a recreational activity (81.6%).
On average, public safety personnel reported exposure to 11.08
(SD 3.23) out of 16 different types of potentially traumatic
events. There were significant mean differences across public
safety personnel categories as detailed in the bottom row of Table
1. Public safety personnel who were RCMP (11.64), paramedics
(11.59), and municipal/provincial police (11.36) tended to report
the highest mean levels of diverse exposures; in contrast, correc-
tional workers (9.88), firefighters (10.22), and call centre opera-
tors/dispatchers (10.96) reported lower mean levels of diverse
exposures. There were also several statistically significant differ-
ences across public safety personnel categories in the frequency of
different types of exposure, indicating substantial variability across
occupational groups. For example, relative to some other public
safety personnel categories, firefighters were often more com-
monly exposed to life threatening natural disasters; fires or explo-
sions; serious transportation accidents; serious accidents at work,
home, or during recreational activity; severe human suffering;
sudden accidental death; and toxic substances, but less commonly
exposed to physical assault, assault with a weapon, sexual assault,
or other unwanted or uncomfortable sexual experiences. Despite
the significant differences between the public safety personnel
42 CARLETON ET AL.
categories, the prevalence of exposure to all types of potentially
traumatic events, including combat and captivity, were all substan-
tial and appear to warrant concern.
The frequencies of exposure for each potentially traumatic
event type are provided in Table 2. The potentially traumatic
event identified as occurring most frequently across all public
safety personnel was a serious transportation accident (i.e.,
71.3% who reported being exposed to that event type reported
the exposures occurred 11 or more times during their life span).
In contrast, exposure to a life-threatening natural disaster oc-
curred least frequently (i.e., 91.7% who reported being exposed
to that event type reported the exposures occurred fewer than
six times). There was substantial variability with respect to
exposure frequency to each potentially traumatic event type,
suggesting that while most public safety personnel will be
exposed to most types of potentially traumatic event (see Table
1), the frequency of exposure appears influenced by their most
typical duties (see Table 2). For example, 89.0% of firefighters
exposed to fire or explosion reported 11exposures, whereas
82.7% of correctional workers exposed to fire or explosion
reported fewer than six exposures.
Worst, Most Distressing Potentially Traumatic
Events—Critical Incidents
Table 3 presents how frequently each type of potentially
traumatic event was identified as the worst event, and therein
considered a possible critical incident, either for the entire
sample or for each public safety personnel category. Across the
entire sample, the potentially traumatic events most commonly
identified as the worst event were sudden violent death (28.0%),
followed by sudden accidental death (14.0%), and serious trans-
portation accident (13.9%). Across public safety personnel cat-
egories the percentages for each of three events most commonly
identified as worst were generally comparable, except for cor-
rectional workers. Correctional workers most commonly iden-
tified sudden violent death as the worst event, but appeared to
more commonly identify a physical assault as the worst event
relative to other public safety personnel categories and to less
commonly identify a serious transportation accident or a sudden
accidental death as the worst event. Despite the general com-
parability, there were important differences in other areas that
may also warrant careful consideration. For example, firefight-
ers appeared to more commonly to identify a fire, an explosion,
or a serious transportation accident as the worst event relative
to some other public safety personnel categories, followed by
sudden accidental death, but less commonly identified physical
assault, assault with a weapon, or sexual assault as the worst
event. Municipal/provincial police and RCMP more commonly
identified a sudden violent death as the worst event relative to
other public safety personnel categories, whereas firefighters
and paramedics more commonly identified a sudden accidental
death as the worst event relative to other public safety personnel
categories. Indeed, a sudden violent death was reported as the
worst event for all groups except firefighters. The patterns of
differences may be driven primarily by work-related duties, but
other factors such as perceived responsibility and available
support may also be critical determinants.
Potentially Traumatic Events and Positive Screens for
Mental Disorders
The relationships between potentially traumatic events and pos-
itive screens for mental disorders are presented in Table 4. All of
the models were adjusted for sociodemographic covariates as well
as public safety personnel category to facilitate reliable compari-
sons. Most exposures to potentially traumatic events were associ-
ated with significantly increased odds of screening positive for
several mental disorders. There was substantial diversity across the
results; nevertheless, there were several fairly consistent patterns.
Positive screening for PTSD was significantly associated with all
types of trauma except for serious transportation accidents and
sudden accidental death (significant Adjusted Odds Ratios [AORs]
ranged from 1.23 for natural disaster to 2.51 for severe human
suffering). Positive screening for depression was significantly as-
sociated with all types of trauma except for fire or explosion
(significant AORs ranged from 1.19 for serious injury, harm, or
death they caused to someone else to 2.01 for severe human
suffering). Positive screening for generalised anxiety disorder was
significantly associated with all types of trauma except captivity,
life threatening illness or injury, and serious injury, harm, or death
they caused to someone else (significant AOR ranged 1.27 for
natural disaster to 2.07 for severe human suffering). Positive
screening for panic disorder was significantly associated with all
types of trauma except for serious transportation accident, life
threatening illness or injury, and sudden violent death (significant
AOR ranged 1.29 for captivity to 2.77 for severe human suffering).
There were also several dose-response relationships such that the
odds of screening positive for PTSD (AORs 1.10, 95% confidence
interval, CI [1.09, 1.16], p.001), depression (AOR 1.10, 95% CI
[1.07, 1.13], p.001), generalised anxiety disorder (AOR 1.08,
95% CI [1.05, 1.11], p.001), and panic disorder (AOR 1.16,
95% CI [1.10, 1.21], p.001) all increased as the total number of
exposures to different types of potentially traumatic events in-
creased.
The associations between potentially traumatic events and
screening positive for social anxiety disorder appeared more vari-
able. Screening positive for social anxiety disorder was only sig-
nificantly associated with exposure to a toxic substance (AOR
1.29, 95% CI [1.05, 1.59], p.05), physical assault (AOR 1.43,
95% CI [1.01, 2.03], p.05), sexual assault (AOR 1.26, 95%
CI [1.02, 1.56], p.05), other unwanted or uncomfortable sexual
experience (AOR 1.33, 95% CI [1.08, 1.63], p.01), captivity
(AOR 1.22, 95% CI [1.002, 1.47], p.05), and severe human
suffering (AOR 1.52, 95% CI [1.20, 1.94], p.001). Despite
several nonsignificant relationships, there was nonetheless a dose-
response relationship such that the odds of screening positive for
social anxiety disorder increased as the total number of exposures
to different types of potentially traumatic events increased (AOR
1.04, 95% CI [1.01, 1.07], p.05).
