The Prevention of Trauma Reactions
Tracey Varker
Doctor of Philosophy July 2009
Tracey Varker PhD Thesis Abstract
Abstract Exposure to traumatic or stressful events has been linked to the development of trauma symptomatology in a minority of individuals for some time now. Although there have been many studies which have examined the nature and aetiology of trauma reactions, few researchers have examined whether it is possible to prevent reactions to trauma. This is somewhat surprising, given the impact that an adverse trauma reaction can have to both an individual and an organisation (if the individual is also an employee). One exception is the body of work which has been created by researchers who investigated the psychological intervention known as psychological debriefing. This intervention has been designed to be administered immediately after an individual experiences a traumatic event, and is said to mitigate an individual’s reaction to trauma. The scientific evidence for this intervention, however, has been equivocal. At the time that this thesis was being prepared, there were only two published randomised controlled trials of group debriefing. In addition, the impact of psychological debriefing upon an individual’s memory for a traumatic event had never before been examined. This is important to note, because in many instances an individual who is a witness to a crime, will receive psychological debriefing before they give a statement to police officers. For Study 1, a randomised controlled trial of group debriefing was conducted. The aim was to assess the effect of this intervention upon eyewitness memory for a stressful event and eyewitness stress reactions, with a sample drawn from the general community ( n = 61). Participants were randomly allocated to one of three groups: debriefing; debriefing with an experimenter confederate present (who supplied 3 pieces of misinformation to the group regarding the stressful event); and a no-treatment control. All groups were shown a very stressful video and were again reviewed one month later. Members of the debriefing group where a confederate provided misinformation were more likely to recall this misinformation as fact than members of the other two groups. The debriefing group was also more accurate in their recall of peripheral content than the confederate group. Across all groups, participants were found to be more accurate at central rather than peripheral recall yet more confident for incorrect memories of the video than correct memories. Although the video was rated as being distressing, it was found that there were no significant differences between the three groups on measures of affective distress.
ii Tracey Varker PhD Thesis Abstract
The results of Study 1 add to the growing body of literature which suggests that psychological debriefing is an ineffective intervention for mitigating the effects of trauma. As such, new intervention methods must be developed and explored. A new and promising area of research is targeted interventions which are applied to at-risk groups before they are exposed to traumatic incidents. This type of intervention is known as “resilience training”, i.e., preparing an individual before they are exposed to a potentially harmful situation. In order to explore whether resilience training has any promise as a burgeoning area of research, a randomised controlled trial of resilience training was conducted in Study 2. No such trial had ever been conducted before. One key purpose of Study 2 was also to investigate whether resilience training caused any adverse effects for individuals, given that no research previously existed on the types of reactions that such an intervention may cause. Furthermore, the impact of resilience training upon an individual’s memory for a stressful event was also examined. For Study 2, a randomised controlled trial of resilience training was conducted. The aim was to assess the effect of this intervention upon eyewitness stress reactions and eyewitness memory for a stressful event, with a sample drawn from the general community ( n = 80). Individuals were randomly assigned to either the resilience or the control condition. In small groups, participants received either resilience training, or the control training. All participants received training in session 1, were then shown a very stressful video in session 2, and were again reviewed after one month. Receiving the resilience training did not have a beneficial effect upon individuals’ stress reactions for a stressful event. In addition, the resilience training did not affect the number of central or peripheral memories that participants were able to correctly recall. This has important implications in terms of eyewitness testimony, given that people who experience stressful or traumatic incidents are often required to make statements or give evidence about what they have witnessed. If an intervention were to impede an individual’s ability to accurately recall the event, then this could have serious consequences. Once it was indicated that the resilience training did not have a negative impact upon individuals, the next step was to further develop the intervention, and trial it on an at-risk population who had the potential to receive significant benefits from this type of training. Such a group is police officers, who routinely face traumatic, sad and stressful incidents through-out the course of their career. For Study 3, a stratified randomised trial of resilience training was carried out with Victorian police officers ( n = 89). The aim of the study was to assess the efficacy of resilience training in mitigating stress
iii Tracey Varker PhD Thesis Abstract reactions, and decreasing reliance on drugs and alcohol. New recruit police officers were allocated to either the resilience or the control condition by virtue of the squad that they had been randomly allocated to when they entered the Police Academy. In groups, participants received either the resilience training or the control training, at a number of different intervals over the twenty weeks during which they were stationed at the Academy. Participants were reviewed again 6-months after they completed their training at the Academy. Resilience was conceptualised to consist of three domains: Health and Well-being, Reactivity to Trauma, and Workplace Functioning. Overall, there was no significant difference between the groups for resilience across all three domains. There was, however, a significant difference for Workplace Functioning, with those who received the resilience training more likely to show no deterioration or improvement in this domain at the 6-month follow-up. Immediately following the training there were no significant differences between the groups for participant satisfaction. Over time however, the satisfaction of those in the resilience group increased while satisfaction of those in the control group decreased. It may be that the efficacy of the resilience training was most evident to participants once they had a chance to consider the training in light of their working experiences. All recruits except one showed resilience for the Reactivity to Trauma domain, indicating that resilience in this domain is the norm. No significant differences were found between the groups for drug and alcohol usage. Resilience training was not found to have any beneficial effects and it may be possible that further effects of this resilience training will be most evident at a time point further down the line. Overall the results of this thesis provide support for the inclusion of resilience training as part of training for new recruit police officers.
iv Tracey Varker PhD Thesis Acknowledgements
Acknowledgements
I would like to express many thanks to Professor Grant Devilly, my supervisor, mentor and friend, who has provided me with constant support, guidance and encouragement throughout this PhD. I would also like to thank the Victoria Police service, the staff of the Victoria Police Academy, and in particular all of the police recruits who attended the Academy between 2007 and 2008. Without your help, this project would never have been possible. You are some of the most decent and courageous people that I have ever had the privilege of meeting. Thank-you also to the members of the community who participated in the first two studies of this thesis, who willingly gave of their time and also agreed to watch a rather unpleasant video. Thank you to my family and to my wonderful close friends for supporting me through the many years of study that it has taken to complete this thesis. Words are inadequate to express my appreciation of the love and support that has been given to me by my parents, Rob and Sue, and my brother and sister, Erin and Simon. Your continued support and encouragement contributed to the completion of this PhD. Finally, Shaun, thank you for listening to me, encouraging me, for always knowing how to make me smile, and most of all, thank you for believing in me.
Further Acknowledgements Thank you to Professor Andrew Scholey for giving me the helping hand that I needed in the final months of this PhD. Thank you to the National Drug and Law Enforcement Research Fund (NDLERF) for providing financial support for this project.
v Tracey Varker PhD Thesis Declaration
Declaration I declare that this thesis contains no material which has been accepted for the award to the candidate of any other degree or diploma, except where due reference is made in the text of this thesis. I also declare that to the best of my knowledge this thesis does not contain material previously published or written by another person except where due reference is made in the text of this thesis.
I further declare that the ethical principles and procedures specified in the Swinburne University of Technology Human Research Ethics document on human research and experimentation have been adhered to in the presentation of this thesis.
Name: Tracey Varker
Signed: ______
vi Tracey Varker PhD Thesis Publications
Table of Contents
Abstract...... ii
Acknowledgements ...... v
Declaration ...... vi
List of Tables ...... xvi
List of Figures...... xix
List of Appendices...... 20
Chapter One: Reactions to Trauma: Classification, Prevalence, Psychological Theories and Treatment...... 22
1.1 Preamble to the Current Studies...... 22
1.2 Arrangement of Chapters...... 23
1.3 Operational Definitions...... 24
1.4 Introduction ...... 26
1.5 Classifications of Reactions to Stress and Trauma...... 26 1.5.1 Post-traumatic Stress Disorder ...... 26
1.6 Prevalence of Traumatic Stress and Related Disorders...... 29 1.6.1 Community Incidence and Prevalence ...... 29 1.6.2 Comorbidity of Trauma Related Disorders ...... 30
1.7 Psychological Theories of Traumatic Stress ...... 31 1.7.1 Cognitive Theories ...... 32 1.7.1.1 Information Processing Theory ...... 32 1.7.1.2 Social Cognitive Theories ...... 35 1.7.2 Behavioural Theories ...... 37 1.7.2.1 Classical Conditioning ...... 37 1.7.2.2 Operant Conditioning ...... 38 1.7.2.3 Davey’s Two-Component Conditioning Model ...... 38 1.7.2.4 Mowrer’s Two-Factor Learning Theory ...... 42
1.8 Conclusion...... 47
vii Tracey Varker PhD Thesis Publications
Chapter Two: Psychological Debriefing, Vulnerabilities to the Development of Pathology Following Trauma and Misinformation ...... 49
2.1 Psychological Debriefing...... 49 2.1.1 Introduction ...... 49 2.1.2 The History of PD ...... 50 2.1.3 Critical Incident Stress Debriefing (CISD) ...... 50 2.1.4 Individual Debriefing ...... 52 2.1.5 Group Debriefing ...... 53 2.1.6 Summary of PD ...... 55
2.2 Vulnerabilities to the Development of Pathology Following Trauma.... 56 2.2.1 Introduction ...... 56 2.2.2 Pre-Trauma Vulnerabilities ...... 56 2.2.2.1 Personality ...... 56 2.2.2.2 Previous Trauma Exposure ...... 56 2.2.2.3 Personal History of Psychiatric Disorder ...... 57 2.2.2.4 Gender ...... 57 2.2.3 Peri-Trauma Vulnerabilities ...... 58 2.2.3.1 Severity of Trauma and Perceived Life Threat ...... 58 2.2.4 Post-Trauma Vulnerabilities ...... 58 2.2.4.1 Social Support ...... 58 2.2.4.2 Optimism ...... 59 2.2.4.3 Anger ...... 59
2.3 Misinformation ...... 60 2.3.1 Introduction ...... 60 2.3.2 The Misinformation Effect ...... 60 2.3.3 Memory Conformity ...... 61 2.3.4 Misinformation in Groups ...... 62 2.3.5 Misinformation and Memory Quality ...... 63 2.3.6 Summary of Misinformation ...... 65
2.4 Conclusion...... 65
Chapter Three: Study 1- A Randomised Controlled Trial (RCT) of Group Debriefing.... 66
3.1 Study 1: Overview ...... 66 3.1.1 Introduction ...... 66
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3.1.2 Project Aims ...... 67 3.1.3 Hypotheses ...... 68
3.2 Study 1: Method and Materials...... 68 3.2.1 Participants ...... 68 3.2.2 Approvals ...... 69 3.2.3 Consent Forms and Information Sheet ...... 69 3.2.4 Recruitment and Group Allocation ...... 69 3.2.5 Measures ...... 71 3.2.5.1 Demographics ...... 71 3.2.5.2 The Depression, Anxiety and Stress Scale ...... 71 3.2.5.3 The Interpersonal Support Evaluation List-12 ...... 71 3.2.5.4 Word recall ...... 72 3.2.5.5 Memory of the video ...... 72 3.2.5.6 Response to Stress ...... 73 3.2.5.7 The PTSD Symptom Scale – Self-Report ...... 73 3.2.5.8 Participant Satisfaction ...... 74 3.2.6 Setting ...... 74 3.2.7 Procedure and Questionnaires ...... 74 3.2.8 Interventions ...... 76 3.2.8.1 Debriefing ...... 76 3.2.8.2 Debriefing with a Confederate ...... 77 3.2.8.3 Non-treatment Control ...... 77
3.3 Study 1: Results ...... 77 3.3.1 Data Screening, Randomisation and Descriptive Statistics ...... 78 3.3.2 Hypothesis 1 ...... 82 3.3.3 Hypothesis 2 ...... 86 3.3.4 Hypothesis 3 ...... 87 3.3.5 Hypothesis 4 ...... 88 3.3.6 Hypothesis 5 ...... 88 3.3.7 Hypothesis 6 ...... 89 3.3.8 Hypothesis 7...... 93 3.3.9 Subsidiary Analyses ...... 93
3.4. Study 1: Discussion...... 94 3.4.1 Introduction ...... 94
ix Tracey Varker PhD Thesis Publications
3.4.2 Evaluation of Study 1 ...... 95 3.4.3 Limitations of Study 1 ...... 97 3.4.4 Areas for Future Research ...... 98 3.4.5 Summary of Study 1 ...... 99
Chapter Four: Is it Possible to Prevent Stress Reactions? Stress, Appraisal, Coping and Resilience ...... 100
4.1 Introduction ...... 100
4.2 Overview of Psychological Theories of Stress Related to Resilience.... 100 4.2.1 Stress ...... 100 4.2.2 Stress Inoculation Training ...... 102 4.2.3 Serial Approximation and Desensitisation ...... 103 4.2.4 Occupational Stress ...... 105
4.3 Burnout...... 106
4.4 Coping...... 109
4.5 Hardiness...... 113
4.6 Resilience...... 115
4.7 Preventing Stress Reactions...... 120
4.8 Conclusion...... 125
Chapter Five: Proof of Concept: Study 2- Resilience Training for Witnessing Stressful Situations ...... 126
5.1 Study 2: Overview ...... 126 5.1.1 Introduction ...... 126 5.1.2 Project Aims ...... 128 5.1.3 Hypotheses ...... 128
5.2 Study 2: Method and Materials...... 129 5.2.1 Participants ...... 129 5.2.2 Approvals ...... 129 5.2.3 Consent Form and Information Sheet ...... 129 5.2.4 Recruitment and Group Allocation ...... 130 5.2.5 Measures ...... 131 5.2.5.1 Demographics ...... 131
x Tracey Varker PhD Thesis Publications
5.2.5.2 The Depression, Anxiety and Stress Scale ...... 131 5.2.5.3 The Interpersonal Support Evaluation List-12 ...... 131 5.2.5.4 Word recall ...... 131 5.2.5.5 Memory of the video ...... 131 5.2.5.6 Response to Stress ...... 132 5.2.5.7 The PTSD Symptom Scale – Self-Report ...... 132 5.2.5.8 Participant Satisfaction ...... 132 5.2.5.9 The Ten Item Personality Inventory ...... 132 5.2.6 Setting ...... 132 5.2.7 Procedure and Questionnaires ...... 132 5.2.8 Interventions ...... 134 5.2.8.1 Resilience Training ...... 134 5.2.8.2 Control Training ...... 135
5.3 Study 2: Results ...... 135 5.3.1 Data Screening, Randomisation and Descriptive Statistics ...... 135 5.3.2 Hypothesis 1 ...... 139 5.3.3 Hypothesis 2 ...... 144 5.3.4 Hypothesis 3 ...... 144 5.3.5 Hypothesis 4 ...... 145 5.3.6 Hypothesis 5 ...... 147
5.4 Study 2: Discussion...... 148 5.4.1 Introduction ...... 148 5.4.2 Evaluation of Study 2 ...... 148 5.4.3 Limitations of Study 2 ...... 150 5.4.4 Areas for Future Research ...... 151 5.4.5 Summary ...... 151
Chapter Six: Resilience Training in the Real World...... 152
6.1 Introduction ...... 152
6.2 Prevalence of PTSD in Police ...... 153
6.3 Occupational Stress and Police ...... 154
6.4 Operational Stress and Police...... 156
6.5 Police, Drugs and Alcohol...... 157
xi Tracey Varker PhD Thesis Publications
6.6 Resilience Training and Police ...... 160