The associations between potentially traumatic events and
screening positive for an alcohol use disorder also appeared more
variable. Screening positive for an alcohol use disorder was only
significantly associated with exposure to physical assault (AOR
2.10, 95% CI [1.19, 3.17], p.05) and sudden violent death
(AOR 3.39, 95% CI [1.36, 8.43], p.01). In contrast, screening
positive for an alcohol use disorder was significantly inversely
associated with combat exposure (AOR 0.61, 95% CI [0.41,
43
TRAUMATIC EXPOSURES AMONG PUBLIC SAFETY PERSONNEL
Table 2
Prevalence of Potentially Traumatic Exposures Among Canadian Public Safety Personnel Categories
Type of exposure
Total
Municipal/provincial
police RCMP
Correctional
workers Firefighters Paramedics
Call centre operators/
dispatchers
%(n)%(n)%(n)%(n)%(n)%(n)%(n)
Life threatening natural disaster
1 to 5 times 91.7 (2,376) 96.7 (590) 93.5 (700) 94.0 (236) 80.4 (360) 93.2 (369) 88.3 (121)
6 to 10 times 3.5 (90) 2.1 (13) 3.7 (28)
1
6.5 (29) 2.8 (11) 3.7 (5)
11 or more times 4.8 (125) 1.2 (7) 2.8 (21) 4.4 (11) 13.2 (59) 4.0 (16) 8.0 (11)
Fire or explosion
1 to 5 times 50.4 (1,805) 62.7 (584) 59.8 (596) 82.7 (253) 7.4 (50) 50.8 (257) 39.2 (65)
6 to 10 times 10.1 (361) 13.4 (125) 12.8 (127) 4.6 (14) 3.7 (25) 11.1 (56) 8.4 (14)
11 or more times 39.6 (1,419) 23.9 (222) 27.5 (273) 12.8 (39) 89.0 (605) 38.1 (193) 52.4 (87)
Serious transportation accident
1 to 5 times 22.7 (907) 18.6 (194) 19.4 (216) 85.8 (331) 7.7 (53) 12.8 (74) 21.2 (39)
6 to 10 times 6.0 (241) 8.1 (84) 7.1 (79) 6.5 (25) 3.5 (24) 4.2 (24) 2.7 (5)
11 or more times 71.3 (2,845) 73.4 (766) 73.5 (818) 7.8 (30) 88.8 (611) 83.0 (480) 76.1 (140)
Serious accident at work, home,
or during recreational
activity
1 to 5 times 66.6 (2,091) 69.2 (553) 74.3 (602) 83.1 (310) 60.9 (332) 47.5 (228) 49.6 (66)
6 to 10 times 6.5 (205) 8.0 (64) 6.1 (49) 4.8 (18) 7.7 (42) 5.2 (25) 5.3 (7)
11 or more times 26.9 (844) 22.8 (182) 19.6 (159) 12.1 (45) 31.4 (171) 47.3 (227) 45.1 (60)
Exposure to toxic substance
1 to 5 times 61.3 (1,439) 75.5 (407) 63.8 (398) 72.6 (146) 34.3 (191) 71.6 (247) 61.0 (50)
6 to 10 times 7.4 (174) 6.7 (36) 7.5 (47) 4.5 (9) 8.4 (47) 8.1 (28) 8.5 (7)
11 or more times 31.3 (735) 17.8 (96) 28.7 (179) 22.9 (46) 57.3 (319) 20.3 (70) 30.5 (25)
Physical assault
1 to 5 times 41.8 (1,543) 36.5 (377) 36.3 (397) 53.9 (243) 60.8 (262) 44.3 (236) 18.7 (28)
6 to 10 times 9.5 (350) 11.4 (118) 8.8 (96) 8.9 (40) 8.4 (36) 10.3 (55) 3.3 (5)
11 or more times 48.7 (1,797) 52.0 (537) 54.9 (600) 37.3 (168) 30.9 (133) 45.4 (242) 78.0 (117)
Assault with a weapon
1 to 5 times 57.6 (1,797) 57.7 (519) 54.7 (531) 64.8 (228) 69.2 (225) 60.6 (252) 26.9 (42)
6 to 10 times 9.4 (294) 9.0 (81) 10.4 (101) 5.7 (20) 8.0 (26) 12.5 (52) 9.0 (14)
11 or more times 32.9 (1,027) 33.3 (299) 34.9 (338) 29.6 (104) 22.8 (74) 26.9 (112) 64.1 (100)
Sexual assault
1 to 5 times 47.1 (1,089) 38.6 (253) 34.0 (248) 73.1 (187) 75.7 (140) 61.2 (208) 36.3 (53)
6 to 10 times 11.0 (255) 12.2 (80) 11.2 (82) 3.1 (8) 11.9 (22) 14.1 (48) 10.3 (15)
11 or more times 41.9 (968) 49.2 (322) 54.8 (400) 23.8 (61) 12.4 (23) 24.7 (84) 53.4 (78)
Other unwanted or
uncomfortable sexual
experience
1 to 5 times 55.2 (1,225) 52.0 (314) 50.1 (335) 64.3 (198) 76.8 (129) 61.8 (205) 31.4 (44)
6 to 10 times 7.7 (171) 8.3 (50) 6.1 (41) 4.9 (15) 5.4 (9) 11.1 (37) 13.6 (19)
11 or more times 37.2 (825) 39.7 (240) 43.8 (293) 30.8 (95) 17.9 (30) 27.1 (90) 55.0 (77)
Combat
1 to 5 times 78.4 (349) 74.4 (99) 78.3 (94) 82.1 (55) 73.2 (30) 83.6 (61) 90.9 (10)
6 times or more 21.6 (96) 25.6 (34) 21.7 (26) 17.9 (12) 26.8 (11) 16.4 (12)
1
Captivity
1 to 5 times 78.9 (712) 74.6 (209) 77.2 (237) 82.2 (120) 96.6 (28) 92.4 (61) 76.0 (57)
6 times or more 21.2 (191) 25.4 (71) 22.8 (70) 17.8 (26)
1
7.6 (5) 24.0 (18)
Life threatening illness or injury
1 to 5 times 54.2 (1,594) 57.9 (424) 60.8 (465) 79.0 (300) 48.7 (219) 27.9 (126) 36.6 (60)
6 to 10 times 6.3 (184) 8.2 (60) 7.2 (55) 6.3 (24) 4.4 (20) 3.3 (15) 6.1 (10)
11 or more times 39.6 (1,165) 33.9 (248) 32.0 (245) 14.7 (56) 46.9 (211) 68.8 (311) 57.3 (94)
Severe human suffering
1 to 5 times 41.8 (1,187) 44.6 (332) 49.1 (372) 55.6 (163) 31.6 (149) 27.8 (128) 38.7 (43)
6 to 10 times 6.2 (177) 6.6 (49) 7.4 (56) 3.8 (11) 6.6 (31) 4.8 (22) 7.2 (8)
11 or more times 51.9 (1,473) 48.8 (363) 43.5 (329) 40.6 (119) 61.9 (292) 67.4 (310) 54.1 (60)
Sudden violent death
1 to 5 times 36.4 (1,426) 25.6 (268) 30.8 (337) 75.3 (323) 40.4 (249) 33.4 (183) 36.1 (66)
6 to 10 times 13.1 (512) 13.3 (139) 12.6 (138) 10.0 (43) 16.9 (104) 13.5 (74) 7.7 (14)
11 or more times 50.5 (1,977) 61.1 (639) 56.5 (618) 14.7 (63) 42.7 (263) 53.1 (291) 56.3 (103)
Sudden accidental death
1 to 5 times 34.6 (1,321) 31.2 (316) 29.7 (319) 86.0 (319) 27.0 (171) 26.8 (149) 27.3 (47)
6 to 10 times 10.7 (408) 13.4 (136) 10.6 (114) 5.7 (21) 12.2 (77) 8.4 (47) 7.6 (13)
11 or more times 54.8 (2,092) 55.4 (561) 59.7 (642) 8.4 (31) 60.8 (385) 64.8 (361) 65.1 (112)
44 CARLETON ET AL.
0.91], p.05), which may be related to evidence that military
may report lower past-year prevalence of alcohol use disorders
than civilians (e.g., Waller, McGuire, & Dobson, 2015). There was
no significant dose-response relationship between screening posi-
tive for an alcohol use disorder and the total number of exposures.
Population Attributable Fractions
The relationships between population attributable fractions for
types of trauma exposures and positive screenings for mental
disorders are presented in Table 5. There are many assumptions
that need to be considered when interpreting a population attrib-
utable fraction. These assumptions include: (a) a causal relation-
ship between an exposure and outcome, which cannot be assessed
with cross-sectional data; and (b) population attributable fractions
are influenced by the prevalence of exposure in the population
such that higher prevalence produces a higher population attribut-
able fraction. For the current results, the population attributable
fraction nonetheless provides an initial estimate of the proportion
of an outcome (i.e., a positive screen for a mental disorder) that
might be reduced if the exposure (i.e., the specific traumatic event)
never occurred. Doing so allows for theoretically relative compar-
isons of the relationship between each type of trauma and each
type of exposure. The population attributable fractions were only
calculated where there was a significant association between a
positive screening for the mental disorder and exposure to the
specific type of trauma (see Table 4).
The results suggest that eliminating all trauma exposures in
this population might produce estimated reductions in positive
screens for PTSD of 68.0%, depression of 56.8%, generalised
anxiety disorder of 51.1%, panic disorder of 79.5%, and social
anxiety disorder of 29.1% (see Table 5). There were several
specific potentially traumatic events that, if eliminated, would
have produced reductions in positive screenings. For example,
if we eliminated exposure to severe human suffering in this
population, we might see estimated reductions in positive
screens for PTSD of 45.6%, for generalised anxiety disorder of
Table 2 (continued)
Type of exposure
Total
Municipal/provincial
police RCMP
Correctional
workers Firefighters Paramedics
Call centre operators/
dispatchers
%(n)%(n)%(n)%(n)%(n)%(n)%(n)
Serious injury, harm, or death
you caused to someone
else
1 to 5 times 64.4 (580) 67.1 (230) 65.5 (201) 74.1 (60) 51.6 (33) 56.2 (50) 35.3 (6)
6 to 10 times 6.8 (61) 6.7 (23) 7.5 (23) 8.6 (7) 1.6 (1) 5.6 (5)
a
11 or more times 28.9 (260) 26.2 (90) 27.0 (83) 17.3 (14) 46.9 (30) 38.2 (34) 52.9 (9)
Note. RCMP Royal Canadian Mounted Police.
a
Not presented because of insufficient sample size (i.e., n5).