6.7 The Police Resilience Training Programme...... 162 6.7.1 Module 1: Introduction ...... 162 6.7.2 Module 2: Policing Expectations ...... 164 6.7.3 Module 3: Physical Responses to Trauma ...... 165 6.7.3.1 Psycho-education ...... 165 6.7.3.2 Muscle Relaxation ...... 166 6.7.3.3 Calm Breathing Exercise ...... 166 6.7.4 Module 4: Coping Skills ...... 166 6.7.4.1 Thought-Challenging and Cognitive Restructuring ...... 167 6.7.4.2 Guided Self-Dialogue...... 168 6.7.5 Module 5: Social Support ...... 169 6.7.6 Module 6: Drugs and Alcohol ...... 170 6.7.7 Module 7: Help Services Available ...... 171 6.7.8 Module 8: Conclusion ...... 172
6.8 Conclusion...... 172
Chapter Seven: Study 3- A Controlled Trial of Resilience Training for Police...... 173
7.1 Study 3: Overview ...... 173 7.1.1 Introduction ...... 173 7.1.2 Project Aims ...... 174 7.1.3 Hypotheses ...... 174
7.2 Study 3: Method and Materials...... 176 7.2.1 Method A: Development of the Resilience Training Programme ...... 176 7.2.1.1 Review of the Literature ...... 176 7.2.1.2 Identification of How to Structure the Resilience Training Programme Sessions ...... 179 7.2.1.3 Write-up of the Manuals and Handbooks ...... 184 7.2.2 Method B: Implementation and Evaluation of the Resilience ...... Training Programme ...... 185 7.2.2.1 Participants ...... 185 7.2.2.2 Approvals ...... 185 7.2.2.3 Consent Forms and Information Sheet ...... 185 7.2.2.4 Recruitment and Group Allocation ...... 186
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7.2.2.5 Design ...... 189 7.2.2.6 The Training Programmes ...... 190 7.2.2.7 Measures ...... 190
7.3 Study 3: Results ...... 199 7.3.1 Data Screening ...... 199 7.3.2 Attrition, Session Attendance, Questionnaire Completion and Training Integrity Adherence ...... 203 7.3.3 Descriptive Statistics ...... 204 7.3.4 Hypotheses ...... 209
7.4 Study 3: Discussion...... 236
7.5 Limitations of Study 3...... 246
7.6 Areas for Future Research...... 247
7.7 Summary of Study 3...... 248
Chapter Eight: Conclusion...... 251
References...... 254
Appendix 1: Study 1- Glossary of Terms...... 279
Appendix 2: Study 1- Participant Information...... 280
Appendix 3: Study 1- Consent Form...... 282
Appendix 4: Study 1- Intake Questionnaire Package...... 283
Appendix 5: Study 1- Follow-up Questionnaire Package...... 292
Appendix 6: Adherence Rating Template ...... 300
Appendix 7: Study 2- Glossary of Terms...... 302
Appendix 8: Study 2- Participant Information...... 303
Appendix 10: Study 2- The Ten-Item Personality Inventory ...... 306
Appendix 11: Study 2- Resilience Training Guidelines...... 307
Appendix 12: Study 2- Resilience Training Handouts ...... 310
Appendix 13: Study 2- Accident Management Training Guidelines ...... 312
Appendix 14: Study 2- Accident Management Training Handouts...... 318
xiii Tracey Varker PhD Thesis Publications
Appendix 15:Study 3- Glossary of Terms...... 322
Appendix 16: Resilience Training Manual for New Recruit Police Officers...... 324
Appendix 17: Study 3- Information Sheet...... 433
Appendix 18: Study 3- Consent Form...... 435
Appendix 19: Study 3 – Time 1 Questionnaire Package ...... 436
Appendix 20: Study 3 – Time 2 Questionnaire Package- Intervention Condition...... 447
Appendix 21: Study 3 –Time 2 Questionnaire Package- Control Condition...... 452
Appendix 22: Study 3 – Time 3 Questionnaire Package- Intervention Condition...... 457
Appendix 23: Study 3 – Time 3 Questionnaire Package- Control Condition...... 473
Appendix 24: Study 3- Integrity Summaries...... 475
Appendix 25: Skewness & Kurtosis Statistics for Data, Pre & Post Transformation...... 490
Appendix 26: Means and Standard Deviations for the Dependent Variables...... 491
Appendix 27: Human Ethics Clearance for the Research Projects...... 496
xiv Tracey Varker PhD Thesis Publications
Publications Arising from the Thesis
Devilly, G. J., & Varker, T. (2008). The effect of stressor severity on outcome following group debriefing. Behaviour Research and Therapy, 46, 130-136
Devilly, G. J., Varker, T., Hansen, K., & Gist, R. (2007). An analogue study of the effects of psychological debriefing on eyewitness memory, Behaviour Research and Therapy, 45(6), 1245-1254
xv Tracey Varker PhD Thesis List of Tables
List of Tables Table Heading Page 1 Demographic Characteristics of the Sample (Study 1) 80
2 Internal Reliability Coefficients of all Measures at Time 1 and Time 2 82 (Study 1; N = 61) 3 3 (Condition) x 2 (Time) Repeated Measures ANOVA for Emotional 84 Responses to the Video (Study 1) 4 Means and Standard Deviations for Emotional Responses to the Video, 85 by Condition (Study 1) 5 3 (Condition) x 2 (Time) Repeated Measures ANOVAs for 91 Video Memory and Confidence Scores (Study 1) 6 Means and Standard Deviations for Video Memory Scores, in Session 92 1 and at Follow-up (Study 1) 7 Demographic Characteristics of the Sample (Study 2) 138 8 Internal Reliability Coefficients of all Measures at Time 1 and 139 Time 2 (Study 2; N = 80) 9 3 (Condition) x 2 (Time) Repeated Measures ANOVA for Emotional 141 Responses to the Video (Study 2) 10 Means and Standard Deviations for Emotional Responses to the Video, 142 by Condition (Study 2) 11 One way ANOVAs for Training Elements (Study 2) 143 12 3 (Condition) x 2 (Time) Repeated Measures ANOVAs for Video 146 Memory and Confidence Scores (Study 2) 13 Means and Standard Deviations for Video Memory Scores, Directly 147 After Watching the Video and at Follow-up (Study 2) 14 Exercises Included in the Resilience Programme (Study 3) 178 15 Training Sessions and Corresponding Modules (Study 3) 183 16 Questionnaires that were Administered at Time 1, Time 2 and Time 3 191 (Study 3) 17 Transformations Made to Variables Prior to Analyses to Meet the 202 Assumption of Normality 18 Age Range of Participants (Study 3) 205
xvi Tracey Varker PhD Thesis List of Tables
19 Baseline Characteristics of the Sample (N = 89; Study 3) 206 20 Internal Reliability Coefficients for all Measures Used at the Three 208 Different Data Collection Intervals (Study 3) 21 Correlations between Major Variables and Age (Study 3; N = 89) 210 22 F-Statistics for Gender, Relationship Status, Station Location and the 211 Major Variables 23 2 (Condition) x 2 (Time) Repeated Measures ANCOVA for the Pre- 214 Programme Major Variables (Study 3) 24 Number and Percentage of Recruits who Reliably had No 215 Deterioration/Improvement for Affective Distress (Study 3) 25 Number and Percentage of Recruits who Reliably had No 216 Deterioration/Improvement for Relationship Satisfaction (Study 3) 26 Total Substance Involvement and Alcohol Involvement Cut-off Scores, 217 Pre-Programme and at Follow-up (Study 3) 27 Number of Participants in the Intervention and the Control Groups, 219 who Demonstrated Resilience for Substance Involvement (Study 3) 28 Number of Participants in the Intervention and the Control Groups, 220 with Good General Health Scores and Poor General Health Scores (Study 3) 29 Number of Participants in the Intervention and the Control Groups, 221 who Demonstrated Resilience for General Health (Study 3) 30 Number and Percentage of Recruits who had were Below “Cut-off C” 222 in the Domain of Reactivity to Trauma 31 The Means and Standard Deviations for Each of the Three Types of 223 Burnout, for the Resilience and Control Condition, and for a Clinical Sample and a Normal Sample (Study 3) 32 Single Sample Two-Tailed T-Tests Comparing the Resilience and 224 Control Group to a Clinical Sample and a Normal Sample, for Each of the Three Types of Burnout (Study 3) 33 Number and Percentage of Recruits who had Low, Moderate and High 226 Risk Levels for each of the Three Types of Burnout (Study 3) 34 Number of People who Showed Resilience for Each of the Three 227 Domains of Resilience (Study 3)
xvii Tracey Varker PhD Thesis List of Tables
35 Number and Percentage of Recruits who could Remember Training 229 Modules (Study 3) 36 2(Time) x 2(Condition) Repeated Measures ANOVAs for Training 230 Satisfaction and Degree of Importance (Study 3) 37 One-way ANOVAs for Attitudes Towards Victims of Crime (Study 3) 234 38 One-way ANOVAs for Attitudes Towards Sexual Offenders (Study 3) 236
xviii Tracey Varker PhD Thesis List of Figures
List of Figures
Figure Heading Page
1.1 Davey’s Two-Process Model of Conditioning 40
1.2 Mowrer’s Two-Factor Theory: Stage 1 Classical Conditioning as 44 Applied to the Development of a Post-Car Accident Fear
1.3 Mowrer’s Two-Factor Theory: Stage 2 Operant Conditioning as 46 Applied to the Development of a Post-Car Accident Fear 3.1 Post-traumatic Stress Symptomatology Cluster Severity by Condition at 87 Follow-up (Study 1) 3.2 Number of Correctly Answered Misinformation Items between the 89 Three Groups over Time 5.1 Post-traumatic Stress Symptomatology Cluster Severity by Condition at 144 Follow-up (Study 2) Diagram Showing the Flow of Participants Through Each Stage (Study 188 7.1 3) 7.2 Design of Questionnaire Administration (Study 3) 189 7.3 Interaction between Time and Condition for Participant Satisfaction 231 Interaction between Time and Condition for Training Content 7.4 232 Importance
xix Tracey Varker PhD Thesis List of Appendices
List of Appendices Appendix Description Page
1 Study 1- Glossary of Terms 279
2 Study 1- Participant Information Sheet 280
3 Study 1- Consent Form 282
4 Study 1- Intake Questionnaire Package 283
5 Study 1- Follow-up Questionnaire Package 292
6 Study 1- Adherence Rating Template 300
7 Study 2- Glossary of Terms 302
8 Study 2- Participant Information Sheet 303
9 Study 2- Consent Form 305
10 Study 2- The Ten Item Personality Inventory 306
11 Study 2- Resilience Training Guidelines 307
12 Study 2- Resilience Training Handouts 310
13 Study 2- Accident Management Training Guidelines 312
14 Study 2- Accident Management Training Handouts 318
15 Study 3- Glossary of Terms 322
16 Study 3- Trainer Manual and Recruit Handbook 324
17 Study 3- Information Sheet 432
18 Study 3- Consent Form 434
19 Study 3- Time 1 Questionnaire Package 435
20 Study 3- Time 2 Questionnaire Package- Intervention Condition 446
21 Study 3- Time 2 Questionnaire Package- Control Condition 451
22 Study 3- Time 3 Questionnaire Package- Intervention Condition 456
23 Study 3- Time 3 Questionnaire Package- Control Condition 472
20 Tracey Varker PhD Thesis List of Appendices
24 Study 3- Training Integrity Summaries 474
25 Study 3- Skewness & Kurtosis Statistics for Data, Pre & Post 489 Transformation. 26 Study 3- Means and Standard Deviations for Gender on the 490 Dependent Variables
27 Human Research Ethics Clearance for the Research Projects 496
21 Tracey Varker PhD Thesis 1. Reactions to Trauma
Chapter One: Reactions to Trauma: Classification, Prevalence, Psychological Theories and Treatment
1.1 Preamble to the Current Studies This thesis focuses on interventions which are aimed at mitigating stress reactions to traumatic events in at-risk populations. Although it is known that not all of those who are exposed to a traumatic event go on to develop a stress reaction, for the minority who do develop an adverse reaction, symptoms can sometimes be highly debilitating. In recent years psychological debriefing (PD), an early intervention aimed at preventing stress reactions following exposure to a traumatic event, has received a great deal of attention, and has also been the source of a great deal of controversy (see Devilly & Cotton, 2004). Although several well-designed studies have examined the efficacy of individual debriefing, there has only ever been two published randomised controlled trials (RCTs) of group debriefing, despite the fact that group debriefing is routinely administered. As such the first aim of this thesis was to further examine the efficacy of group debriefing using a RCT. In addition, the effect of group debriefing upon memory for a traumatic event was also examined. This study was named “Study 1”. The results of Study 1 indicated that group debriefing appeared to have little or no effect upon reducing stress reactions. Therefore, the focus of this thesis was shifted, and another viable option for the prevention of stress reactions following exposure to a traumatic event was considered. The literature relating to resilience training was explored, with this training based upon the notion that it may be possible to prepare an individual for a traumatic event before its occurrence through controlled exposure, education and skills training. By minimising the gap between anticipated fear or anxiety and actual fear or anxiety, it was deemed theoretically plausible that a person would experience less dissonance and thus cope with a stressful event better. A notable gap in the literature was identified in that a RCT of resilience training had never been conducted before. Therefore the aim of this second study was to investigate whether individuals can become prepared for a traumatic event through the provision resilience training. Further, we wished to explore whether such training had any impact upon
22 Tracey Varker PhD Thesis 1. Reactions to Trauma
individuals memory for the traumatic event, given the results of Study 1 and the likely use of resilience with emergency workers. This study was named “Study 2”. Study 2 demonstrated that resilience training did not have a benficial effect upon individuals in terms of both their stress reactions or memory for a stressful video. Based upon these results it was decided that a resilience training programme would be developed, implemented and tested in a real world application. In order to successfully trial a resilience programme aimed at preventing stress reactions in the real-word, it was necessary to identify a population that would be likely to be exposed to a traumatic event. Police officers were identified as such a group and were, therefore, the population used in the final study of this thesis. This study was a randomised stratified controlled trial of resilience training for new recruit police officers. The aim of this study was to assess the efficacy of resilience training upon: (a) resilience; (b) stress reactions; and (c) drug and alcohol consumption. This study was named “Study 3”. This study provided a strong rationale for further development and assessment of resilience training programmes.
1.2 Arrangement of Chapters Chapter 1 presents a review of the stress and trauma literature. In particular, classifications of reactions to stress and trauma, the prevalence of traumatic stress, psychological theories of traumatic stress, and psychosocial treatments for traumatic stress are focused upon. Chapter 2 discusses PD, vulnerabilities to the development of pathology following trauma and misinformation. Deficits in the debriefing literature are explored and a number of pre-trauma, peri-trauma, and post-trauma vulnerabilities which are known to effect the development of pathology following trauma are discussed. The phenomenon known as the “misinformation effect” is discussed and the ways in which misinformation, group processes and responses to trauma are linked are explored. The possible negative effects of providing people with misinformation, particularly when they have been exposed to a traumatic event, are also highlighted. Chapter 3 presents Study 1, a RCT of group debriefing and an examination of the effect of group debriefing upon memory for traumatic events. Future directions for traumatic stress research are discussed, and some of the future directions which are formulated in this chapter form the basis of Study 2. Chapter 4 presents a review of the
23 Tracey Varker PhD Thesis 1. Reactions to Trauma
current literature associated with the prevention of stress reactions. In particular, stress, burnout, appraisal, coping, hardiness and resilience theories are discussed and methods for preventing reactions are conceptualised. Chapter 5 presents Study 2, a RCT analog of resilience training and an examination of the effect of this training upon memory for stressful events. The real world applications of the results found from Study 2 are also discussed. In Chapter 6 resilience training is discussed in relation to the real world, and the rationale for conducting a trial of resilience training with police officers is provided. This chapter also serves as the introduction to Study 3, an examination of the efficacy of resilience training for police officers. Chapter 7 presents Study 3 and the methodology, the assessment instruments used and the process of statistical analyses are detailed. Chapter 7 also presents the conclusions of Study 3, discussing its limitations and directions for future research. Lastly, Chapter 8 presents the overall conclusions of this thesis.
1.3 Operational Definitions Due to the confusion regarding the terminology used in the area of trauma, the following definitions will be used for the purposes of the three study’s which are presented in this thesis (refer to Appendices 1, 7 and 15 for summaries). • Psychological Debriefing (PD) will be defined as, “a generic term for a range of brief crisis intervention models, which primarily aim to mitigate trauma related psychopathology, particularly that of PTSD” (Devilly, Wright, & Gist, 2003; McNally, Bryant, & Ehlers, 2003). • Central Memory will be defined as memory for any facts or elements directly related to the central character or event. • Peripheral Memory will be defined as any information associated with the event that is not directly related to the central character or event. This information includes background details. • Misinformation Effect will be defined as an instance “when eyewitnesses to a situation are presented with misleading information, which causes their memory to be distorted” (Loftus, Miller, & Burns, 1978). • Memory Conformity will be defined as “the phenomenon whereby an
24 Tracey Varker PhD Thesis 1. Reactions to Trauma
individual’s memory of an event can be influenced by discussion of the event with other individuals who have borne witness to the same event” (Memon & Wright, 1999). • Memory Confidence will be defined as the level of confidence that an individual has that their memory is correct. • Confederate will be defined as a person who is part of the research team, who pretends to be a participant. This person provides participants with information that is pre-determined, and serves as an experimental manipulation. • ‘Affective distress’ comprises the three related negative emotional states of depression, anxiety and stress. It is measured by summing scores from each of the 3 aforementioned scales of the DASS-21 (Lovibond & Lovibond, 1995). • Interpersonal Support will be defined as the participant’s perception of the level of interpersonal support they have available to them, including support for material aid, someone to talk to about problems and someone to do things with. • Resilience will be defined as “the capacity of a given system to implement early, effective adjustment processes to alleviate strain imposed by exposure to stress, thus efficiently restoring homeostatic balance or adaptive functioning within a given psychological domain following a temporary perturbation therein” (Layne, Warren, Watson, & Shalev, 2007, p. 500). In Study 3 of this thesis, resilience will be considered to comprise three life domains, with an individual considered resilient only if they show no change or improvement across all three domains. The first of the domains, ‘Health and Well-being’, will encompass factors associated with general health and well-being. Measures of general health, affective distress (depression, anxiety and stress), drug and alcohol use, and personal relationship satisfaction will be used for assessment, with resilience in this domain equal to no change or improvement across time, for all four of these measures. The second of the domains, ‘Reactivity to Trauma’, will reflect the amount of self-reported PTSD symptomatology experienced by the individual following exposure to potentially traumatic policing events. A measure of PTSD symptomatology will be used to assess this domain, and resilience will equal a score on this measure which is below a clinical cut-off point. The third of the domains, ‘Workplace Functioning’ will reflect the individual’s ability to work and function in a stressful occupation. A measure of burnout will be used to
25 Tracey Varker PhD Thesis 1. Reactions to Trauma
assess this domain, and in addition the individual’s use of both police and community mental health services will be measured. Resilience in this domain will equal scores for at least two out of the three types of burnout (i.e., emotional exhaustion, depersonalisation, personal accomplishment) which are within the low risk range, and not having accessed police help services, or external help services.
1.4 Introduction When individuals are exposed to a traumatic event, a small percentage of these individuals go on to develop what is known as Post Traumatic Stress Disorder (PTSD; American Psychiatric Association, 1994). PTSD is a chronic, debilitating disorder that is characterised by feelings of fear; an increase in arousal; avoidance of stimuli associated with the trauma event; and persistent and distressing re-experiencing of the traumatic event (American Psychiatric Association, 1994). The disorder often leads the sufferer to be incapacitated both psychological and physiologically, and leads to poor physical health (Deykin et al., 2001; Zayfert, Dums, Ferguson, & Hegel, 2002), reduced work productivity (Kessler & Frank, 1997), and an increased use of health resources (Bolton et al., 2004; Deykin et al., 2001; Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000).
1.5 Classifications of Reactions to Stress and Trauma
1.5.1 Post-traumatic Stress Disorder Post-traumatic Stress Disorder (PTSD) is a recognised illness associated with exposure to a traumatic event. Such events are experienced with fear, helplessness, or horror and are exemplified by accidents, sexual and physical assault or duties such as handling human remains. PTSD was first labelled as such in the DSM-III (American Psychiatric Association, 1980), which described a consistent pattern of symptoms following trauma of all types. Before that time, it was known by many different names, including “shell shock” in World War I, “war neurosis” in World War II, “combat stress reaction” in the Vietnam War. Shortly after World War II, a formal classification of
26 Tracey Varker PhD Thesis 1. Reactions to Trauma
reactions to trauma was created, known as “Gross Stress Reaction”, a reaction to severe combat or civilian catastrophe that “may progress to one of the neurotic reactions… if the reaction persists” (DSM-I; American Psychiatric Association, 1952). However, this conceptualisation was soon viewed as flawed with its failure to take into account exposure to trauma of all types. According to DSM-IV , there are six criteria that must be met before a diagnosis of PTSD can be made. The first criterion, Criterion A (APA, 1994), states that a person must have experienced, witnessed or have been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and responded with feelings of intense fear helplessness or horror. With adoption of the latter criterion, the DSM-IV attempts to address the general belief that people differ with respect to risk factors or vulnerability to PTSD (Friedman, 1997). The change represents an operationalisation of the understanding that the essence of a traumatic event is a dynamic interaction between the external event and the internal response (Hodgins, 2000). This definition also allows a diagnosis not only for primary victims but also for secondary or related victims such as the family of victims and emergency workers. In addition, it allows for a diagnosis to be made when there is no direct threat to life, but when physical integrity is compromised, such as in the case of rape or child sexual abuse. This criterion has become the most contentious, as in DSM-III-R it was necessary to experience a stressor that “would be markedly distressing to almost anyone”, whilst DSM-IV states that one must be confronted with bodily harm to oneself or others and to have responded with fear helplessness or horror. Thus, DSM-IV has shifted the emphasis from merely the severity of the stressor, to a mixture of exposure to a stressor and one’s reaction to it (Tomb, 1994). Therefore, those that have indirectly experienced (“been confronted with”) traumatic situations, and demonstrated an extreme reaction may also be diagnosed with PTSD. The second criterion, Criterion B (APA, 1994), reflects re-experiencing symptoms. The essential feature of this cluster of symptoms is the persistent re- experiencing of the traumatic event. The symptoms include: recurrent intrusive recollections or intrusions (including nightmares) regarding the event, acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations, and/or dissociative flashback episodes), and psychological
27 Tracey Varker PhD Thesis 1. Reactions to Trauma
distress and physiological reactivity when exposed to cues that represent the traumatic event. The person only needs to have one re-experiencing symptom in order to meet the criterion. However, the symptoms must cause significant distress and impairment which lasts one month or more. Criterion C (APA, 1994) comprises the avoidance symptoms, with it necessary for the affected person to exhibit significant avoidance in at least three ways to meet the criterion. Although the DSM-IV does not subdivide this category, it is speculated that it is more useful to consider there being two types of Criterion C symptoms: effortful avoidance and numbing/dissociation; which represent two separate underlying mechanisms (Foa, Riggs, & Gershuny, 1995). Effortful avoidance symptoms include efforts to avoid thoughts, feelings, and/or conversations associated with the trauma; and efforts to avoid activities, places and/or people that arouse recollections of the trauma. Numbing/dissociation symptoms include intentional and unintentional avoidance of cues related to the traumatic event; diminished interest or participation in significant activities; feelings of detachment or estrangement from others; restricted range of affect (e.g., inability to have loving feelings). There is an additional symptom that does not clearly fall into either category: sense of foreshortened future. Some traumatised people possess a belief that they will not have a normal life, believing for example that they will not have a career, marriage, children or a normal life span. A number of physiological symptoms are represented by Criterion D (APA, 1994). These persistent symptoms are characterised by increased arousal (which were not present before the trauma) are: difficultly falling asleep; irritability or outbursts of anger; difficulty concentrating; hyper-vigilance; and an exaggerated startle response in response to stimuli. There is also evidence that many of those with PTSD also do not habituate to repeated presentations of stimuli, as do those without PTSD (Shalev, Orr, Peri, Schreiber, & Pitman, 1992). The fifth criterion, Criterion E (APA, 1994), is that the duration of the Criterion B, C and D symptoms is at least one month. Therefore a person would not meet the criterion if they had nightmares, flashbacks, or an exaggerated startle response for a week or two. Criterion F (APA, 1994), the final criterion, is that the disturbance caused by the symptoms causes significant distress or impairment in social, occupational, and/or other important areas of functioning. If a person is experiencing symptomatology that does not interfere with day-to-day living or cause distress, then a diagnosis of
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PTSD should not be made. A delayed onset is defined when the symptoms begin at least six-months after the trauma. Acute reactions require symptom duration of at least one but fewer than three months, whereas chronic reactions last at least three months or more. While a traumatic event is a necessary pre-condition, it alone is insufficient to produce posttraumatic stress symptoms, and most research in this area has focused on individual variations in response to traumatic events (Dalgleish, 1999). In order to understand the onset and severity of the posttraumatic stress response, the traumatic event must be understood in relation to the characteristics of the individual who experienced it (Dalgleish, 1999; Fairbank, Ebert, & Caddell, 2001; Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001; McFarlane, 1996; O’Leary, Alday, & Ickovics, 1998). Few studies have investigated how the individual characteristics, and the nature of the traumatic event itself, interact to inform the development of posttraumatic stress symptoms and PTSD. Yap and Devilly (2004) suggested that longitudinal studies are necessary to elucidate the complex aetiological process that underlies the development of this disorder. Prospective studies have shown that most trauma survivors display a range of PTSD reactions in the initial weeks after a traumatic event, but that most of these people adapt effectively within approximately three months. Those that fail to recover by this time are at risk for chronic PTSD (e.g., Blanchard et al., 1996; Koren, Arnon, & Klein, 1999; Riggs, Rothbaum, & Foa, 1995).
1.6 Prevalence of Traumatic Stress and Related Disorders
1.6.1 Community Incidence and Prevalence The largest and most highly regarded epidemiological study of PTSD, known as the National Comorbidity Study (NCS), was conducted by Kessler, Sonnega, Bromet, Hughes and Nelson (1995) in the United States. The researchers gathered information related to PTSD (using the DSM-III-R criteria), including the kinds of traumas most often associated with PTSD, socio-economic correlates, comorbidity of PTSD with other disorders, the duration of the disorder and the life-time prevalence. The lifetime
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prevalence rate for experience of a significant traumatic event (e.g., rape, assault, natural disaster, serious car accident, etc) was found to be 51.2% for women and 60.7% for men. However, not all of those who experienced a traumatic event went on to develop PTSD, resulting in a PTSD prevalence of 7.8% (10.4% for women, 5.0% for men) - a figure clearly below the rate of exposure. In the National Comorbidity Survey Replication (NCS-R; Kessler, Berglund, Demler, Jin, & Walters, 2005), a nationally representative sample of 5692 individuals were interviewed using the World Health Organization Composite International Diagnostic Interview. Similarly to the NCS, the overall lifetime prevalence rate of PTSD was found to be 6.8%. In the Australian National Morbidity Study (Creamer, Burgess, & McFarlane, 2001), data was obtained from a stratified sample of 10, 641 participants who responded to the Australian National Survey of Mental Health and Well-being. Creamer and colleagues found an estimated 12-month, PTSD prevalence rate of 1.3% in the general population, with 64.6% of men and 49.5% of women having ever experienced at least one traumatic event. The lifetime prevalence of PTSD among those respondents who were exposed to a traumatic event was found to range (according to the type of trauma experienced) between 2% and 65%. Of those who had experienced any traumatic event, 1.9% of men and 2.9% of women met criteria for PTSD over the previous 12 months.
1.6.2 Comorbidity of Trauma Related Disorders Comorbidity is the co-occurrence of more than one diagnosable disorder in an individual at the same time. Many studies have examined the comorbidity of disorders in traumatised populations, through the use of three types of studies: epidemiological studies with community samples; studies of particularly at-risk populations; and studies with clinical populations. The disorders that PTSD has most frequently been associated with are depression, anxiety, alcohol and substance use, anger and guilt (Forbes, Creamer, Hawthorne, Allen & McHugh, 2003). The NCS (Kessler et al., 1995) reported that 88% of males and 79% of females with lifetime PTSD met criteria for at least one other psychiatric diagnosis. In study 3 of this thesis, substance use and / or abuse in relation to exposure to trauma, is one of the key outcome variables. As such, only comorbidity research which addresses drug and alcohol use will be reviewed here. Substance abuse and dependence often develops as a secondary disorder when other coping mechanisms fail to comfort or reduce distress. A DSM-IV diagnosis of
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substance abuse is made when an individual’s pattern of alcohol consumption is maladaptive, as indicated by the occurrence of at least one of the following within a 12- month period: substance use that results in role impairment (e.g., failed work or home obligations); substance use in a hazardous situation (e.g., driving while intoxicated; substance-related legal problems; or social or interpersonal problems due to substance use. In a famous at-risk study, known as the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990), 3016 Vietnam veterans, era veterans (veterans who did not serve in Vietnam) and civilian controls were examined. It was found that of those Vietnam veterans diagnosed with chronic PTSD, 99% qualified for another psychiatric diagnosis at some stage, compared to 41% of those without PTSD. The most prevalent co-morbid disorder in the study was substance abuse or dependence (75%), followed by generalised anxiety disorder (44%) and major depression (20%). In an epidemiological study with a group of young adults, (Breslau, Davis, Andreski, & Peterson, 1991) found that 83% of her non-veteran PTSD sample met the criteria for at least one other psychiatric disorder compared to 44% of those without PTSD. The most common conditions were substance abuse or dependence (43%), major depression (37%) and agoraphobia (22%). In the National Comorbidity Study (NCS) Kessler and colleagues (1995) also found PTSD to be strongly co-morbid with affective disorders, anxiety disorders, conduct disorders and substance use disorders. They found that 52% of men and 28% of women with PTSD also met the lifetime criteria for alcohol abuse or dependence. For drug abuse, the numbers were 35% and 27% respectively . Substance abuse and dependence has consistently been shown to be co- morbid with PTSD (e.g., Boudewyns, Woods, Hyer, & Albrecht, 1991; Breslau, Davis, Peterson, & Schultz, 1997; Brown, Fulton, Wilkeson, & Petty, 2000; Iveziae, Bagariae, Orue, Mimica, & Ljubin, 2000; Mills, Teesson, Ross, & Peters, 2006).
1.7 Psychological Theories of Traumatic Stress Traumatic stress refers to the emotional, cognitive, behavioural and physiological experience of individuals who are exposed to, or who witness events that overwhelm their coping and problem-solving abilities (Lerner & Shelton, 2001). Such events are far beyond normal challenges faced in life, such as losing a job, serious illness, or going through a divorce. Traumatic events are typically unexpected and
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uncontrollable, and leave a powerful impact on an individual. They compromise an individual’s sense of safety and security, and leave the person feeling insecure and vulnerable (Lerner & Shelton, 2001). Traumatic stressors also frequently result in physical reactions that are more severe than those experienced due to “normal” stress. Examples of traumatic events include: rape, assault, industrial accident, motor vehicle accident, viewing the dead, and viewing severe burns, dismemberment or an open wound. Numerous theoretical perspectives have been presented in an effort to explain the response to trauma, including behavioural (Keane, Zimering, & Caddell, 1985; Keane, Zimmering, & Caddell, 1985), biological (Bremner, Davis, Southwick, Krystal, & Charney, 1994; van der Kolk & Saporta, 1993), cognitive (Creamer, Burgess, & Pattison, 1992; Foa, Steketee, & Rothbaum, 1989) and psychobiological (Jones & Barlow, 1990) theories. Each of these approaches has contributed to the current understanding of PTSD, however for the purpose of this review the cognitive and behavioural theories will be the focus. As will become apparent, the interventions trialled in this thesis will be based upon these theories, which have been shown to be the most effective in providing rationales for PTSD treatments.