Table 3
Prevalence of Worst Potentially Traumatic Exposures Across Canadian Public Safety Personnel Categories
Type of worst exposure
Total
Municipal/provincial
police RCMP
Correctional
workers Firefighters Paramedics
Call centre operators/
dispatchers
%(n)%(n)%(n)%(n)%(n)%(n)%(n)
Life threatening natural disaster 2.0 (77) 1.0 (10) 1.4 (15) 1.5 (7) 2.7 (17) 3.5 (19) 4.9 (9)
Fire or explosion 3.2 (123) 2.2 (22) 2.5 (26)
a
8.0 (51) 3.0 (16) 3.2 (6)
Serious transportation accident 13.9 (540) 12.9 (128) 14.4 (151) 5.9 (28) 22.2 (141) 13.6 (73) 10.3 (19)
Serious accident at work, home,
or during recreational activity 3.4 (130) 2.5 (25) 2.5 (26) 4.6 (22) 4.6 (29) 3.7 (20) 4.3 (8)
Exposure to toxic substance .5 (18)
a
a
1.1 (5)
a
a
a
Physical assault 4.9 (190) 3.9 (39) 5.1 (53) 13.0 (62) 1.3 (8) 3.4 (18) 5.4 (10)
Assault with a weapon 6.3 (245) 8.4 (84) 8.8 (92) 8.4 (40) 1.3 (8) 2.6 (14) 3.8 (7)
Sexual assault 5.1 (196) 5.2 (52) 4.9 (51) 8.2 (39) 1.3 (8) 5.2 (28) 9.7 (18)
Other unwanted or uncomfortable
sexual experience 1.4 (53) .9 (9) .9 (9) 3.4 (16)
a
2.6 (14)
a
Combat 1.1 (43) 1.6 (16) 1.0 (10) 1.7 (8) .9 (6)
a
a
Captivity .6 (25) .7 (7) .7 (7) 1.9 (9)
a
a
a
Life threatening illness or injury 6.6 (255) 6.0 (60) 5.5 (58) 12.0 (57) 4.7 (30) 6.1 (33) 9.2 (17)
Severe human suffering 7.0 (272) 6.9 (69) 4.3 (45) 6.9 (33) 8.7 (55) 11.5 (62) 4.3 (8)
Sudden violent death 28.0 (1,086) 32.6 (324) 32.9 (344) 24.0 (114) 21.7 (138) 21.4 (115) 27.6 (51)
Sudden accidental death 14.0 (542) 11.5 (114) 12.3 (129) 6.3 (30) 20.4 (130) 20.5 (110) 15.7 (29)
Serious injury, harm, or death
you caused to someone else 2.1 (81) 3.2 (32) 2.7 (28) .8 (4) .9 (6) 1.9 (10)
a
Note. RCMP Royal Canadian Mounted Police.
a
Not presented because of insufficient sample size (i.e., n5).
45
TRAUMATIC EXPOSURES AMONG PUBLIC SAFETY PERSONNEL
Table 4
Relationship Between Trauma Exposures and Positive Screens for Mental Disorders Among Canadian Public Safety Personnel
Type of exposure
PTSD Depression
Generalized
anxiety disorder
Social anxiety
disorder Panic disorder
Alcohol use
disorder
Any mental
disorder
AOR [95% CI] AOR [95% CI] AOR [95% CI] AOR [95% CI] AOR [95% CI] AOR [95% CI] AOR [95% CI]
Total sample
Life threatening natural disaster 1.23
[1.04, 1.46] 1.32
ⴱⴱⴱ
[1.12, 1.55] 1.27
ⴱⴱ
[1.06, 1.53] 1.00 [.82, 1.21] 1.54
ⴱⴱⴱ
[1.18, 2.00] .91 [.68, 1.21] 1.15 [.99, 1.33]
Fire or explosion 1.37
ⴱⴱ
[1.08, 1.74] 1.24 [.996, 1.55] 1.38
[1.07, 1.77] .85 [.66, 1.10] 1.92
ⴱⴱⴱ
[1.30, 2.82] 1.17 [.76, 1.79] 1.07 [.87, 1.31]
Serious transportation accident 1.30 [.93, 1.81] 1.46
[1.07, 2.01] 1.49
[1.05, 2.13] .92 [.65, 1.30] 1.24 [.77, 1.99] 1.37 [.75, 2.52] 1.21 [.91, 1.63]
Serious accident at work, home, or
during recreational activity 1.65
ⴱⴱⴱ
[1.32, 2.07] 1.62
ⴱⴱⴱ
[1.32, 2.00] 1.49
ⴱⴱⴱ
[1.18, 1.88] 1.16 [.91, 1.47] 1.56
ⴱⴱ
[1.11, 2.18] 1.26 [.86, 1.84] 1.59
ⴱⴱⴱ
[1.32, 1.91]
Exposure to toxic substance 2.12
ⴱⴱⴱ
[1.75, 2.57] 1.62
ⴱⴱⴱ
[1.36, 1.93] 1.44
ⴱⴱⴱ
[1.19, 1.75] 1.29
[1.05, 1.59] 1.88
ⴱⴱⴱ
[1.41, 2.50] .98 [.71, 1.35] 1.49
ⴱⴱⴱ
[1.27, 1.76]
Physical assault 1.74
ⴱⴱⴱ
[1.24, 2.43] 1.95
ⴱⴱⴱ
[1.44, 2.64] 1.55
[1.11, 2.18] 1.43
[1.01, 2.03] 2.19
ⴱⴱ
[1.24, 3.85] 2.10
[1.19, 3.71] 1.65
ⴱⴱⴱ
[1.28, 2.13]
Assault with a weapon 1.65
ⴱⴱⴱ
[1.28, 2.12] 1.75
ⴱⴱⴱ
[1.39, 2.20] 1.48
ⴱⴱ
[1.14, 1.91] 1.08 [.83, 1.39] 1.64
[1.12, 2.39] 1.30 [.88, 1.93] 1.36
ⴱⴱ
[1.12, 1.66]
Sexual assault 1.50
ⴱⴱⴱ
[1.24, 1.81] 1.46
ⴱⴱⴱ
[1.23, 1.74] 1.41
ⴱⴱⴱ
[1.15, 1.72] 1.26
[1.02, 1.56] 1.66
ⴱⴱⴱ
[1.24, 2.23] 1.28 [.93, 1.75] 1.44
ⴱⴱⴱ
[1.23, 1.70]
Other unwanted or uncomfortable
sexual experience 1.50
ⴱⴱⴱ
[1.25, 1.80] 1.58
ⴱⴱⴱ
[1.33, 1.87] 1.49
ⴱⴱⴱ
[1.23, 1.82] 1.33
ⴱⴱ
[1.08, 1.63] 1.74
ⴱⴱⴱ
[1.30, 2.32] 1.34 [.99, 1.82] 1.51
ⴱⴱⴱ
[1.29, 1.77]
Combat 1.43
ⴱⴱⴱ
[1.18, 1.73] 1.34
ⴱⴱ
[1.12, 1.61] 1.31
ⴱⴱ
[1.07, 1.61] 1.09 [.87, 1.36] 1.51
ⴱⴱ
[1.15, 1.98] .61
[.41, .91] 1.24
[1.04, 1.49]
Captivity 1.32
ⴱⴱⴱ
[1.12, 1.56] 1.36
ⴱⴱⴱ
[1.16, 1.60] 1.19 [.99, 1.42] 1.22
[1.002, 1.47] 1.29
[1.01, 1.65] 1.05 [.77, 1.42] 1.31
ⴱⴱⴱ
[1.12, 1.53]
Life threatening illness or injury 1.43
ⴱⴱⴱ
[1.17, 1.73] 1.35
ⴱⴱⴱ
[1.13, 1.62] 1.13 [.93, 1.38] 1.21 [.97, 1.50] 1.33 [.99, 1.77] 1.25 [.90, 1.73] 1.21
[1.03, 1.43]
Severe human suffering 2.51
ⴱⴱⴱ
[1.99, 3.18] 2.01
ⴱⴱⴱ
[1.63, 2.47] 2.07
ⴱⴱⴱ
[1.63, 2.64] 1.52
ⴱⴱⴱ
[1.20, 1.94] 2.77
ⴱⴱⴱ
[1.88, 4.08] 1.30 [.90, 1.87] 1.77
ⴱⴱⴱ
[1.48, 2.12]
Sudden violent death 1.99
ⴱⴱⴱ
[1.30, 3.05] 1.83
ⴱⴱⴱ
[1.27, 2.64] 1.63
[1.09, 2.43] 1.26 [.85, 1.88] 1.78 [.96, 3.29] 3.39
ⴱⴱ
[1.36, 8.43] 1.46
[1.07, 2.00]
Sudden accidental death 1.28 [.90, 1.82] 1.63
ⴱⴱ
[1.16, 2.29] 1.60
[1.10, 2.35] 1.09 [.75, 1.58] 1.89
[1.06, 3.37] 1.44 [.76, 2.74] 1.12 [.83, 1.53]
Serious injury, harm, or death you
caused to someone else 1.39
ⴱⴱⴱ
[1.18, 1.64] 1.19
[1.01, 1.39] 1.14 [.95, 1.36] 1.02 [.84, 1.24] 1.34
[1.05, 1.71] 1.16 [.87, 1.55] 1.15 [.99, 1.33]
Total number of different types of
potentially traumatic exposures 1.13
ⴱⴱⴱ
[1.09, 1.16] 1.10
ⴱⴱⴱ
[1.07, 1.13] 1.08
ⴱⴱⴱ
[1.05, 1.11] 1.04
[1.01, 1.07] 1.16
ⴱⴱⴱ
[1.10, 1.21] 1.05 [.997, 1.10] 1.07
ⴱⴱⴱ
[1.05, 1.10]
Notes. AOR odds ratio adjusted for sex, age, marital status, race/ethnicity, education, urban/rural work location, province of residence, total years of service, and public safety officer category;
PTSD posttraumatic stress disorder; CI confidence interval.