1.7.1 Cognitive Theories
1.7.1.1 Information Processing Theory Most of the current cognitive theories of PTSD are based upon (Lang, 1977, 1979) bio-informational theory of fear. Lang defined emotion as a memory structure organised as a multidimensional network of “propositions”. Lang viewed fear as a cognitive (memory) network that contains information about: (a) the stimuli that elicits the fear; (b) verbal, physiological, cognitive and behavioural responses evoked by the stimuli; and (c) interpretative information about the stimuli and associated response (Lang, 1977). Lang proposed that significant behaviour change is mediated by the processing of an affective memory structure, and by the alteration of its associated cognitive and physiological response. When confronted with fear-relevant stimuli (e.g., a car following involvement in a car accident) one’s network of memories, responses, attitudes and beliefs become primed and made more accessible to experience.
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Individuals with anxiety disorders, according to Lang, have an unusually coherent and stable fear network that requires the presence of few associated elements in the environment for activation. In other words, such individuals are hyper-prepared to perceive threat in ambiguous situations and to attend to fear-relevant cues in their environment. Distress elicited from cues promotes both physical and emotional avoidance (both physical and emotional, Foa & Kozak, 1986; Litz & Hearst, 1994) Rachman (1980) proposed a theoretical account for fear reduction based on emotional processing. He defined emotional processing as the decline of emotional disturbance to the extent that other experiences and behaviours proceed without disruption, and as a process that was dependent upon direct experiencing of the emotional disturbance (Telch, Valentiner, Ilia, Petruzzi, & Hehmsoth, 2000). He regarded the return of fear and disturbing dreams, and unpleasant intrusive thoughts to be some of the signs of incomplete processing . Rachman (1984, 1991) noted that fears can be acquired through conditioning as well as other processes such as vicarious and verbal transmissions. He proposed that there are three major associative pathways to the acquisition of fear: (1) classical conditioning, (2) observational experiences, and (3) instructional or informational experiences. In addition, Rachman postulated that direct fear-conditioning would lead to severe fears, whilst indirect fear-conditioning (i.e., vicarious or instructional pathways) would lead to mild to moderate fears. He predicted that directly-conditioning fears would be characterised by more elevated physiological and behavioural symptoms than cognitive symptoms, while indirectly-conditioned fears would be characterised by more elevated cognitive symptoms than physiological and behavioural symptoms. Rachman referred to this prediction as the ‘differential-anxiety- response’ hypothesis. Based on Lang’s bio-informational theory of fear and Rachman’s emotional processing theory, Foa and Rothbaum (1989; 1998) developed the fear network theory. Foa, Steketee and Rothbaum (1989) propose that after a traumatic event, a fear network, which stores three types of information about the threatening event is formed. Consistent with Lang’s theory, the three types of stored information are: (a) information about the feared stimulus situation (sensory details); (b) information about verbal, physiological and overt behavioural responses; and (c) information about the meaning of the stimulus and the response (Foa et al., 1989). This fear network acts as a programme for escape and avoidance behaviour, and is thought to be stable, broadly
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generalised and thus easily accessed. According to the theory, because trauma-related stimuli are highly represented in the fear network, they are readily activated by internal and external cues (Foa & Kozak, 1986). This explains the intrusive and re-experiencing symptoms, and hypervigilance that are characteristic of PTSD. In addition, Foa, et al., (1989) propose that PTSD is distinguished from other anxiety disorders by the monumental significance that the traumatic event holds, in conjunction with the violation of an individual’s formerly held core beliefs about safety. Therefore the traumatic event leads to a representation in memory that is dramatically different to those created by everyday experiences. Foa and Kozak (1986) suggest that adaptive recovery from trauma depends on two conditions. First, emotional engagement must occur. The fear structure must be activated by fear-relevant information and accessed, so that the cognitive schema can be modified. According to information processing theory, if this activation is sufficiently repetitive and prolonged and conducted in a safe environment, the stimulus-response associations will be weakened and will reduce the magnitude and intensity of the fear network. Second, there needs to be an introduction of corrective information that challenges the fear-related schema. This new information facilitates the formation of new cognitive schemas (Foa & Kozak, 1986) Ehlers and Clark (2000) have proposed a cognitive model to explain persistent PTSD. They suggest that PTSD becomes persistent when individuals process a traumatic event in a way which produces a sense of serious, current threat. Their model proposes that the sense of current threat arises as a consequence of (i) excessively negative appraisals of the trauma and/or its sequelae and (ii) a disturbance of autobiographical memory for the trauma. The perceived threat may be external (i.e., ‘nowhere is safe’) or internal (i.e., ‘I can’t trust my own judgement’). They suggest that once activated, the perception of current threat is accompanied by intrusions, re- experiencing symptoms, arousal, anxiety symptoms and other emotional responses. The perceived threat also motivates a series of behavioural and cognitive responses (e.g., avoidance). While these responses are intended to reduce the perceived threat and distress they prevent cognitive change and subsequently maintain the disorder (Dunmore, Clark, & Ehlers, 1999; Ehlers & Clark, 2000). A second source of a sense of current threat is the nature of the trauma memory itself. Ehlers and Clark argue that persistent PTSD is associated with trauma memories
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that are poorly elaborated and poorly integrated into existing autobiographical memories (see also Foa, Molnar, & Cashman, 1995; van der Kolk & Fisler, 1995). They propose that poor elaboration and incorporation of trauma memories accounts for the difficulty PTSD sufferers have in intentionally recalling aspects of the trauma memory, whilst experiencing unintentional triggering of re-experiencing symptoms and intense emotions to trauma related cues (Dunmore, Clark, & Ehlers, 2001). In addition, poorly elaborated memories make cause the incorporation of information that might disconfirm negative appraisals to be difficult. According to Ehlers and Clark there is a reciprocal relationship between the nature of the traumatic memory and the appraisal of the trauma. When individuals with persistent PTSD recall the traumatic event, their recall is biased by their appraisals and the individual also selectively retrieves information that is consistent with their appraisals.
1.7.1.2 Social Cognitive Theories Information processing theorists have proposed that knowledge acquired throughout life is represented in memory in the form of abstract mental frameworks known as “schemas” (Bartlett, 1932). Piaget (1952) described schemas as the building blocks of knowledge and intellectual development. Schemas are specific networks of information about a given stimulus domain, that influence the encoding and interpretation of information, and are stored in long-term memory (James, 2003). They serve as pre-existing theories that provide a basis for anticipating the future, and guide memory, aide in the interpretation of new information, and influence how we retrieve stored memories (Fiske & Taylor, 1984). When a person recalls an event from the past, they activate schemas in a conscious manner, whilst when a person is engaged in a procedural task, such as riding a bike, they are activated in an unconscious manner. When a person performs a complex task such as driving a car, there is a dynamic interplay between unconscious (automatic) and conscious activation (James, Southam, & Blackburn, 2004). Horowitz (1986) who argued initially within a psychodynamic paradigm, argued that when faced with trauma people have a need to process and integrate the new trauma knowledge with pre-existing cognitive schemata. He argued that this “completion tendency”, keeps the trauma knowledge held in active memory until the processing is
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complete, and the experience is resolved. Horowitz argued that, at this stage, individuals may be unable to match their thoughts and memories (flashbacks, nightmares, intrusive recollections) of the trauma with their existing schemas because it lies outside the realm of normal experience. In response to this conflict, psychological defense mechanisms are activated to avoid memories of trauma, and to limit the extent to which it is recalled. This results in the individual exhibiting numbing, avoidance or denial of the trauma. Horowitz suggests that the individual oscillates between phases of avoidance and intrusions of the trauma. This oscillation allows the trauma information to be processed, and as this occurs the oscillations become less frequent and intense. Failure to process the trauma information is proposed to lead to persistent posttraumatic reactions, with the information remaining in active memory without becoming fully integrated and continuing to intrude and be avoided. With respect to the meaning component of trauma memories, theorists have focused on the content of cognitions, people’s basic assumptions about the world, and the impact of traumatic events on these assumptions. Janoff-Bulman (1992b) regards three assumptions as the most significant in influencing one’s response to trauma: (1) the perceived benevolence of the world; (2) the meaningfulness of the world; (3) and the worthiness of the self. The first assumption, that the world is a benevolent place, involves a person’s perception of the extent to which good versus bad events occur in the world, and the fact that there is a general over-riding belief that more good events occur than bad. The assumption of the meaningfulness of the world involves people’s beliefs about the distribution of outcomes. People generally believe that they directly control what happens to them through their own actions. The third assumption of vulnerability involves beliefs about oneself. A person’s measure of self-worth is predictive of how deserving they believe they are of good or bad outcomes. For example, a person with high self-worth would have very few perceptions of vulnerability, believing that their moral character would serve to protect them from the world. Also known as the ‘just world belief’ , this is the belief that good things happen to good people and bad things happen to bad people (Resick, 2001). According to this model, under normal circumstances an individual’s world- view changes and grows when information is assimilated and accommodated into the existing perspective. Janoff-Bulman (1992) suggests that a traumatic event shatters the deeply held assumptions about oneself and the world, resulting in an intense
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psychological crisis. In order to successfully recover from the event, an individual’s assumptions must be reconstructed and equilibrium must be established. More specifically, the individual must work to re-establish a conceptual system in which either the experience is assimilated into the old set of assumptions or the core set of assumptions are changed so that they can accommodate the traumatic experience. The shattered assumptions theory would seem to predict that those with the most positive experiences in life, and therefore the most positive assumptions should be most affected by traumatic events. However, as several commentators have noted (e.g., Resick, 2001), the exact opposite is the case, with previous exposure to trauma being a major risk factor for developing PTSD (Breslau, Chilcoat, Kessler, & Davis, 1999). Foa and Riggs (1993) posit that instead of those with an exaggerated notion of the world being inherently good or of the world being inherently bad being most likely to develop PTSD, it is those with “flexible” schemas that are least likely to develop PTSD. Those who perceive the world as sometimes good and sometimes bad, and who realise that their ability to cope varies from situation to situation, will be most likely to recover from trauma (Foa & Riggs, 1993). This is due to the relative ease with which such a person can incorporate and process the traumatic event, and because the individual is not required to substantially change their view of themselves or the world (Foa, 1997).
1.7.2 Behavioural Theories Within the behaviourist orientation there have been two major schools of thought and study. The earlier classical conditioning theorists studied the connection between stimuli (events) and the responses that they incited. The later operant conditioning theorists were interested not only in the relationship between a stimulus and a response, but were also interested in the consequence that followed the response. Both the classical and operant theorists focused solely on observable actions displayed by individuals. The principles of classical and operant conditioning were used by Mowrer (1960) as the basis of his Two-Factor Learning Theory, which he used to describe the acquisition and maintenance of fear.
1.7.2.1 Classical Conditioning Classical conditioning was first discovered by the Russian physician and physiologist Ivan P. Pavlov (1849-1936). In his famous experiment conducted with his
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laboratory dogs, Pavlov decided to investigate his observation that his dogs salivated (unconditioned response- UCR) both when food (unconditioned stimulus- UCS) was present, and before the standard feeding time. To investigate this phenomenon he paired the presentation of a ringing bell (a neutral stimulus that did not trigger salivation with the presentation of the UCS (food). After about 20 pairings or “trials” the formerly neutral action of ringing the bell activated salivation- even when food was not presented. The neutral stimulus became a conditioned stimulus (CS) that activated salivation (now a conditioned response-CR). Thus, as a result of conditioning, the CR will occur either when presented with the UCS or the CS. Pavlov also recognised that repeated non-reinforced presentation of an UCS resulted in a decline in the strength of response it elicits, also known as habituation . In relation to the treatment of fear, anxiety or phobia, habituation occurs when a stimulus that causes anxiety is repeatedly presented, until the anxiety response that it elicits declines.
1.7.2.2 Operant Conditioning The later school of behaviourism, known as operant conditioning (also known as reinforcement theory), emerged from the work of B. F. Skinner (1904-1990). Interested in studying the effect of environmental consequences, Skinner conducted a series of experiments in which rats and pigeons “operated” on the environment instead of being passive. Through his experiments he discovered that whether a response to a stimulus continues to occur depends on the consequences that follow that behaviour. He noted that the promptness of the administration of that consequence is also important. Skinner’s work was furthered by E. Thorndike (1874-1949), who is considered to be the originator of reinforcement theory. Thorndike described several principles regarding the effect of consequences upon behaviour. His “law of effect” stated that the strength of connection between a stimuli and a response is an effect or result of the consequence that follows the behaviour.
1.7.2.3 Davey’s Two-Component Conditioning Model In more recent times, conditioning models have been re-visited by Davey (1993), in the development of his two-component conditioning model. Davey adopts the view that emotional responses may be influenced by unconscious learned associations derived from intense or repeated aversive events. His two-process conditioning model
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includes two components: (a) a CS-UCS associative component of the same type as Pavlovian conditioning models (although the associations are complex cognitive processes); and (b) a UCS revaluation component which describes how the processes that influence an individual’s evaluation of the UCS can influence the resultant CR (see Figure 1.1).
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Expectancy Evaluation Based Upon: Situational, social and verbal information, and existing beliefs
Conditioned Cognitive
Stimulus (CS) OUTCOME Conception of EXPECTATIONS Unconditioned
Stimulus (UCS)
Conditioned EVALUATION
Response OF UCS
UCS Revaluation Processes:
a) Experience with UCS; b) Social/verbal
information; c) Self-observation of
reactions to CS & UCS; and d) Individual
coping strategies
Figure 1.1 Davey’s Two-Process Model of Conditioning
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The factors upon which the expectancy evaluation is based may influence the strength of the outcome expectancy. This process was exemplified by a series of experiments (Davey, 1992; Honeybourne, Matchett, & Davey, 1993), which showed that there is a pre-experimental UCS-expectancy bias. The researchers found that subjects enter selective association studies with an inflated estimate of the probability of fear relevant stimuli being followed by aversive consequences. In a ‘threat’ conditioning procedure, subjects were told that they might receive shock following some stimuli but in fact they received none. Subjects began the experiment with a significantly higher expectancy of aversive UCSs following fear relevant stimuli (snake and spider) than fear irrelevant stimuli (cat and pigeon). This UCS-expectancy bias with fear relevant stimuli dissipated with continued non-reinforcement, but could be reinstated by a single stimulus-UCS pairing. Davey (1992) concluded that (a) this phenomenon could not be the result of a computational bias because subjects received no presentations of the UCS on which computations could be based, and that (b) this bias could explain the main effects found in the traditional human laboratory selective association conditioning procedure. These include the frequent reports of differential CRs to fear relevant stimuli during preconditioning habituation, their resistance to extinction, and (because of the peculiarities of the design of laboratory selective association conditioning studies) the failure to find significantly superior acquisition with fear relevant stimuli. Davey and Matchett (1994) conducted a further series of experiments in order to investigate the relationship between trait-anxiety, UCS rehearsal and CR retention or incubation . Incubation refers to the situation where subjects exhibit an increased magnitude fear response over successive exposures to an un-reinforced CS (Eysenck, 1979). Davey and Matchett (1994) found that reliable incubation-like effects could be found in laboratory analogues of phobic acquisition. These effects, however, were dependent upon: (a) inter-trial rehearsal of the UCS; and (b) high levels of anxiety (either state or trait anxiety) during the rehearsal process (Davey, 1993). Incubation was also found to be related to higher ratings of the aversiveness of the UCS, which may be related to the participants’ evaluation of the UCS. Davey and Matchett (1993) suggested that this increase in perceived aversiveness to the UCS may be caused access to fearful and anxious memories during rehearsal, being facilitated by anxiety. This results in increased aversiveness of the rehearsal process for anxious participants. Davey (1993) considers the aforementioned findings in terms of trauma related
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disorders, pointing to the existing accounts of trauma-related memory processing (e.g., Foa et al., 1989; Horowitz, 1986; Lang, 1977) which maintain that post-traumatic processing of trauma related memories is adaptive or leads to therapeutic resolution of the memory networks associated with trauma. However, Davey believes that his results imply that intrusion activated rehearsal of trauma may not always be beneficial, and may in fact lead to an increased evaluation of the trauma, if conducted under conditions of stress or anxiety. This may occur as the result of a strengthening of the association between the trauma memory and other anxiety-relevant memories that is mediated by anxiety. In the case of PTSD, if an individual is in an anxious state, which is mediated by either situational or trait factors, the characteristic intrusions that occur immediately post-trauma may become increasingly aversive and trigger PTSD (Davey, 1993).
1.7.2.4 Mowrer’s Two-Factor Learning Theory Mowrer’s Two-Factor Learning Theory (1960) of phobias integrates the contributions of both classical and operant conditioning to explain how fear is acquired and maintained. The first stage of Mowrer’s (1960) model involves the pairing of a neutral stimulus with an aversive stimulus that causes discomfort and anxiety, and uses the principles of classical conditioning. Mowrer suggests that an aversive unconditioned stimulus (UCS) elicits an unconditioned response (fear and arousal). Other neutral stimuli (e.g., a word, thought or image) become paired (conditioned stimuli [CS]) with the UCS such that the previously neutral stimuli come to elicit fear and arousal, a conditioned response (CR). This CR may transfer to other stimuli through the processes of secondary conditioning, higher-order conditioning and stimulus generalisation. Through these processes, the number of CS increases and stimuli that are similar to the original CS also gain anxiety-eliciting properties. These processes of have been invoked to explain some of the re-experiencing and avoidance symptoms of PTSD (e.g., Foa et al., 1989; Keane, Zimering et al., 1985; Keane, Zimmering et al., 1985). This first stage of the Mowrer’s model conceptualises a traumatic incident, such as a car accident (Figure 1.2), in terms of classical conditioning. The car accident and the associated helplessness, pain and/or threat of physical harm or death are UCS that evoke UCR of terror and anxiety. Stimuli associated with accident-induced UCS that are present at the time of the accident, such as persons, situations, or events (e.g., driving in a car), can produce a CR characterised by fear and anxiety. Thus, some
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stimuli that are present during the accident situation, such as driving in a car, become CS for fear and anxiety. Classical conditioning theory also posits that fear and anxiety responses can generalise to other stimuli with similar properties to the CS. Therefore, the anxiety response elicited by the stimulus of the accident might, for example, generalise to other modes of transport (Kilpatrick, Resnick, Saunders, & Best, 1998).
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AVOIDANCE UCS UCR (e.g., Crash / imminent pain) (Fear)
UCS + Neutral UCR (Crash) (Driving Car) (Fear)
Pairing CS CR (Driving Car) (Fear)
GENERALISATION
CS 1 + Neutral CR (Driving Car) (In Vehicle) (Fear)
CS 2 CR (In Vehicle e.g., On Bus) (Fear)
Note: CS 1 = originally conditioned stimulus; CS 2 = generalised conditioned stimulus
Figure 1.2
Mowrer’s Two-Factor Theory: Stage 1 Classical Conditioning as Applied to the Development of a Post-Car Accident Fear.
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According to the second stage of Mowrer’s theory, the conditioned fear produced by the first stage, is then expected to have motivational and reinforcing properties. In other words, the resulting conditioned fear response sets the stage for other behaviours whose function it is to avoid or escape the situations or stimuli that produce the conditioned fear response. Such behaviours become strengthened through negative reinforcement, which is produced by an immediate reduction in anxiety following avoidance (Foa et al., 1989). This whole process then serves to maintain fear and arousal, as the avoidance and escape behaviour terminates the CS before the individual has the opportunity to realise that the CS may no longer be followed by the aversive UCS. As such, for the example of the car accident the accident victim will avoid all stimuli or situations that remind them of the accident (i.e., travelling in a vehicle). This avoidance response is negatively reinforced by a reduction in anxiety as a result of the avoidance behaviour. The avoidance behaviour becomes resistant to extinction and must be changed to produce a reduction in the fear response (Figure 1.3) (Kilpatrick et al., 1998).
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Arousal/ Avoidance/ Fear Escape
Driving Increased Avoid/ Decreased/ Arousal Escape Arousal
Punisher Negative Reinforcement
Reinforcement Trap
Figure 1.3
Mowrer’s Two-Factor Theory: Stage 2 Operant Conditioning as Applied to the Development of a Post-Car Accident Fear
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Thus, according to the two-factor model fear is acquired through classical conditioning, but thereafter, it is maintained through operant conditioning with a person finding that their anxiety is relieved when they avoid the place, situation or activity that they fear. Based on this conceptualisation, Keane, Zimmering, and colleagues (1985) suggested that individuals exposed to a traumatic event, may become conditioned to a wide variety of stimuli, through the processes of higher order conditioning and stimulus generalisation. These stimuli become associated with the traumatic event, eliciting anxiety (Foa et al., 1989). Keane, Zimmering, and colleagues (1985) propose that the characteristic PTSD responses (e.g., re-experiencing the traumatic event via thoughts, recollections and nightmares) are part of the normal recovery process following trauma. However, when a high degree of generalisation, higher order conditioning and avoidance occur, these symptoms are maintained over time and anxiety increases. They argue that extinction is achieved through exposure to the conditioned stimulus until habituation occurs. Following habituation, the fear response is extinguished. For PTSD patients exposure is usually not complete during normal activities or sleep because avoidance occurs preventing extinction (Foa et al., 1989). Mowrer’s Two-Factor Theory provides a powerful explanation for many of the prominent features of PTSD. It is able to explain the wide range of potential trauma reminders for individuals, physiological and emotional arousal elicited by those reminders, and the central role of avoidance in the maintenance of PTSD. However it does not clearly distinguish the aetiology of PTSD from other anxiety disorders. It has also been criticised for its simplicity and inability to explain changes between stimuli such as contiguity, generalisation and incubation (Davey, 1993; Rescorla, 1978).
1.8 Conclusion Although many people are exposed to a traumatic event at some stage during their lifetime, the development of PTSD as a result of this exposure is not inevitable, and in fact it is quite unlikely. However, for a minority of people exposure to a traumatic event will cause them to go on to develop trauma symptomatology. In Chapter 1, the nature and aetiology of this symptomatology have been discussed, as have the psychological theories which are currently used to account for trauma symptomatology. In this chapter, the current treatments for PTSD have also been discussed, and the
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theoretical framework which was used to develop these treatments was reviewed. The cognitive theories that were reviewed in Chapter 1 are used to inform the development of new PTSD treatment protocols. Currently, the only protocol which aims to mitigate PTSD is psychological debriefing. In the next chapter the psychological debriefing literature will be reviewed and so will the literature relating to vulnerabilities to the development of pathology following trauma and misinformation. In Chapter 5 a RCT of group psychological debriefing is reported.
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Chapter Two: Psychological Debriefing, Vulnerabilities to the Development of Pathology Following Trauma and Misinformation
In the following chapter a number of topics will be reviewed. The common thread between each of these topics is their relationship to emergency services workers. A review of psychological debriefing will be conducted. This intervention has been used with high level of frequency amongst emergency workers in recent times therefore the evidence associated with the intervention will be critically assessed. Next, the vulnerabilities to the development of pathology following trauma are reviewed, with each of these vulnerabilities discussed in relation to emergency services personnel. In Chapter 7 of this thesis, a real-life trial of resilience training for police officers is prevented. This study measures the pre-training vulnerabilities of the police officers involved in the study, therefore it is important that the vulnerabilities to the development of pathology following trauma literature is reviewed to provide the reader with an understanding of these concepts. Finally, misinformation is explored. Emergency services personnel face an increased chance of having to provide eyewitness testimony due to the nature of their work. Given this, it is important that psychological interventions provided to emergency services personnel do not increase the person’s estimation of threat, or interfere with their memory, for traumatic situations. In both Study 1 and Study 2 of this thesis, the misinformation effect will be explored.
2.1 Psychological Debriefing
2.1.1 Introduction Psychological Debriefing (PD) is the generic term used to describe a variety of brief crisis intervention models, which each have the major aim of mitigating trauma related pathologies, and in particular PTSD (Devilly & Annab, 2008). Of the number of models utilised, Critical Incident Stress Debriefing (CISD; Everly, Flannery, & Eyler, 2002) is the oldest and most widely used. As such, this model is focused on in the current review. Although CISD is commonly utilised after a traumatic event (Devilly, Gist, & Cotton, 2006; Rose, Bisson, & Wessely, 2004; Wessely & Deahl, 2003), in recent years researchers have begun to question the efficacy of the intervention
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(Campfield & Hills, 2001; Deahl et al., 2000; Gist & Devilly, 2002). The current review examines the history of PD, current debriefing models, and increasing concerns regarding these models.
2.1.2 The History of PD The provision of PD has military origins, with World War I and II soldiers “debriefed” by commanders immediately after a significant battle. The expectation was that sharing personal stories about a battle would improve morale and better prepare soldiers for future combat. Parallel to this, battlefield psychiatrists developed strategies to address the needs of soldiers who were incapacitated by acute combat stress. Described by Kardiner and Spiegel (1947), this approach was based on three principles: proximity, immediacy and expectancy. The approach was based on the idea that soldiers would recover more quickly from their combat experiences if they were treated near the battlefield, were treated shortly after their problems were identified, and if there was a strong expectation that they would be quickly returned to active duty. This type of debriefing was designed to be a ‘mental health’ debrief, and was distinct to the operational debrief that soldiers underwent where operational aspects of the campaign (such as reviewing the execution of military manoeuvrers) were discussed. Subsequent to the crisis intervention movement of the 1970s PD was developed to deal with the increase in frequency of civilian disasters. Various mental health professionals created PD programmes as group interventions for workers involved in traumatic situations (e.g., Armstrong, O'Callahan, & Marmar, 1991; Dyregrov, 1989; Mitchell, 1983; Raphael, 1986; Young, 1988), all of which were designed to reduce and prevent adverse psychological responses to the traumatic event. The key elements of PD are ventilating emotions about the trauma, while discussing one’s thoughts and feelings, and reactions with a trained professional, who in turn, provides psycho-education about traumatic stress responses and attempts to normalise these reactions (McNally et al., 2003).
2.1.3 Critical Incident Stress Debriefing (CISD) Critical Incident Stress Debriefing (CISD), developed by Jeffery Mitchell
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(1983), has become the most widely accepted and commonly used PD intervention. It is best described as a generic term for a type of immediate intervention following trauma (usually within 3 days) that seeks to relieve stress with the goal of mediating or avoiding long term pathology (Devilly et al., 2006). Originating from emergency services work and para-military organisations Mitchell (1983) adapted the technique for use in civilian disaster situations. The goals CISD was designed to achieve are “(a) to mitigate the harmful effects of traumatic stress on emergency personnel and (b) to accelerate normal recovery processes in normal people who are experiencing normal reactions to abnormal events” (Everly & Mitchell, 1995; p. 174). A single debriefing session is said to “generally alleviate the acute stress responses which appear at the scene and immediately afterwards and will eliminate or at least inhibit, delayed stress reactions” (Mitchell, 1983; p.36). The CISD model’s core goal is to prevent stress reactions, and is based on the core premise that everyone experiencing a “critical incident” is at risk for later psychopathology (Devilly & Annab, 2008). PD is typically applied to individuals whose work entails risk for exposure to trauma, such as law enforcement personnel, emergency medical technicians, fire fighters, military personnel and disaster workers such as the Red Cross. It may be attractive to workers in these occupations, because it is not presented as a clinical intervention, but instead claims to be an opportunity for individuals to share their common “normal reactions to abnormal events”. PD is founded on the belief that promptly taking someone through traumatic experiences will aid people in recovering from psychological damage. Although initially designed as a group intervention, and to be seen as one part of a comprehensive, systematic, multi-component approach to the management of traumatic stress (Mitchell, 1983), PD has also been used with individuals (Tehrani & Westlake, 1994) and as a stand-alone intervention. According to its advocates, debriefing works because it is delivered soon after the trauma, provides psychosocial support, an opportunity to express trauma related thoughts and emotions, and because it provides tips on coping and stress management advice (McNally et al., 2003). The CISD protocol that (Everly & Mitchell, 1997) describe is a group process of seven distinct phases, presented below:
1) Introduction, where the process is explained, rules are outlined and expectations are set.
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2) Fact phase, in which the group members describe their roles and tasks during the incident and provide facts for each other about what occurred. Members relate what they saw, did and heard. 3) Thought phase, in which the group members are asked to remember their first thoughts as awareness of the event and its magnitude developed. 4) Reaction phase, during which the group members talk about their emotional reactions to the experience. This is sometimes labelled the “feelings” phase. 5) Symptom phase, in which members are asked to review their own physical, emotional, behavioural, and cognitive symptoms during the event and after. 6) Teaching phase, where the facilitator provides information about common, likely, or possible stress responses. 7) Re-entry phase, where the facilitator provides a summary, answers any questions, and provides referral information.
CISD sessions usually last one to three hours, and are typically conducted within 24 to 72 hours of the traumatic event. It is claimed that the goal of CISD is to obtain “psychological closure subsequent to the crisis” (Everly, Flannery, & Mitchell, 2000; p. 26). More recently, CISD has been revamped, and new components have been added to the programme (i.e., other self-help activities). This new programme, called Critical Incident Stress Management (CISM; Everly & Mitchell, 1999), is claimed by advocates to represent a distinct intervention from CISD. Others, such as (Devilly & Cotton, 2003), argue however that CISD and CISM are yet to be sufficiently differentiated, and are yet to be contrasted to determine any differential efficacy.
2.1.4 Individual Debriefing Although initially Mitchell (1983) described a debriefing session as “either an individual or group meeting between the rescue worker and a caring individual (facilitator) who is able to help the person to talk about his feelings and reactions to the critical incident (p. 37), Mitchell now argues that CISD is only suitable to be administered to groups, not to single individuals. A Cochrane Review, in the form of a meta-analysis, was conducted on the PD literature by (Rose et al., 2004). Of the numerous studies considered, only 11 studies
52 Tracey Varker PhD Thesis 2. Psychological Debriefing, Vulnerabilities and Misinformation that utilised PD (using normalisation and ventilation) were found to meet the inclusion criteria of administering a single session within one month of the trauma, and using a randomised design. Only studies that conducted PD with individuals and couples were found to meet the researchers’ criteria. The review was not only restricted to CISD, with all PD methods included in the review. Upon review, (Rose et al., 2004) concluded that there is “no current evidence that single session individual PD is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents”. None of the studies reported a significant reduction in posttraumatic symptomatology in those that received the debriefing compared to those who did not. In the only 2 long term RCTs discovered, it appears that debriefing increased long-term traumatic distress (Bisson, Jenkins, Alexander, & Bannister, 1997; Hobbs, Mayou, Harrison, & Worlock, 1996). Another meta-analysis of individual debriefing, (Van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002) found that studies that used the CISD method had no efficacy in reducing symptoms of post-traumatic stress. The authors offered a possible explanation for this finding, suggesting that CISD may interfere with the alternation of intrusion and avoidance that interferes with the natural processing of a traumatic event. They suggest it may also interfere in a larger sense, with victims being inadvertently directed away from the support of family, friends, or other sources of social support. It has been argued however, by (Everly & Mitchell, 2000) that debriefing was not designed for individual use. Everly and Mitchell support the assertion that clinicians should use caution implementing a group crisis intervention protocol with individuals singularly (Busuttil & Busuttil, 1995). However, they did not go so far as to say that the use of debriefing for individuals is inappropriate. Results of RCTs conducted to date indicate that PD delivered to individuals or couples does not prevent PTSD or other psychopathology (Rose, Brewin, Andrews, & Kirk, 1999), and may worsen psychological outcomes in some participants (Mayou, Ehlers, & Hobbs, 2000).