p.05.
ⴱⴱ
p.01.
ⴱⴱⴱ
p.001.
46 CARLETON ET AL.
Table 5
Population Attributable Fractions (PAF) for Types of Trauma Exposures on Positive Screens for Mental Disorders Among Canadian Public Safety Personnel
Type of exposure
PTSD Depression
Generalized
anxiety disorder
Social anxiety
disorder Panic disorder
Alcohol use
disorder
Any mental
disorder
PAF % [95% CI] PAF % [95% CI] PAF % [95% CI] PAF % [95% CI] PAF % [95% CI] PAF % [95% CI] PAF % [95% CI]
Total sample
Life threatening natural disaster 9.96 [1.63, 17.59] 12.73 [5.17, 19.68] 12.32 [2.83, 20.88] 23.38 [8.93, 35.54]
Fire or explosion 18.53 [4.28, 30.66] 19.98 [3.93, 33.34] 39.84 [17.41, 56.17]
Serious transportation accident 23.11 [3.35, 38.83] 26.30 [2.40, 44.35]
Serious accident at work, home, or
during recreational activity 27.66 [15.75, 37.89] 25.89 [15.04, 35.36] 23.60 [9.79, 35.29] 28.32 [6.82, 44.86] 19.78 [11.69, 27.13]
Exposure to toxic substance 33.32 [25.25, 40.51] 21.56 [13.75, 28.67] 18.00 [8.39, 26.60] 13.32 [2.30, 23.09] 32.60 [18.24, 44.44] 14.12 [8.34, 19.53]
Physical assault 33.09 [13.21, 48.41] 37.45 [21.32, 50.28] 28.60 [6.47, 45.49] 24.33 [.00, 42.92]
a
48.79 [15.16, 69.08] 47.28 [12.03, 68.41] 23.48 [11.12, 34.11]
Assault with a weapon 28.54 [14.45, 40.31] 30.35 [18.36, 40.58] 24.06 [8.18, 37.19] 32.02 [7.49, 50.05] 13.75 [4.60, 22.03]
Sexual assault 20.69 [11.14, 29.21] 18.50 [9.93, 26.25] 18.86 [7.70, 28.67] 13.40 [.79, 24.40] 29.53 [12.60, 43.18] 13.98 [7.73, 19.81]
Other unwanted or uncomfortable
sexual experience 19.72 [10.82, 27.72] 20.93 [13.05, 28.11] 20.85 [10.62, 29.91] 15.45 [3.81, 25.68] 30.66 [14.95, 43.47] 14.78 [9.03, 20.17]
Combat 5.31 [2.33, 8.19] 4.02 [1.41, 6.57] 4.27 [.89, 7.54] 7.36 [1.93, 12.50] 2.15 [.37, 3.90]
Captivity 6.74 [2.51, 10.80] 6.97 [3.22, 10.58] 5.13 [.00, 10.15]
a
7.32 [.00, 14.34]
a
4.45 [1.87, 6.97]
Life threatening illness or injury 19.10 [8.64, 28.36] 15.83 [6.40, 24.32] 7.84 [.86, 14.33]
Severe human suffering 45.63 [35.32, 54.30] 34.84 [25.09, 43.32] 39.18 [27.28, 49.14] 24.84 [10.74, 36.72] 54.55 [37.00, 67.21] 23.34 [15.90, 30.13]
Sudden violent death 40.62 [16.28, 57.88] 35.24 [14.02, 51.22] 31.76 [5.15, 50.91] 67.29 [22.16, 86.25] 18.59 [2.36, 32.13]
Sudden accidental death 29.02 [8.72, 44.80] 30.72 [5.70, 49.11] 41.90 [3.08, 65.16]
Serious injury, harm, or death you
caused to someone else 9.11 [4.37, 13.62] 4.44 [.23, 8.47] 9.49 [1.11, 17.15]
Total number of different types of
potentially traumatic exposures 68.02 [55.80, 76.86] 56.77 [43.24, 67.07] 51.11 [33.26, 64.19] 29.06 [3.66, 47.76] 79.46 [64.73, 88.04] 39.31 [26.14, 50.13]
Note. PTSD posttraumatic stress disorder; CI confidence interval. Population attributable fractions (PAFs) were based on estimates derived from multivariate logistic regression models that
adjusted for sex, age, marital status, race/ethnicity, education, urban/rural work location, province of residence, total years of service, and public safety officer category.
a
Borderline statistical significance. Em dash (—) population attributable fractions not computed because of nonsignificant adjusted odds ratio.
47
TRAUMATIC EXPOSURES AMONG PUBLIC SAFETY PERSONNEL
39.2%, for panic disorder of 54.6%, and for social anxiety
disorder of 24.8%. Similarly, if we eliminated exposure to
physical assault in this population, we might see estimated
reductions in positive screens for depression of 37.5% and for
alcohol use disorder of 67.3%. If we eliminated exposures to
toxic substances in this population, we might see estimated
reductions in positive screens for social anxiety disorder of
13.3% and alcohol use disorder (67.3%).
Discussion
The current research provides novel results that can inform a
better understanding of exposure patterns for potentially traumatic
events among diverse Canadian public safety personnel, help iden-
tify which exposures are potentially critical incidents, and assess
for relationships between exposures to potentially traumatic events
and positive screenings for diverse mental disorders. Most of the
general population report exposure to one or more potentially
traumatic events (i.e., 89.7%; Kilpatrick et al., 2013); however, the
current results indicate substantial proportions of public safety
personnel report a larger number of exposures to many different
potentially traumatic events. Most public safety personnel reported
being exposed to most of the types of trauma listed in the LEC for
DSM–5 (Blevins et al., 2015;Weathers et al., 2013), and at levels
that appear much higher than available estimates from the general
population (Mean 11.08, SD 3.23 vs. Mode 3.3, SD
2.32; Kilpatrick et al., 2013, p. 7). Almost all public safety per-
sonnel (i.e., more than 90%) reported exposures to each of sudden
violent death, sudden accidental death, serious transportation ac-
cident, and physical assault. In contrast, among the general popu-
lation 51.8% report exposure to “death of family/close friend
because of violence/accident/disaster” and 53.1% report exposure
to “physical or sexual assault” (Kilpatrick et al., 2013, p. 18).
Among public safety personnel exposed to a potentially traumatic
event type, the frequencies of exposure ranged from 96.6% expe-
riencing the event fewer than 6 times up to 89% experiencing the
event 11times. Accordingly, the results appear to support the
contention that public safety personnel are exposed to a diversity
of potentially traumatic events more frequently than the general
population (Oliphant, 2016).
There were also significant differences between public safety
personnel categories with respect to frequencies of different expo-
sure types. The differences were generally congruent with what
may be expected for each type of work. For example, firefighters
were more commonly exposed to life threatening natural disasters,
fires or explosions, whereas police were more likely to report
exposures to serious injury, harm, or death they caused to someone
else. Despite the differences, there was also clear overlap in
frequency of exposure to each type of event across public safety
personnel categories. The overlap is also congruent with what may
be expected for public safety personnel work, given that a serious
transportation accident, for example, is likely to involve many
different public safety personnel categories working interactively
to manage the event.
The current results also provide the first information about the
events diverse Canadian public safety personnel identified most
often as the worst, most distressing events, which can inform
decisions regarding designating events as critical incidents. The
potentially traumatic event most commonly identified as the worst
event was sudden violent death, which was identified twice as
often as the next most common events that were sudden accidental
death and serious transportation accident. The results are consis-
tent with previous notions that critical incidents typically involve
death or gruesome injurious incidents (Beaton et al., 1998;Don-
nelly & Bennett, 2014) and suggest such events should be consid-
ered defensible candidates for critical incidents. The identified
events also imply an important role played by uncertainty in
perceiving an exposure as potentially traumatic or critical nature of
events; specifically, the sudden and, therefore, unexpected nature
of the event. Previous research has implicated a critical role for
uncertainty in the experience of mental disorders (Carleton, 2016a,
2016b), particularly PTSD (Banducci, Bujarski, Bonn-Miller,
Patel, & Connolly, 2016;Boelen, Reijntjes, & Smid, 2016;
Fetzner, Horswill, Boelen, & Carleton, 2013;Oglesby, Boffa,
Short, Raines, & Schmidt, 2016). Given the potentially moderating
influence of an event being unexpected, exposures that are infre-
quent or inconsistent with expectations (e.g., a firefighter causing
serious injury, harm, or death to someone else) should be consid-
ered defensible candidates for critical incidents.
Previous research has indicated that potentially traumatic events
involving vulnerable victims may play a critical moderating role in
whether firefighters and paramedics perceive an event as traumatic
or critical (Beaton et al., 1998;Donnelly & Bennett, 2014). Ac-
cordingly, events that are particularly unexpected or that involve
vulnerable populations (e.g., children) should also be considered
defensible candidates for critical incidents. Previous research with
firefighters exposed to children who were harmed supports the
notion that potentially traumatic events involving vulnerable pop-
ulations may be particularly likely candidates for critical incidents
(Katsavouni, Bebetsos, Malliou, & Beneka, 2016;B. K. Richard-
son & James, 2017). There may even be sufficient justification to
further delineate the types of potentially traumatic events assessed
by the LEC (Blevins et al., 2015;Weathers et al., 2013) into adult
and child categories to better understand what might constitute
critical incident and the relationships between exposure and mental
disorders.
There appears to have been a propensity to focus on PTSD as
the hallmark mental disorder related to traumatic exposure (Amer-
ican Psychiatric Association, 2000,2013;Oliphant, 2016). The
current results support such biases in that exposures to almost all
types of potentially traumatic events were associated with signif-
icantly increased odds of positive screening of PTSD; however, the
current results also suggest that most exposures to potentially
traumatic events were associated with significantly increased odds
of screening positive for several different mental disorders, includ-
ing comorbid indicators for PTSD and major depressive disorder
per previous research (Cougle et al., 2009;Najavits & Capezza,
2014;O’Donnell et al., 2004;Stein & Kennedy, 2001). Exposure
to sudden violent death was the event most commonly identified as
the worst and was associated with increased odds of screening
positive for any mental disorder. In contrast, the largest odds ratios
for screening positive for any and all disorders, except alcohol use
disorders, were associated with exposure to severe human suffer-
ing, which was not among the most commonly events identified as
worst or most distressing; nevertheless, such exposures may be
particularly detrimental to the mental health of public safety per-
sonnel and therein defensible as a candidate for critical incidents.
Sudden accidental death and serious transportation accidents were
48 CARLETON ET AL.
also commonly identified as the worst events. Sudden accidental
death was only significantly related to positive screening for
depression, generalised anxiety disorder, and panic disorder. Sim-
ilarly, serious transportation accidents were only significantly re-
lated to depression and generalised anxiety disorder.
The current results also indicate a seemingly robust dose-
response relationship. Specifically, the odds of screening positive
for PTSD, generalised anxiety disorder, panic disorder, and social
anxiety disorder all increased as the total number of exposures to
different types of potentially traumatic events increased. The re-
sults help to inform a previously identified significant relationship
between increasing years of public safety personnel service and
increasing positive screens for one or more mental disorders (Car-
leton, Afifi, Turner, Taillieu, Duranceau, et al., 2018). In other
words, more time spent in service appears to provide more time for
exposure to potentially traumatic events, which appears to increase
risk for screening positive for one or more mental disorders. The
results also support the utility of the recent cumulative trauma
revision to DSM–5 (American Psychiatric Association, 2013;Kil-
patrick et al., 2009).
The population attributable fraction results underscored a sub-
stantive and burdensome relationship between exposure to poten-
tially traumatic events and positive screens for mental disorders.
The results parallel those of previous research assessing the impact
of child abuse on mental disorders and suicide in that the anteced-
ent abuse appears to serve as a potentially critical risk factor (Afifi
et al., 2008,2014;Sareen et al., 2008). Eliminating potentially
traumatic events for public safety personnel is likely impractical;
nevertheless, the population attributable fraction results suggest
doing so may be related to a reduction of positive screenings for
PTSD, depression, generalised anxiety disorder, and panic disorder
by more than half, as well as nearly one third of positive screenings
for social anxiety disorder. The results also implicate exposure to
severe human suffering, physical assault, toxic substances, and
sudden violent death as defensible candidates for critical incidents.
The incomplete association between positive screenings and po-
tentially traumatic events suggests that other variables, such as
other operational stressors (e.g., shift work, working alone), or-
ganisational stressors (e.g., interactions with coworkers and super-
visors), familial stressors (e.g., difficulties caused by public safety
personnel lifestyle), and individual differences (e.g., personality)
may also be extremely important factors involved in public safety
personnel mental health.
Limitations
There are several limitations to the current work that offer
directions for future research. First, the public safety personnel
sample was self-selected rather than being random and stratified,
which means the results may not be broadly representative. Sec-
ond, participants responded to an anonymous survey, which means
potential problems with biased, erroneous, and missing data; fur-
thermore, mental disorders screens are only approximations with-
out diagnostic interviews. Future epidemiological researchers
should consider using interviews for assessments and diagnoses.
Third, the current results assessed frequencies of exposures to the
diverse potentially traumatic events using retrospective recall and
an artificially plateaued exposure at 11times. Future research
should consider using more accurate methods for assessing expo-
sure frequency and allow for no artificial ceiling. Fourth, the
prevalence and impact of other operational, organisational, famil-
ial stressors, and individual difference variables were not assessed,
and may be significant and substantial. Future researchers should
assess the impacts of other stressors and individual difference
variables on public safety personnel mental health. Fifth, the
cross-sectional nature of the data does not allow for potentially
important assessments of risk; for example, traumatic stressors
could precede and increase vulnerability for other operational
stressors, including behaviours requiring performance manage-
ment, or the reverse could be true. In any case, future researchers
should use longitudinal designs to assess for risk factors that can
be targeted and to identify best practices for administering addi-
tional resources or interventions (e.g., critical incident stress de-
briefing).