2.1.5 Group Debriefing Only a small number of studies have investigated the efficacy of group debriefing. Chemtob, Tomas, Law and Cremniter (1997) reported that after 43 Hurricane survivors received group sessions of debriefing, their scores on the Impact of Events Scale (a measure of subjective distress) improved. However, it was not explicitly
53 Tracey Varker PhD Thesis 2. Psychological Debriefing, Vulnerabilities and Misinformation stated that the CISD model was used, and given that the debriefing was conducted six- months after the traumatic event (rather than the typical 24 - 72 hours), the approach used in this study is certainly not representative of the typical debriefing protocol. In addition, a review by Everly and Boyle reported that the study had a Cohen’s d of 1.35, however a re-examination of this finding by (Devilly et al., 2006) revealed a Cohen’s d of approximately half this size ( d between 0.57 and 0.68, depending on parameter estimates). In another examination of group debriefing, (Jenkins, 1996) conducted an assessment of 36 emergency workers who had attended a mass shooting. Jenkins found that those participants who had attended a group debriefing session ( n = 15) were more likely to have a reduction in anxiety and depressive symptoms, as measured by the SCL-90-R. However, there are several major methodological weaknesses which limit the utility of this study. The pre-event SCL-90-R scores were obtained by asking the participant to “remember how you were feeling a week before the shooting” (p. 481). Such a retrospective approach introduces the potential for reconstructive memory bias, and may also reflect non-specific halo effects arising from visible displays of concern at a time of high perceived need (Devilly et al., 2006). Additionally, participants self- selected participation in debriefing, which raises a number of concerns regarding internal validity, and the researchers did not stipulate the debriefing procedure that was applied. There have only been two published controlled trials of group debriefing, both of which were conducted after the Cochrane Review had been published. In the first of these, a group RCT of group debriefing was conducted by Adler and colleagues (2008) using 952 U.S. peacekeepers. CISD was compared to a stress management class (SMC) and survey-only (SO). Overall, CISD was not found to hasten recovery as compared to the other two conditions, and a small effect was found for alcohol use, with those in the CISD condition reporting slightly higher alcohol use scores than the other two groups post-deployment. For this study no clear positive effects were found to be related to CISD, although no strong negative effects were found either. The second controlled trial of group debriefing was an analogue study by Devilly and Annab (2008), where 64 students were shown a stressful video of paramedics attending to injured and dead victims of a road traffic accident. Participants were randomly divided into two groups, and half were debriefed following viewing of the video whilst the other half remained in
54 Tracey Varker PhD Thesis 2. Psychological Debriefing, Vulnerabilities and Misinformation the testing room, partook in refreshments, and chatted amongst themselves. Participants were followed-up after one-month. The researchers found that although both groups rated the video as distressing, there were no significant differences in measures of affective distress or trauma symptomatology, between those participants who received the debriefing and those who did not. At the follow-up those participants who received the debriefing recalled wanting to talk more to someone about the video than those who did not. (Devilly & Annab, 2008) suggest that this finding may be explained by cognitive dissonance, with those individuals who received debriefing overestimating, in retrospect, the degree to which they wanted to be debriefed. As previously discussed, there has only ever been two RCTs of group debriefing. The vast majority of studies suffer from general limitations such as poor reporting, inadequate sample sizes, low response rates, and sampling bias. While some of these factors are not always unavoidable, they do limit the ability to generalise and replicate the research. The few relatively well-constructed studies in the area of individual debriefing have failed to indicate any clear benefits of group PD (Deahl et al., 2000). Indeed, some researchers suggest that such programmes may be detrimental to longer term recovery (e.g., Devilly & Cotton, 2003; McNally et al., 2003). As such, there is clearly a need for another RCT of group debriefing, in order to extend our understanding of the effect of this intervention. In order to address this, an analogue RCT of group debriefing was conducted for Study 1.
2.1.6 Summary of PD PD is a relatively new intervention, which was designed with the intention of mitigating stress reactions following exposure to traumatic events. The oldest and most widely used form of PD is CISD, which is a seven phase form of debriefing. PD has been used with both individuals and with groups of people, despite the fact that there is limited evidence supporting the use of this intervention. In the Cochrane Review, it was found that of the 11 RCTs which have been conducted for individual debriefing, debriefing has only been found to have either no effect, or to make individuals worse. There has only ever been two published RCTs of group debriefing, therefore there is clearly a need for further research to be conducted, investigating group debriefing. In order to address this deficit in the literature, in Study 1 of this thesis, a RCT of group debriefing is reported.
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2.2 Vulnerabilities to the Development of Pathology Following Trauma
2.2.1 Introduction The likelihood of developing PTSD is moderated by both trauma-specific and person-specific variables. Ascertaining exactly which factors serve as protective factors and which act as risk factors is an area of research which has received a great deal of attention in recent years. Assessing the myriad of factors which can affect the development of PTSD, or examining the relationship between protective and / or risk factors and resilience, are two areas of research which require further development. However such an examination is beyond the scope of this thesis. For Study 3, factors which are known to cause vulnerability for individuals who are exposed to trauma will be measured, so that these factors can be taken into account when the efficacy of the police resilience programme is evaluated. In the following section the vulnerabilities which will be measured in Study 3 will be briefly reviewed.
2.2.2 Pre-Trauma Vulnerabilities 2.2.2.1 Personality A great deal of research has been conducted to investigate whether personality is related to the development of post-traumatic reactions after exposure to a traumatic event. Personality variables have repeatedly been shown to be related to post-traumatic symptom severity (e.g., McFarlane, 1988; Morgan & Matthews, 1995; Schnurr, Friedman, & Rosenberg, 1993; Schnurr & Vielhauer, 2000; Sutker, Davis, Uddo, & Ditta, 1995). One of the most consistent findings is the positive relationship between neuroticism and post-traumatic distress (Breslau et al., 1991; Charlton & Thompson, 1996; Davidson, Kudler, & Smith, 1987). In order to assess for this factor, in Study 3 personality will be measured in order to check that both groups are similar in composition.
2.2.2.2 Previous Trauma Exposure An association between previous exposure to traumatic experiences and post- traumatic symptomatology resulting from subsequent trauma has often been reported
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(e.g., Breslau et al., 1999; Brewin, Andrews, & Valentine, 2000; Ozer, Best, Lipsey, & Weiss, 2003). High rates of childhood trauma have been reported in Vietnam veterans with PTSD (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993). Previous victimisation in women who have been raped, and previous combat stress have each been found to have an adverse effect on the likelihood and severity of the psychological sequelae of the later trauma (Foa & Riggs, 1993; Solomon, Mikulincer, & Jakob, 1987). Previous trauma exposure will be measured in Study 3 to ensure that the composition of both groups is equal for this factor.
2.2.2.3 Personal History of Psychiatric Disorder People with a history of psychiatric problems appear to be at greater risk for the development of post-traumatic symptomatology following exposure to a traumatic incident. In particular, anxiety disorders, depressive disorders, personality disorder and alcohol abuse have been associated with the development of post-traumatic symptoms (Blanchard et al., 1996; Ehlers, Mayou, & Bryant, 1998; Green, Grace, Lindy, Gleser, & Leonard, 1990; Ozer et al., 2003; Ursano et al., 1999). In order to check that both groups in the current study have an equal incidence of personal history of psychiatric disorder, this factor will be measured in Study 3.
2.2.2.4 Gender Studies with community samples have produced evidence to suggest that women are more likely than men to develop post-traumatic symptomatology after exposure to trauma (e.g., Beals et al., 2005; Kessler et al., 1995; Weaver & Clum, 1995). In a study of the effects of previous exposure to trauma, Breslau and colleagues (1999) found that men are more likely to be exposed to trauma than women, but that trauma-exposed women are more likely to develop PTSD, even when the type of traumatic event is controlled for. In addition, they found that women’s higher risk of PTSD was not attributable to sex differences in history of previous exposure to trauma. Results from studies involving police officers, however, have not been consistent with these findings. Carlier, Lamberts and Gersons (1997) found no relationship between gender and post- traumatic symptomatology, whilst Hodgins and colleagues (Hodgins, Creamer, & Bell, 2001) found that gender was not predictive of post-traumatic stress symptoms in their investigation of Australian police officers.
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2.2.3 Peri-Trauma Vulnerabilities 2.2.3.1 Severity of Trauma and Perceived Life Threat Trauma severity and perceived life threat have been found to be related to post- traumatic symptomatology in a number of studies (Donovan, Padin Rivera, Dowd, & Blake, 1996; Lauterbach & Vrana, 2001; Lee, Vaillant, Torrey, & Elder, 1995; Vernberg, LaGreca, Silverman, & Prinstein, 1996). Overall, the evidence for civilian populations suggests that events involving personal injury, forced sexual penetration, threat of death (Kilpatrick et al., 1989) or events that are largely unpredictable and uncontrollable are associated with more severe PTSD symptoms (Foa, Zinbarg, & Rothbaum, 1992; Janoff-Bulman, 1992a; Leskin, Kaloupek, & Keane, 1998). However, research regarding the relationship between critical incident stressors and the presence of distress has been equivocal for emergency services personnel (see Bryant & Harvey, 1995; Carlier et al., 1997; McFarlane, 1988). For the current study, the type of incidents that the police officers are exposed to (e.g., death, violence, sexual crime), and the frequency of such traumatic incidents will be measured, in order to verify whether both groups have been exposed to traumatic incidents to the same degree.
2.2.4 Post-Trauma Vulnerabilities 2.2.4.1 Social Support After a traumatic event victims are typically in great need of supports of all types. They are often very sensitive to how others react to them, and how others describe or make attributions about both the event, and the role the victim played (Johnson et al., 1997). The extent to which a victim’s social network validates or invalidates their experience can have an important effect on the victims’ psychological adaptation following a traumatic event. This type of validation, known as social support, is commonly defined as “the degree of emotional and instrumental support received by a person from the people in his or her environment” (Maercker & Müller, 2004, p. 346). Those victims that perceive themselves as receiving poor or few social supports following a traumatic event are more likely to have higher levels of post- trauma symptomatology (Cordova, Cunninghman, Carlson, & Andrykowski, 2001; Marmar et al., 1999; Southwick, Morgan, & Rosenberg, 2000). Likewise, studies that have explored the relationship between social support and post-traumatic
58 Tracey Varker PhD Thesis 2. Psychological Debriefing, Vulnerabilities and Misinformation symptomatology in emergency services personnel have found that those who receive poor or few social supports are more likely experience post-trauma symptoms (Carlier et al., 1997; Regehr, Hill, & Glancy, 2000; Stephens, 1996). For all studies in this thesis (Study 1, Study 2 and Study 3) social support will be measured, in order to check whether all groups involved in the studies received equal levels of perceived social support.
2.2.4.2 Optimism Optimism can be regarded as the generalised expectation of a positive outcome, whilst pessimism is defined as the generalised expectation of a negative outcome (Schweizer, Beck-Seyffer, & Schneider, 1999). Optimists make every effort to remain engaged with their goals, confronting the reality of the threat and dealing with it, whilst pessimists often instead try to ignore the problem or wish the problem away (Carver et al., 1993). The disposition of optimism plays an important role in a diverse range of behavioural and psychological outcomes when people are faced with adversity, with optimists displaying better physical and mental well-being than pessimists (Ebert, Tucker, & Roth, 2002; Peterson & Bossio, 1991; Schweizer et al., 1999). For example, optimism has been linked to a variety of positive outcomes, including faster recovery from surgery (Fitzgerald, Tennen, Affleck, & Pransky, 1993; Scheier et al., 1989), lower illness burden after natural disaster (Costello, 1998), less distress and fewer HIV- related concerns in gay men (Taylor et al., 1992), less distress in women following a failed IVF attempt (Litt, Tennen, Affleck, & Klock, 1992), and the mediation of distress among students who experienced traumatic events (Brodhagen & Wise, 2008). Optimism will be measured for the Study 3, in order to check whether both groups have similar levels of optimism.
2.2.4.3 Anger Anger is considered to be the experience and expression of hostile or furious feelings, which are either expressed or withheld (Spielberger et al., 1985). It has been implicated in the development of PTSD, with Riggs, Dancu, Gershuny, Greenberg and Foa (1992) finding in a prospective study, that one week after an assault, victims had higher state anger scores than non-victims. In addition, anger elevation at one week post-assault was also found to be predictive of PTSD severity one month later. The
59 Tracey Varker PhD Thesis 2. Psychological Debriefing, Vulnerabilities and Misinformation authors suggested that this finding may be explained by the fear network conceptualisation of PTSD as detailed in Chapter 1 (Foa et al., 1989), with the activation of anger allowing victims to avoid feelings of anxiety, thereby impeding the processing of distress feelings. Studies have also found a positive relationship between anger and PTSD development in MVA survivors (Ehlers et al., 1998), combat veterans (Chemtob, Hamada, Roitblat, & Muraoka, 1994), and assault victims (Andrews, Brewin, Rose, & Kirk, 2000; Koenen, Hearst-Ikeda, Caulfield, & Muldar, 1997). In Study 3, trait anger will be measured, to check whether both groups have a similar baseline level of anger.
2.3 Misinformation
2.3.1 Introduction In eyewitness memory situations, presenting misleading information to subjects often distorts memory. This area of research is now reaching maturity in non-clinical applications and has been termed the misinformation (Belli, Lindsay, Gales, & McCarthy, 1994; Loftus et al., 1978; Zaragoza & Mitchell, 1996). The current review examines the theories accounting for the misinformation effect, and details the evidence that supports its existence. The memory conformity effect is reviewed, and evidence relating to the impact of misinformation upon groups of individuals, and upon memory quality are also discussed.
2.3.2 The Misinformation Effect Several different theories have been posited to explain the misinformation effect. Loftus (1978, 1979a, 1979b) supports the view that assumes that misinformation irreversibly distorts a witness’s memory of the original event through a mechanism called “overwriting”. Memory for the original event detail is destroyed and the memory for the suggested detail becomes an integral part of the event memory. An alternative theory of memory impairment assumes that the original memory is maintained, and therefore, is available at least in principle (Frost & Weaver, 1997). However, it is argued that the misleading information renders the original information inaccessible as it becomes difficult or impossible to retrieve (Bekerian & Bowers, 1983). Discontented
60 Tracey Varker PhD Thesis 2. Psychological Debriefing, Vulnerabilities and Misinformation with the then existing theories, Lindsay and Johnson (1989) developed the “source misattribution” theory, which states that inaccurate memories are the result of confusion between the sources of events. Traces of the original and misleading information are both represented in memory, but the source of misleading information is mistakenly attributed to that of the originally witnessed event, due to the fact that the post-event misinformation is more recent and, therefore, more salient in memory. In one of the earliest investigations of eyewitnesses’ susceptibility to misleading suggestions, Loftus and colleagues (1978) developed a three-stage protocol. Subjects were shown a sequence of scenes, then verbally misinformed about details of the event, before then completing a forced choice recognition test that asked participants to choose between the item originally shown and that suggested in the post-event information. The researchers found that misleading information produced less accurate responding than for control items, and concluded that the results suggest that “information to which a witness is exposed after an event, whether that information is consistent or misleading, is integrated into the witness's memory of the event” (Loftus et al., 1978; p. 19).