Summary
Overall, the current results offer the first empirical evidence
using a general population measure (i.e., LEC-5) with a large
sample of diverse Canadian public safety personnel that potentially
traumatic event exposures are heterogenous and frequent among
Canadian public safety personnel. In addition, despite the frequent
focus on PTSD among public safety personnel (Oliphant, 2016),
many different types of potentially traumatic event exposure can
be associated with many different mental disorders. The results
support the growing evidence that traumatic exposures can be
significantly associated with several mental disorders, including
PTSD, but also depression, generalised anxiety disorder, panic
disorder, and social anxiety disorder; accordingly, the results raise
important questions about focusing resources exclusively on PTSD
for public safety personnel. The current results are also the first
empirical evidence of differences in patterns of potentially trau-
matic event exposure among diverse Canadian public safety per-
sonnel. The results suggest a complex interactive pattern between
public safety personnel category, types of exposure, uncertainty,
perceptions of exposure, and mental disorders.
More important, the current results also offer the first empirical
evidence where diverse public safety personnel are assessed using
a general population measure (i.e., LEC-5) to identify events
perceived as worst and therein arguably candidates for being
included as critical incidents (i.e., serious transportation accidents,
sudden violent death, and sudden accidental death); however, the
current results also evidence disparities between perceptions of
specific potentially traumatic events as critical and relationships
between specific potentially traumatic events and mental disorders.
Specifically, serious transportation accidents and sudden acciden-
tal death were not associated with the largest adjusted odds ratios
for any disorder; instead, severe human suffering and physical
assault produced much larger adjusted odds ratios. In short,
whether a specific event constitutes a critical incident and warrants
a specific critical incident intervention may be heavily dependent
on context; that said, exposures to sudden violent death and severe
human suffering both appear to be broadly defensible as particu-
larly problematic for all public safety personnel and their mental
health. There also appears to be sufficient evidence that an event
could be considered a critical incident whenever a public safety
personnel perceives the incident as critical, therein justifying a
specific intervention. As such, identifying a subset of criterion A
49
TRAUMATIC EXPOSURES AMONG PUBLIC SAFETY PERSONNEL
stressors as critical incidents may miss several important stressors
that might otherwise be considered too germane to public safety
personnel work to warrant additional resources. The results high-
light the need for adequate, pervasive, and evidence-based mental
health care treatments and supports to mitigate the negative impact
of repeated exposures to diverse potentially traumatic event expo-
sures on public safety personnel.
Résumé
Le personnel de sécurité publique canadien (p. ex. les travailleurs
des services correctionnels, les répartiteurs, les ambulanciers et les
policiers) sont régulièrement exposés a
`des événements au poten-
tiel traumatique, certains desquels sont présentés comme des évé-
nements critiques justifiant le recours a
`des ressources addition-
nelles. Malheureusement, les données disponibles concernant le
personnel de sécurité publique canadien qui permettraient de
mesurer les associations entre les événements au potentiel trauma-
tique et la santé mentale se font encore rares. La recherche actuelle
quantifie les estimations liées a
`l’exposition a
`divers incidents
parmi plusieurs catégories de personnel de sécurité publique. Au
total, 4 441 membres du personnel de sécurité publique (dont 31,7
% de femmes) de six catégories différentes (répartiteurs, travail-
leurs des services correctionnels, pompiers, policiers municipaux/
provinciaux, ambulanciers et agents de la Gendarmerie royale
canadienne) ont pris part a
`l’étude. Parmi les événements rapportés
par les participants, notons des morts violentes subites (93,8 %) ou
accidentelles (93,7 %), des accidents de la route graves (93,2 %) et
des agressions physiques (90,6 %). Souvent, les participants
s’étaient retrouvés confrontés 11 fois ou plus a
`de tels événements.
Des relations déterminantes ont été observées entre l’exposition a
`
des événements traumatisants et l’ensemble des troubles mentaux.
Les morts violentes subites et la souffrance humaine aiguë sem-
blaient particulièrement reliées aux symptômes de trouble mental.
Il était donc justifié de les considérer comme des incidents cri-
tiques. Les résultats actuels permettent d’entrée de jeu de conclure
que (a) les expositions a
`des événements au potentiel traumatique
sont diversifiées et fréquentes parmi l’ensemble du personnel de
sécurité publique; (b) de nombreux types d’expositions peuvent
être associés a
`divers troubles de santé mentale, notamment le
trouble de stress post-traumatique, et les tests de dépistage de
troubles mentaux seraient considérablement réduits en l’absence
d’exposition; et (d) les fractions étiologiques du risque indiquaient
une réduction substantielle des résultats positifs aux tests de
dépistage de troubles mentaux (soit entre 29,0 % et 79,5 %) si
toutes les expositions a
`des événements traumatisants étaient
éliminées chez le personnel de sécurité publique canadien.
Mots-clés : traumatisme, incidents critiques, personnel de sécurité
publique, troubles de santé mentale, blessures de stress
opérationnel.
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52 CARLETON ET AL.
... C&P PSP have duty-specific responsibilities related to law enforcement and the protection of species at risk, fish habitats, and oceans, carry out a wide range of duties, that female PSP may report more mental health disorder symptoms than their male counterparts [7], based on several mediating environmental variables [18,19]; accordingly, we hypothesized that the females would report more mental health disorder symptoms than the males in the current study. Based on previous research, the participants with previous PSP or military experience [20] were expected to report more mental health disorder symptoms than those with no previous work experience, as a function of their previous vocational requirements and more frequent exposures to PPTEs [4,21]. ...
... The study was approved by the University of Regina Institutional Research Ethics Board (REB# 2021-003). The survey was based on a set of validated measures used in a previous study of PSP [4,6,7,16], and by the Public Health Agency of Canada [15,22], but collaboratively redesigned by the research team and the CCG and DFO team to ensure relevant variables were included. The survey was promoted and distributed by the CCG and DFO to member unions via emails, social media posts, and a video encouraging participation. ...
... The prevalence of positive screens for one or more mental health disorders among CCG and C&P PSP (42.0%) is much higher than the prevalence of diagnosed mental health disorders in the general population (10.1%) [40]. The current results indicate that CCG and C&P PSP are facing mental health challenges more than the general public, implying that the observed mental health challenges among CCG and C&P PSP may likely result from their cumulative service experiences which includes more frequent exposure to PPTEs [4] and occupational stressors [46] during their work. The prevalence of positive screens for one or more mental health disorders among CCG and C&P PSP was also comparable to the prevalence among other Canadian PSP (44.5%) [7]. ...
Article
Full-text available
Canadian public safety personnel (PSP) screen positive for one or more mental health disorders, based on self-reported symptoms, at a prevalence much greater (i.e., 44.5%) than the diagnostic prevalence for the general public (10.1%). Potentially psychologically traumatic event (PPTE) exposures and occupational stressors increase the risks of developing symptoms of mental health disorders. The current study was designed to estimate the mental health disorder symptoms among Canadian Coast Guard (CCG) and Conservation and Protection (C&P) Officers. The participants (n = 412; 56.1% male, 37.4% female) completed an online survey assessing their current mental health disorder symptoms using screening measures and sociodemographic information. The participants screened positive for one or more current mental health disorders (42.0%; e.g., post-traumatic stress disorder, major depressive disorder, generalized anxiety disorder, social anxiety disorder, panic disorder, alcohol use disorder) more frequently than in the general population diagnostic prevalence (10.1%; p < 0.001). The current results provide the first information describing the prevalence of current mental health disorder symptoms and subsequent positive screenings of CCG and C&P Officers. The results evidence a higher prevalence of positive screenings for mental health disorders than in the general population, and differences among the disorder-screening prevalence relative to other Canadian PSP. The current results provide insightful information into the mental health challenges facing CCG and C&P PSP and inform efforts to mitigate and manage PTSI among PSP. Ongoing efforts are needed to protect CCG and C&P Officers’ mental health by mitigating the impacts of risk factors and operational and organizational stressors through interventions and training, thus reducing the prevalence of occupational stress injuries.
... The CCG include PSP with duty-specific responsibilities that involve search and rescue operations within four regions: (1) Atlantic; (2) Central; (3) Arctic; and (4) Western regions. The CCG responds to about Previous research with PSP evidenced a specific subset of PPTE as being consistently the "worst" and most likely to be associated with mental health disorders, suggesting additional resources need to be available at the discretion of individual PSP [4]. No such assessments have been made regarding CCG and C&P experiences. ...
... The current study was designed to: (1) assess the history and prevalence of PPTE exposures among CCG and C&P members; (2) clarify the PPTEs perceived by CCG and C&P members as the worst events; (3) assess relationships between lifetime PPTE exposures and positive screening for diverse mental health disorders; and (4) compare PPTE exposure experiences across demographic categories. PPTE exposure frequencies for CCG and C&P members were expected to be higher than the general population, evidenced across previous PSP research [4]. Furthermore, per prior PSP research [4,13,14], PPTE exposures were expected to be associated with positive screens for mental health disorders. ...
... PPTE exposure frequencies for CCG and C&P members were expected to be higher than the general population, evidenced across previous PSP research [4]. Furthermore, per prior PSP research [4,13,14], PPTE exposures were expected to be associated with positive screens for mental health disorders. ...
Article
Full-text available
Canadian Public Safety Personnel (PSP) (i.e., municipal/provincial police, firefighters, paramedics, Royal Canadian Mounted Police, correctional workers, dispatchers) report frequent and varied exposures to potentially psychologically traumatic events (PPTEs). Exposure to PPTEs may be one explanation for the symptoms of mental health disorders prevalent among PSP. The objective of the current study was to provide estimates of lifetime PPTE exposures among Canadian Coast Guard (CCG) and Conservation and Protection (C&P) Officers and to assess for associations between PPTEs, mental health disorders, and sociodemographic variables. Participants (n = 412; 55.3% male, 37.4% female) completed an online survey assessing self-reported PPTE exposures and self-reported symptoms of mental health disorders. Participants reported higher frequencies of lifetime exposures to PPTEs than the general population (all ps < 0.001) but lower frequencies than other Canadian PSP (p < 0.5). Several PPTE types were associated with increased odds of positive screens for posttraumatic stress disorder, major depressive disorder, general anxiety disorder, social anxiety disorder, panic disorder, and alcohol use disorder (all ps < 0.05). Experiencing a serious transportation accident (77.4%), a serious accident at work, home, or during recreational activity (69.7%), and physical assault (69.4%) were among the PPTEs most frequently reported by participants. The current results provide the first known information describing PPTE exposures of CCG and C&P members, supporting the growing evidence that PPTEs are more frequent and varied among PSP and can be associated with diverse mental health disorders.
... PSP [1] include diverse professionals (e.g., border services personnel, correctional workers, fire Marshall investigators, coroners, firefighters, operational and intelligence personnel, paramedics, police, public safety communicators, search and rescue personnel). PPTEs can cause psychological trauma that may be consistent with one or more posttraumatic stress injuries (PTSIs), including but not limited to posttraumatic stress disorder (PTSD), major depressive disorder (MDD), panic disorder, and generalized anxiety disorder (GAD) [1][2][3]. The phrase "psychologically traumatic event" is often preceded by the word "potentially" to underscore the importance of dynamic individual and environmental contextual factors that influence whether an event was, or is perceived as, psychologically traumatic for any given individual at any given time [1][2][3]. ...
... PPTEs can cause psychological trauma that may be consistent with one or more posttraumatic stress injuries (PTSIs), including but not limited to posttraumatic stress disorder (PTSD), major depressive disorder (MDD), panic disorder, and generalized anxiety disorder (GAD) [1][2][3]. The phrase "psychologically traumatic event" is often preceded by the word "potentially" to underscore the importance of dynamic individual and environmental contextual factors that influence whether an event was, or is perceived as, psychologically traumatic for any given individual at any given time [1][2][3]. Relevant to the current editorial, we reflect on two Canadian cases to show how mass causality events and investigations consume many responders before (e.g., public safety communicators, detachment service assistants), during (e.g., police, fire, paramedics) and after the incident (e.g., coroners, correctional workers, media coverage), whose well-being may suffer from the associated processes and outcomes. Thus, we draw on the mass causality incident of 2020 in Nova Scotia, Canada, and the investigation following a prisoner death in 2019 in Newfoundland, Canada, to describe incidents that may be compromising to PSP wellness. ...
... Relevant to the mass casualty, case one, the RCMP were the front line. In general, the RCMP report the highest average number of exposures to PPTE relative to other Canadian PSP, often reporting more than 11 exposures to each different type of PPTE [3]. RCMP officers have reported among the highest proportion of positive screenings for PTSD (30.0%) and MDD (31.7%) among Canadian PSP, with half (50.2%) of the RCMP screening positive for one or more mental health disorders at any given time [32]. ...
Article
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In this editorial, we draw on two Canadian cases to interrogate how mass causality events and investigations consume many responders before (e.g., public safety communicators, detachment service assistants), during (e.g., police, fire, paramedics), and after the incident (e.g., coroners, correctional workers, media coverage). Their well-being may suffer from the associated processes and outcomes. In the current article, we focus on the mass causality incident of 2020 in Nova Scotia, Canada, and the investigation following a prisoner death in 2019 in Newfoundland, Canada, to explore how testifying post-incident can be made more palatable for participating public safety personnel (PSP). Specifically, we study how testifying after an adverse event can affect PSP (e.g., recalling, vicarious trauma, triggers) and how best to mitigate the impact of testimony on PSP well-being, with a lens to psychological “recovery” or wellness. We focus here on how to support those who may have to testify in a judicial proceeding or official inquiry, given being investigated for best-intended actions can result in moral injury or a posttraumatic stress injury, both exacerbated by judicial review, charge, accusation, or inquiry.
... Regular exposure to potentially psychologically traumatic events (PPTEs) such as exposure to threatened or actual physical assaults, serious injury, fires, or explosions [1] is expected during occupational activities of Public Safety Personnel (PSP) [2]. PSP include persons working within the Canadian Coast Guard (CCG) and Conservation and Protection and CISD effectiveness has not been robustly assessed due to inconsistencies across studies. ...
... The study was approved by the University of Regina Institutional Research Ethics Board (REB# 2021-003). The survey was based on a set of validated measures used in a previous study of PSP [2,6,7,21,22], but collaboratively redesigned by members of the research team and the CCG and DFO team to ensure relevant variables were included. The survey was promoted and distributed by the CCG and DFO to member unions via emails, social media posts, and a video encouraging participation. ...
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Public Safety Personnel (PSP) including members of the Canadian Coast Guard (CCG) and Conservation and Protection (C&P) officers, are regularly exposed to potentially psychologically traumatic events (PPTEs) and other occupational stressors. Several mental health training programs (e.g., critical incident stress management [CISM], critical incident stress debriefing [CISD], peer support, mental health first aid, Road to Mental Readiness [R2MR]) exist as efforts to minimize the impact of exposures. To help inform on the impact of several categories of mental health training programs (i.e., CISM, CISD, mental health first aid, Peer Support, R2MR) for improving attitudes toward support and willingness to access supports among CCG and C&P officers, the current study assessed CCG and C&P Officers perceptions of access to professional (i.e., physicians, psychologists, psychiatrists, employee assistance programs, chaplains) and non-professional (i.e., spouse, friends, colleagues, leadership) support, and associations between training and mental health. Participants (n = 341; 58.4% male) completed an online survey assessing perceptions of support, experience with mental health training and symptoms of mental health disorders. CCG and C&P Officers reported access to professional and non-professional support; however, most indicated they would first access a spouse (73.8%), a friend (64.7%), or a physician (52.9%). Many participants would never, or only as a last resort, access other professional supports (24.0% to 47.9%), a CCG or C&P colleague (67.5%), or their leadership (75.7%). Participants who received any mental health training reported a lower prevalence of positive screens for all mental health disorders compared to those who did not received training; but no statistically significant associations were observed between mental health training categories and decreased odds for screening positive for mental disorders. The current results suggest that the mental health training categories yield comparable results; nevertheless, further research is needed to assess the shared and unique content across each training program. The results highlight the need to increase willingness to access professional and non-professional support among CCG and C&P Officers. Revisions to training programs for leadership and colleagues to reduce stigma around mental health challenges and support for PSP spouses, friends, and physicians may be beneficial.