2.3.3 Memory Conformity There is evidence to suggest that the memory of an individual who witnesses an event can be influenced through discussion of the event with other individuals who have also witnessed the event. A famous example of this comes from witness evidence in the 1995 Oklahoma bombing investigation. Key evidence came from three witnesses who had seen Timothy McVeigh rent a truck from Elliot’s Body Shop. One of the three witnesses said that McVeigh had been accompanied by a second man, although initially the other two witnesses did not mention a second man. Later, however, they too claimed to have seen a second man with McVeigh. Months later the first witness confessed he may have been recalling another customer. So why then did all three witnesses describe an accomplice with McVeigh? In later testimony it was revealed that the witnesses had discussed their memories before being questioned (Memon & Wright, 1999). It is likely that the first confident witness unintentionally influenced the others, leading them to report that they too had seen this second man (Memon & Wright, 1999; Schacter, 2001). In an examination of this phenomenon, known as memory conformity, Gabbert and colleagues (2003) had individuals watch different videos of the same criminal event and then perform a recall test. Each video contained unique items which were therefore
61 Tracey Varker PhD Thesis 2. Psychological Debriefing, Vulnerabilities and Misinformation seen by only one witness. Before performing the recall test, half of the participants were encouraged to discuss the events seen on the video in pairs, whilst those in the control condition were not allowed to discuss the video prior to the recall test. It was found that 71% of those witnesses who discussed the video with another witness went on to mistakenly recall items acquired in the discussion.
2.3.4 Misinformation in Groups Errant post-event information, or misinformation, is particularly problematic when it is introduced to a group of witnesses because errant consensus which may arise from a single source (as demonstrated in the McVeigh case), may be considered by police or a jurors as a sign of accuracy (Wright, Self, & Justice, 2000). Previous research has shown that hearing about someone else’s report can alter a person’s confidence in their own report (Luus & Wells, 1994). Similarly, Wright and colleagues (2000) conducted two experiments to investigate the effect of misinformation delivered by another person upon people’s memory reports. In experiment 1, participants were shown several cars, and were then given an “old”/ “new” recognition test in pairs, where pictures of the original cars plus new lures were shown. A small but reliable conformity effect was found, and it was found that providing misinformation lowered accuracy whilst providing accurate information increased accuracy. In experiment 2, participant pairs were shown a storybook of an identical crime, except that one member of the pair saw an accomplice and the other did not. It was found that initial memories were very accurate, but once the crime was discussed with the other person in the pair, most pairs conformed. In addition confidence ratings strongly predicted which person in the pair persuaded the other. It is also known that certain interviewing and questioning techniques are more likely to make individuals susceptible to reporting inaccurate information. In the 1980’s, a series of allegations erupted in the U. S. and Europe, which were known as the “day care ritual abuse cases”. Typically preschool children alleged that they had been sexually abused by day care workers in a series of satanic rituals. Although these allegations were initially treated seriously, widespread scepticism amongst research psychologists ensued (Bottoms & Davis, 1997). Subsequent investigations identified a number of interviewing techniques that were used to induce the children to make false reports (Ceci & Bruck, 1993, 1995).
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In a seminal study conducted by Garven and colleagues (1998) a number of the interviewing techniques that were used by investigators in the first day care ritual case, which occurred at the McMartin Preschool, were identified and tested. This set of interviewing techniques, known as the McMartin techniques, were found to be capable of inducing preschool children to make false allegations against a classroom visitor. Garven and colleagues (1998) randomly allocated to be questioned using either (a) suggestive questions, or (b) the McMartin techniques following a visit from a classroom visitor. They found that 58% of the children interviewed with McMartin techniques made false allegations against the visitor compared to 17% of the children interviewed with suggestive questions. Social influence and reinforcement were found to be the most powerful determinates. The misinformation effect could possibly have ramifications for eyewitness memory following a traumatic incident, where the witnesses are ‘debriefed’ by well- intentioned and unsuspecting counsellors. It is possible that misinformation and group conformity may increase the likelihood of creating a trauma ‘myth’ amongst those receiving debriefing but, and more importantly with respect to this study, may interfere with eyewitness testimony obtained by police directly after the event and in court during trial. This aspect of debriefing has never been experimentally tested. As previously discussed, several studies have examined the effect of a witness talking to another individual about an event upon memory. However, no published study exists which has examined the effect upon memory of a group of witnesses discussing an event. In particular, no study has ever examined the effect of group debriefing and the related possible provision of misinformation by other group members, upon an individual’s memory for an event. Therefore, in order to address this deficit in the literature, the second aim of Study 1 was to examine the impact of group debriefing upon an individual’s memory of an event, and to assess the effect of subtle misinformation giving during PD.
2.3.5 Misinformation and Memory Quality A goal of some misinformation studies is to examine the quality of memories resulting from misinformation. In order to do this Wright and Stroud (1998), for example, required witnesses to use Tulving’s (1985) “remember / know” distinction for accurate and misinformed memories. Brainerd and Reyna (1998) asked people to
63 Tracey Varker PhD Thesis 2. Psychological Debriefing, Vulnerabilities and Misinformation measure memories “identity” (i.e., memory is the same, or a match), “non-identity” (i.e., memory is not the same), and “similarity” (i.e., memory is similar). In yet another approach, Loftus, Donders, Hoffman and Schooler (1989) recorded participants’ reactions times and self-reported confidence levels. For this experiment, it was found that falsely recognised items were more quickly accessed and most confidently held. Several other researcher have similarly noted that following exposure to misinformation participants display more confidence in their incorrect responses than in their correct responses (e.g., Cole & Loftus, 1979; Greene, Flynn, & Loftus, 1982; Ryan & Gesiselman, 1991; Weingardt, Leonesio, & Loftus, 1994). It is suggested that following on from this and other research (e.g., Brainerd, Reyna, & Brandse, 1995) that such results may be obtained because true memories are based on unstable narratives while false memories are based upon relatively stable ‘ideas’. As such, the third aim of the current study was to examine whether an individual’s confidence ratings differ for an untainted memory compared to memories influenced through misinformation given during debriefing. Additionally, a person’s confidence in relation to whether the recalled memory was correct or incorrect was also investigated. Researchers have found that certain conditions maximise the misinformation effect, finding that eyewitnesses are more likely to remember and are less susceptible to misleading post-event information about central rather than peripheral details of an event (e.g., Burke, Heuer, & Reisberg, 1992; Christianson & Loftus, 1991; Clifford & Scott, 1978; Roebers & Schneider, 2000). This effect has primarily been observed with events, where it is assumed that the attentional focus is narrowed and central information is captured first (Yuille & Daylen, 1998). Other researchers, however, have examined this effect without reference to the emotional content of the stimulus material (Migueles & Garcia-Bajos, 1999; Wright & Stroud, 1998). In an investigation of the ease in which peripheral and central memories can be altered through misinformation, Heath and Erickson (1998) demonstrated that it is more difficult to alter a memory for a central detail from a series of slides depicting a crime, than a peripheral one. In order to extend the relatively small body of research in this area, the fourth aim of Study 1 was to further investigate memory for central and peripheral details of an event, and to also examine the effect of misinformation upon memory for central and peripheral details. Prior studies of memory conformity have typically presented co-witness information by incorporating it into a recall questionnaire (see Betz, Skowronski, &
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Ostrom, 1996; Hoffman, Granhag, Kwong See, & Loftus, 2001). As such, no ‘live’ interactions take place, which of course is far removed from what actually occurs in the real world. Therefore, to overcome this short-coming in the existing literature, for Study 1 a confederate was used to present the misinformation, which was a central feature of the investigation.
2.3.6 Summary of Misinformation Memory and the associated areas of the misinformation effect and memory conformity are all topics which have been quite extensively researched. However, there has never been any research conducted in relation to the impact of PD upon an individual’s memory for a traumatic event. As discussed in this Chapter, certain conditions can increase the likelihood of memory conformity and misinformation effects with central and peripheral memory being affected differentially. Given this, it is important that the effect of PD upon an individual’s memory be assessed empirically.
2.4 Conclusion In this section, the literature relating to PD, vulnerabilities to the development of pathology following exposure to trauma, and misinformation have each been discussed in relation to emergency services personnel. Following on from these reviews, in Study 1 of this thesis a randomised controlled trial of group debriefing is reported and the impact of this intervention upon memory is assessed. In Study 2 of this thesis, a randomised controlled trial of resilience is reported, and the impact of this intervention upon memory for the event is assessed. Finally, in Study 3 of this thesis, resilience training is trialled with police officers, and as part of this trial, vulnerabilities to the development of pathology following exposure to traumatic events are considered.
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Chapter Three: Study 1- A Randomised Controlled Trial (RCT) of Group Debriefing
3.1 Study 1: Overview This chapter presents a RCT of group debriefing. The aim was to assess the effect of this intervention upon eyewitness memory for a stressful event and eyewitness stress reactions, with a sample drawn from the general community ( n = 61). Participants were randomly allocated to one of three groups: debriefing; debriefing with an experimenter confederate present (a person who supplied 3 pieces of misinformation to the group regarding the stressful event); and a no-treatment control. All groups were shown a very stressful video and were again reviewed after one month. Members of the debriefing group where a confederate provided misinformation were more likely to recall this misinformation as fact than members of the other two groups. The debriefing group was also more accurate in their recall of peripheral content than the confederate group. Across all groups, participants were found to be more accurate at central rather than peripheral recall yet more confident for incorrect memories of the video than correct memories. Although the video was rated as being distressing, it was found that there were no significant differences between the three groups on measures of affective distress. These findings are discussed in relation to eyewitness testimony and distress mitigation.
3.1.1 Introduction As discussed in Chapter 2, in recent times PD has received a great deal of attention, and it has also been the source of a certain amount of controversy. Although proponents continue to promote and sell their product, an increasing number of researchers are beginning to question the legitimacy of providing an intervention without first confirming the scientific validity of the programme. In a Cochrane review of those few well-designed studies which have examined individual and couples debriefing, (Rose et al., 2004) concluded that there is “no current evidence that single session individual PD is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents”. There have only ever been two RCTs of group debriefing. As such, only very limited stringent scientific evidence exists relating to the
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efficacy of group debriefing. Therefore, to address this deficit in the literature and to provide evidence-based scientific research regarding the efficacy of group debriefing, for Study 1 a RCT of group debriefing was conducted. In Chapter 4, several studies which have examined the effect upon memory of a witness talking to another witness about an event were reviewed. PD has become a frequently utilised intervention for various types of workers involved in traumatic situations (e.g., Armstrong et al., 1991; Dyregrov, 1989; Mitchell, 1983) with CISD the most widely accepted and commonly used PD intervention (Everly et al., 2002). It has been hypothesised elsewhere (Devilly et al., 2006) that overhearing previously unconsidered or unnoticed details during a debriefing session may cause the individual to re-evaluate details of the event and estimations of the degree of threat that they were under during the event. However, while it has been shown that overhearing conversations leads to opinion change (Walster & Festinger, 1962), particularly when not counter-attitudinal (Brock & Becker, 1965), it has yet to be shown that misinformation can be transferred at all during these debriefing sessions. Therefore, the effect of group processes on memory of emotionally laden events was also investigated. In the current analogue study, participants were shown a stressful video of paramedics attending the scene of a car accident. After viewing the video participants received one of three conditions: debriefing; debriefing in a group with a confederate who provided misinformation; or no debriefing. Participants were assessed immediately after this debriefing, and again one-month later. A glossary of terms used in Study 1 is provided in Appendix 1.
3.1.2 Project Aims The equivocal nature of the group debriefing literature has been outlined in this chapter and in Chapter 2. In addition, misinformation has been discussed both in this chapter, and in Chapter 4, and the lack of empirical evidence for the effect of group debriefing upon eyewitness memory has been noted. The overall aims of Study 1 were to examine: (a) the efficacy of group debriefing using a RCT; and (b) the effect of group processes upon memory for emotionally laden events.
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3.1.3 Hypotheses Based on a review of the previous research, the following hypotheses were generated: Part (a) To examine the efficacy of group debriefing
Hypothesis 1: H0: That there will be no differences between the three groups for emotional distress, over time
Hypothesis 2: H0: That there will be no difference between the groups for trauma symptomatology Part (b) To examine the effect of group processes upon memory for emotionally laden events
Hypothesis 3: H1: That irrespective of condition, memory would be better for central rather than peripheral details of the video
Hypothesis 4: H1: That irrespective of condition, confidence would be greater for incorrect memories than for correct ones
Hypothesis 5: H1: That irrespective of condition, those provided with misinformation by the confederate would make more errors than those who did not receive this misinformation
Hypothesis 6: H0: That there will be no differences in the three conditions over time for: (a) central memory for the event; (b) peripheral memory for the event; (c) central memory confidence; (d) peripheral memory confidence; (e) confidence for correct memories; and (f) confidence for incorrect memories.
Hypothesis 7: H0: That there will be no relationship between memory for the event and distress
3.2 Study 1: Method and Materials
3.2.1 Participants The sample for Study 1 comprised 61 individuals (34 male, 27 female) aged between 19 and 60 years of age ( M = 30.7, SD = 11.7) (See Results Section 3.3 for descriptive information; Table 1). Participants were recruited from a University through advertisements, and were randomly allocated to one of three conditions: debriefing, debriefing with confederate, or non-debriefing. The sample comprised mainly of
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University administrators, rather than students, although ethical requirements for the study precluded the collection of student and occupation status within the University. However, the overall mean age for the sample was 30.7 ( SD = 11.7) with a median age of 26 years.
3.2.2 Approvals Approval was obtained from the Swinburne University Human Research Ethics Committee.
3.2.3 Consent Forms and Information Sheet Brief advertisements requesting for volunteers to participate in the study were placed on university notice boards. All individuals who expressed interest in participating in the study were mailed or emailed an information sheet that described the study in more detail (see Appendix 2). Upon arrival at the testing location participants were once again given an information sheet, and had any queries answered. At this time participants were advised that if they had experienced a road traffic accident recently, or had lost friends/family members from a traffic accident, that they may be best served not taking part in the research. Participants then completed and signed an informed consent form (Appendix 3).