... Firstly, both populations are likely to experience multiple potentially traumatic events (PTEs) (e.g., repeated exposure to physical threats, bearing witness to death and destruction, etc.). 6,7 Given that the impact of PTEs is cumulative, those who experience more instances of such events are at a higher risk for developing trauma-related disorders. 8 Secondly, the social dynamics in the military and the first responder milieu are largely similar and contribute to the maintenance of PTSD. ...
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I draw data from an ethnographic experience of participating in correctional officer training at the Correctional Service of Canada (CSC) to explore the position of prisoner health in informing correctional officer discretion. I unpack how through training CSC holds recruits accountable for their actions, reactions, and discretionary behaviors, while also structuring recruit decision-making by enforcing a model that promotes a co-response between health care and security actors in prison. I speak to correctional officer legal vulnerabilities, the value of documentation as a means to rationalize actions, and make recommendations for future research, policy, and training practices.
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This qualitative study explores the contribution of peer support to the mental health and wellbeing of police veterans. Thematic analysis of interview data with veterans ( n = 7), partners ( n = 1) and veteran peer support officers ( n = 10) captures the participant experience. Two key themes were integral to the contribution peer support makes to veteran wellbeing. First, the centrality of police identity and the importance of belonging to a supportive police community. Second, the need for hope and possibilities in transitioning from policing to civilian life. Social work services and trained peers provide veterans with a road map for re-building a life and identity away from the force.
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Substantial media attention has focused on suicide among Canadian Public Safety Personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police). The attention has raised significant concerns about the mental health impact of public safety service, as well as interest in the correlates for risk of suicide. There have only been two published studies assessing lifetime suicidal behaviors among Canadian PSP. The current study was designed to assess past-year and lifetime suicidal ideation, plans, and attempts amongst a large diverse sample of Canadian PSP. Estimates of suicidal ideation, plans, and attempts were derived from self-reported data from a nationally administered online survey. Participants included 5,148 PSP (33.4% women) grouped into six categories (i.e., Call Centre Operators/Dispatchers, Correctional Workers, Firefighters, Municipal/Provincial Police, Paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported past-year and lifetime suicidal ideation (10.1%, 27.8%), planning (4.1%, 13.3%), or attempts (0.4%, 4.6%). Women reported significantly more lifetime suicidal behaviors than men (ORs = 1.15 to 2.62). Significant differences were identified across PSP categories in reports of past-year and lifetime suicidal behaviors. The proportion of Canadian PSP reporting past-year and lifetime suicidal behaviors was substantial. The estimates for lifetime suicidal behaviors appear consistent with or higher than previously published international PSP estimates, and higher than reports from the general population. Municipal/Provincial Police reported the lowest frequency for past-year and lifetime suicidal behaviors, whereas Correctional Workers and Paramedics reported the highest. The results provide initial evidence that substantial portions of diverse Canadian PSP experience suicidal behaviors, therein warranting additional resources and research.
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Background: Canadian public safety personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police officers) are exposed to potentially traumatic events as a function of their work. Such exposures contribute to the risk of developing clinically significant symptoms related to mental disorders. The current study was designed to provide estimates of mental disorder symptom frequencies and severities for Canadian PSP. Methods: An online survey was made available in English or French from September 2016 to January 2017. The survey assessed current symptoms, and participation was solicited from national PSP agencies and advocacy groups. Estimates were derived using well-validated screening measures. Results: There were 5813 participants (32.5% women) who were grouped into 6 categories (i.e., call center operators/dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported current symptoms consistent with 1 (i.e., 15.1%) or more (i.e., 26.7%) mental disorders based on the screening measures. There were significant differences across PSP categories with respect to proportions screening positive based on each measure. Interpretation: The estimated proportion of PSP reporting current symptom clusters consistent with 1 or more mental disorders appears higher than previously published estimates for the general population; however, direct comparisons are impossible because of methodological differences. The available data suggest that Canadian PSP experience substantial and heterogeneous difficulties with mental health and underscore the need for a rigorous epidemiologic study and category-specific solutions.
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The purpose of this study is to assess the psychometric properties of a French version of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), a self-report measure of posttraumatic stress disorder (PTSD) symptoms, and to further validate the existing English version of the measure. Undergraduate students (n = 838 English, n = 262 French) completed the PCL-5 as well as other self-report symptom measures of PTSD and depression online. Both the English and French versions PCL-5 total scores demonstrated excellent internal consistency (English: α = .95; French: α = .94), and strong convergent and divergent validity. Strong internal consistency was also observed for each of the four subscales for each version (α’s > .79). Test-retest reliability for the French version of the measure was also very good (r = .89). Confirmatory factor analysis indicated that the four-factor DSM-5 model was not a good fit of the data. The seven-factor hybrid model best fit the data in each sample, but was only marginally superior to the six-factor anhedonia model. The French version of the PCL-5 demonstrated the same psychometric qualities as both the English version of the same measure and previous versions of the PCL. Thus clinicians serving French-speaking clients now have access to this highly used screening instrument. With regards to the structural validity of the PCL-5 and of the new PTSD diagnostic structure of the DSM-5, additional research is warranted. Replication of our results in clinical samples is much needed.
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The current review and synthesis was designed to provocatively develop and evaluate the proposition that “fear of the unknown may be a, or possibly the, fundamental fear” (Carleton, 2016) underlying anxiety and therein neuroticism. Identifying fundamental transdiagnostic elements is a priority for clinical theory and practice. Historical criteria for identifying fundamental components of anxiety are described and revised criteria are offered. The revised criteria are based on logical rhetorical arguments using a constituent reductionist postpositivist approach supported by the available empirical data. The revised criteria are then used to assess several fears posited as fundamental, including fear of the unknown. The review and synthesis concludes with brief recommendations for future theoretical discourse as well as clinical and non-clinical research.
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The current review and synthesis serves to define and contextualize fear of the unknown relative to related constructs, such as intolerance of uncertainty, and contemporary models of emotion, attachment, and neuroticism. The contemporary models appear to share a common core in underscoring the importance of responses to unknowns. A recent surge in published research has explored the transdiagnostic impact of not knowing on anxiety and related pathologies; as such, there appears to be mounting evidence for fear of the unknown as an important core transdiagnostic construct. The result is a robust foundation for transdiagnostic theoretical and empirical explorations into fearing the unknown and intolerance of uncertainty.
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This study examined associations of Prospective IU and Inhibitory IU with symptom-levels of Prolonged Grief Disorder (PGD), Posttraumatic Stress-Disorder (PTSD), and depression in a sample of bereaved individuals. Specifically, 265 bereaved individuals completed measures of IU, PGD, PTSD, and depression in the first year after the death of a loved one; 134 participants again completed symptom-measures six months later. Cross-sectional analyses showed that Inhibitory IU (but not Prospective IU) was positively associated with symptom-levels of PTSD and depression (but not PGD), even when controlling for neuroticism, worry, and rumination. Prospective analyses showed that Prospective IU (but not Inhibitory IU) at baseline, predicted PGD severity six months later (but not PTSD or depression at follow-up) while controlling for baseline symptom-levels. The findings support the notion that IU is a vulnerability factor for different emotional problems, including those developing after the death of a loved one. Clinical implications of these findings are discussed.
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The risk of developing a substance use disorder (SUD) is significantly higher among veterans with posttraumatic stress disorder (PTSD). Veterans with this co-occurrence have poorer outcomes than singly diagnosed veterans, which may be related to two risk factors: intolerance uncertainty (IU) and low tolerance of emotional distress (TED). We hypothesized low TED and high IU would independently and interactively relate to heightened PTSD symptomatology and trauma-cue elicited SUD cravings. A sample of 70 veterans (Mage = 50; 95% men; 65% Black) with co-occurring PTSD-SUD was recruited. The Posttraumatic Stress Disorder Checklist (PCL), Craving Questionnaire, Distress Tolerance Scale, and Intolerance of Uncertainty Scale were administered. In general, low TED and high IU were significantly correlated with the PCL total and subscale scores. When examined within regression models, low TED was associated with elevated PCL scores and trauma-cue elicited SUD cravings; IU was not. However, there was a significant interaction between IU and TED; veterans with elevated IU and low TED had higher PCL Total, Hyperarousal, and Intrusions scores. This highlights the importance of assessing TED and IU among veterans with co-occurring PTSD-SUD, as these risk factors may not only be prognostic indicators of outcomes, but also treatment targets.