3.2.4 Recruitment and Group Allocation Participants were required to be aged 18 years or over, and were warned that if they had experienced a road traffic accident recently, or had lost friends/family members from a traffic accident, that they may be best served not taking part in the research. Initially, 9 trial groups were planned across a two week period. Using Dyregrov’s (1997) discussion on issues of group size for guidance and taking into consideration time limitations within the research context, it was aimed that groups should equate to six to eight participants. After the first week of the recruitment phase,
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groups were assessed for utility. Groups listing less than four participants were disbanded, and new group times were established. Groups with more than 12 participants were split, with a second group created at the same time in the following weeks. Participants in groups larger than eight, but less than 12 were contacted to see if they were available to attend underpopulated groups until a group size of eight was obtained. This procedure continued during the second week of the recruitment phase, at the end of which, groups containing less than five participants were cancelled. In this way, participants were randomly allocated into 1 of the 12 final trial groups. Four groups were designated as receiving debriefing, 4 groups were designated as receiving debriefing with a confederate in the group, and 4 groups were designated as the non- treatment controls. The running of debriefing and control groups alternated, with the decision of whether a control or a debriefing group was run first, decided by the flip of a coin. Ultimately 18 individuals (12 male, 6 female) aged between 20 and 58 years ( M = 27.5, SD = 12.0), were allocated to the debriefing condition, with an average of 4.5 participants per group (range: 3-8 participants). In the debriefing with a confederate condition there were 22 individuals (11 male, 11 female) aged between 19 and 56 years (M = 29.7, SD = 11.4) with an average group size of 4.5 participants (range: 4-5), whilst in the non-debriefing condition there were 21 individuals (11 male, 10 female) aged between 20 and 60 years ( M = 34.6, SD = 12.0) with an average group size of 5.5 participants (range: 3-8). All participants were recompensed for their time. Originally there were 62 participants who viewed the video however one participant failed to complete the follow-up assessment and was, therefore, excluded. As such, the attrition rate was very low at just 1.6%. The intake self-report questionnaire battery (see Appendix 4) consisted of a demographics survey, the Depression, Anxiety and Stress Scale-21 (DASS-21), the Interpersonal Support Evaluation List (ISEL-12), a word recall task, a memory of the video questionnaire, items related to responses to stress and items assessing participant satisfaction. The follow-up questionnaire battery (see Appendix 5) consisted of the PTSD Symptom Scale – Self-Report (PSS-SR), the DASS-21, the memory of the video questionnaire and items related to stress.
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3.2.5 Measures 3.2.5.1 Demographics
General demographics were obtained using a questionnaire that asked questions related to age, sex, history of trauma and exposure to similar audio visual material. These results are presented in Table 1.
3.2.5.2 The Depression, Anxiety and Stress Scale Depression, stress and anxiety were measured using the short form version of the Depression, Anxiety and Stress Scale (DASS; (Lovibond & Lovibond, 1995), the 21-item DASS-21. This 21-item self-report instrument is designed to measure the three related negative emotional states of depression, anxiety and stress. Each of the three subscales comprise of seven 4-point severity/frequency scales ranging from 0 (Did not apply to me at all) to 3 (Applied to me very much, or most of the time). Acceptable levels of reliability and validity have been reported, with Cronbach’s alphas of .94, .87 and .91 (Antony, Bieling, Cox, Enns, & Swinson, 1998) reported for the three subscales respectively. Test-retest reliability coefficients for the full 42-item version over a 2- week period of .71, .79 and .81 have been noted over a 2-week period (Lovibond & Lovibond, 1995). The DASS-21 has a number of advantages over the 42-item DASS including having fewer items, a cleaner factor structure and smaller inter-factor correlations (Antony et al., 1998). This measure was used to gauge affective distress / underlying mood over the course of the study.
3.2.5.3 The Interpersonal Support Evaluation List-12 Social support was measured by the 12-item Interpersonal Support Evaluation List-12 (ISEL-12), which is the short form version of the 40-item Interpersonal Support Evaluation List (ISEL; Cohen, Mermelstein, Kamarck, & Hoberman, 1985). Initially designed to measure individuals’ perceptions of the availability of four separate functions of social support during times of stress (communicative support, positive comparison, tangible assistance and feelings of belonging), the ISEL has been subjected to extensive reliability and validity testing (Cohen et al., 1985) and has shown to be internally consistent and valid with the general population (Brookings & Bolton, 1988). The ISEL-12 provides an overall measure of perceived social support, and consists of
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three subscales (appraisal, belonging, tangible support).
3.2.5.4 Word recall Participants completed an immediate word recall task in order to assess if any participants had major memory deficits, and to determine if differences in memory existed between the three groups. The word list used in the current study was taken from the Affective Lexicon of English words, and was matched for word length and frequency of usage in the English language (Bradley & Lang, 1999). Groups were read a 16 word list, consisting of four negative, four positive, four neutral and four general threat words. Once the word list was read out loud, participants were asked to recall and write down as many words as they possible could. This was conducted to assess pre- intervention differences which could explain the results independent of experimental manipulation, and was not used as a precondition for entry into the study.
3.2.5.5 Memory of the video A questionnaire was developed for the purpose of this study which evaluated participants’ recollections of the video. A series of 25 questions were asked - each requiring the participant to recall a detail that was shown on the video (for example, “How many ambulances were present?”), and to then indicate how confident they were that this answer was correct (1 = not at all , through to 5 = extremely). Thirteen of the questions related to details that were central to the victim focus in the video (e.g., “How many injured (not dead) victims were there?”), whilst twelve questions related to peripheral details (e.g., “How many police motorcycles were present?”). Three of the 25 questions directly corresponded to the three pieces of misinformation, with one of these pieces of misinformation being classified as central (and included in the 13 central questions), and two of the pieces of misinformation being classified as peripheral (and included in the 12 peripheral questions). In order to check our classification of questions as ‘central’ and ‘peripheral’, the questions were rated by 12 independent judges. The judges were 4 males and 8 females, aged between 20 and 37 years of age. Of these 12, 2 of the individuals’ (16%) highest level of education was to 16 years old, 4 (32%) had completed an undergraduate degree, 4 (32%) had completed Honours, and 2 (16%) had completed a PhD or a Doctorate. The judges were shown the video of paramedics attending the scene of a car accident. They
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were then provided with the following definitions of what constituted a central detail of the video, and what constituted a peripheral detail: Central details - Any facts or elements directly related to the victims in the video. These are not background details; Peripheral details - Any information associated with the event that is not directly related to the victims. This information includes background details. The judges were asked to read each of the 25 video memory questions and to rate on a 6-point Likert scale (1 = central , 6 = peripheral ) how much each of the questions related to a central or a peripheral detail of the video. Thirteen questions were rated by the judges as being central with a mean of 1.95 ( 95% CI: 1.48, 2.42; SD =.74), median of 2.0, and mode of 1. Twelve questions were rated as being peripheral, with a mean of 5.47 ( 95% CI: 5.25,5.69; SD = .34), median of 5.58, and mode of 6.
3.2.5.6 Response to Stress In total 16 questions were designed specifically for this study to assess the participants’ behavioural responses (e.g., “To what extent did you physically distract yourself from the content of the video”) and emotional reactions (e.g., “How anxious are you about the video we are about to show you” and “to what degree could you empathise, i.e., feel for, the accident victims) to the video. During the initial session participants were asked eight questions at various stages, assessing anticipatory anxiety about the video, levels of distress at pre-video, post-video and post-condition phases, the extent of physical and mental distraction from the video, and levels of empathy for people depicted in the video. A final ninth item asked participants to rate the appropriateness the presented material as a television road safety advertisement for commercial television.
3.2.5.7 The PTSD Symptom Scale – Self-Report Although no attempt was made to induce PTSD, an assessment was made of the level of intrusions, avoidance and arousal caused by the video 4 weeks after participants had viewed it using the PTSD Symptom Scale-Self-Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993) . This questionnaire is based upon the Diagnostic and Statistical Manual of Mental Disorders - 4th edition (DSM-IV; APA, 1994 ) criteria for trauma symptomatology, and contains items assessing the 17 PTSD symptoms, which make up the three clusters and assesses incapacity due to these problems. For all items,
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symptom frequency over the preceding two weeks is reported on a 4-point scale. A total score is obtained by summing each symptom rating. Subscale scores are calculated by summing symptoms in the Re-Experiencing, Avoidance, and Arousal clusters. Foa and colleagues (1993) found the Cronbach’s α coefficient for the total score to be .91, whilst the subscale α ’s ranged from .78 to .82. In addition, Foa and colleagues (1993) found the one-month test-retest reliability for the total score to be .74, while test-retest reliability for subscales ranged from .56 to .71. Convergent validity of the PSS-SR, with the IES and State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, 1970) has been demonstrated, with correlations ranging from .52 to .81 (Foa et al., 1993). Acceptable levels of validity and reliability have been reported in assessment of the symptom severity scale, with a Cronbach’s alpha of .92 and test-retest reliability of .83 across 10-22 days (Foa, 1995). For this experiment ‘the event’ was the video, and for analysis purposes the summed intrusions, avoidance and arousal score was termed ‘trauma-type symptomatology’.
3.2.5.8 Participant Satisfaction This was assessed by a single item requiring participants to rate “How satisfied were you with the way in which you were dealt with after watching the video?” on a 5- point scale ranging from 1 (Not at all) to 5 (Extremely). This question was asked both at the end of the initial session and at the one-month follow-up.
3.2.6 Setting All trials were conducted in a single meeting room containing a central conference table and non-fixed seating for 10. The audiovisual stimulus was projected onto a wall that was in close proximity, allowing the participants to feel as though they were immersed in the accident scene. The room also contained an area to facilitate provision of refreshments. This setting was maintained for all groups.
3.2.7 Procedure and Questionnaires After informed consent was obtained, the pre-video components of the questionnaires were then distributed, which included demographics, questions related to
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anticipatory anxiety, the DASS-21, and the ISEL-12. Once these were completed, participants were told that they would be read a list of words and that they were to try and remember as many of the words as possible. They were instructed that once the word list had been completely read out, they were to write down as many words, in any order, from the list as they could remember. They were instructed that they were not allowed to begin writing until the word list had been completely read out. Upon completion of the immediate recall task, participants were informed that they would now be viewing a video of emergency workers attending the scene of a car accident. They were again reminded that some may find the video distressing and that they were free to leave with no obligation to complete the experiment. The lights were then turned off and the video started. The video stimulus is approximately 10 minutes of live footage following US emergency workers attending the scene of a single car road accident. During the first nine minutes the video focuses on the assistance given to the four surviving victims. While obvious that three of the victims are in pain and shock, there are no obvious indicators as to the extent or type of their injuries. Thus, for this portion of the video, viewers are exposed mainly to emotional and psychological implications of the accident, with no exposure to any high degree of physical trauma (such as open wounds, bleeding etc). The final minute of the video depicts the scene after removal of the surviving victims. In this section viewers witness the removal of the single fatality resulting from the crash. While astute viewers may have noticed indications suggesting the existence of a fifth victim within the car previously, the final minute concentrates solely on the removal of the body from the car. For the final five seconds, a close-up of the deceased’s disfigured face is shown. At completion of the video, the lights were turned back on and the post-video components of the questionnaire were filled in. These questions assessed behavioural and emotional reactions to the video (e.g., mental avoidance). Once completed, debriefing groups (normal or with a confederate) were informed that they would soon receive a session of debriefing conducted by a trained psychologist in regards to the contents of the video. The facilitator then directed them to help themselves to refreshments while she fetched the assigned debriefer (see below). For the control groups, the facilitator informed participants that there would be a short break in proceedings, as it was necessary for participants to have a break before filling in the
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final questionnaires. They were directed to help themselves to refreshments in the meantime, and told that they were free to chat to one another. Forty minutes later (after refreshments with or without debriefing) the post- condition component of the questionnaire was distributed. This assessed memory for aspects of the video and confidence of these memories. At completion of the questionnaire, participants in the non-debriefed group were also provided with contact details of the local psychologist and facilitator in case any further concerns or questions should arise following the session. All groups were then informed that one month later they would be sent a follow-up questionnaire together with a reply-paid envelope. A separate researcher who was described to the participants as the ‘audio-visual expert’ rated the debriefer for adherence to Critical Incident Stress Debriefing, using a seven stage template as elaborated upon below. The treatment adherence rating form had the assessor rate the therapist on a 6 point Likert-type scale for each of the 7 stages of intervention. This rating judged both whether an aspect had been completed and whether it had been conducted competently (see Appendix 6 for Adherence Rating template). One-month after their participation in the study, participants completed and returned the follow-up questionnaire. Participants who did not return the questionnaire within 10 days of it being sent to them were given a reminder phone call. The follow-up questionnaire contained questions which assessed behavioural and emotional reactions to watching the video; memory for aspects of the video; the extent to which they talked about the video after the intervention session, or wanted to talk about the video with others; whether viewing the video changed the participants’ driving behaviour and treatment satisfaction. They also filled in the PSD, DASS-21, and were asked whether they thought that such a video would be appropriate to be shown on commercial television.
3.2.8 Interventions 3.2.8.1 Debriefing Treatment groups were provided with a 40 to 50 minute session of PD based on the seven stage CISD model of debriefing, led by a psychologist specialised in the treatment of trauma and PTSD. Following an initial introduction and explanation of the rules (stage 1), participants were sequentially encouraged to talk about what they saw
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(stage 2), thought (stage 3) and felt (stage 4) about the video. Participants were then queried about experiencing any stress responses to watching the video (stage 5), after which components of the normal stress reaction were then discussed (stage 6). Finally, participants were asked if they had any questions regarding what they had just discussed, before being provided with the contact details of both the debriefer and the facilitator, in case any further issues, concerns or general questions should arise following the session.
3.2.8.2 Debriefing with a Confederate The same protocol as that detailed above for the debriefing groups was followed for debriefing with a confederate. The only difference was that during the debriefing session the confederate supplied misinformation to the group about central and peripheral details relating to the video. When asked to describe, “What they saw” on the video, the confederate stated: (a) that she had noticed “how the deceased’s legs looked so limp in his black trousers when the paramedics moved him”, when in fact he was wearing dark blue trousers (central misinformation); (b) that she “had noticed that there were a number of emergency workers attending the scene, with some people wearing white hard hats, some wearing blue and some wearing red”, when in fact only one person was wearing a white hard hat (peripheral misinformation); and c) that she “was amazed at the number of bystanders watching the events – even two helicopters were circling the accident, probably news reporters”, when in fact no helicopters were shown on the video (complete misinformation).
3.2.8.3 Non-treatment Control The non-debriefed control groups were invited to partake in refreshments, and left to chat amongst themselves for a period of 40 minutes. The facilitator remained in the room, but avoided overtly participating in the groups’ discussion. If drawn into conversation, the facilitator joined the discussion but endeavoured to not influence the flow of conversation.
3.3 Study 1: Results The results section will begin with a summary of the descriptive statistics of the
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sample. The analyses will be broken down into parts, according to each of the aims of the study. The two primary aims of this study were: (1) to determine the efficacy of group debriefing; and (2) to examine the effect of group processes upon memory for emotionally laden events. Hypotheses will be presented in turn under each of the aims, with the appropriate analyses following.
3.3.1 Data Screening, Randomisation and Descriptive Statistics All data entry and analyses were conducted using Statistica Version 6.1 for Windows (2004) and ClinTools Version 4.1 (Devilly, 2007a). Prior to analysis all independent variables were examined for accuracy of data entry, missing values, presence of univariate and multivariate outliers and the distribution of data. Cases with a small number of missing values (3 or less) were retained, and the missing values replaced with the individuals’ mean score for the corresponding measure subscale (where possible), or with the mean score for the measure. Of the original 61 participants, one participant also failed to complete the DASS component of the follow-up questionnaire, and this participant was therefore removed from analyses involving the DASS. To determine whether the data was normally distributed both graphic and statistical methods were employed. Box plots and frequency histograms for each variable were examined to conceptualise the distribution of the data and to compare the shape of the data with the normal curve. Descriptive statistics were then generated for each variable and were examined for outliers using methods recommended by Tabachnik and Fidell (2001), whereby univariate outliers are characterised as cases with a z score over 3.29 (p < .001). No univariate outliers were identified. Using Mahalanobis distance no multivariate outliers were detected. The data were assessed for nonlinearity and heteroscedasticity by using Statistica to examine bivariate scatterplots for each combination of variables. The data appeared linear and homoscedastic. The variables were examined for multicollinearity by looking at their bivariate correlation coefficients. Correlations of r >.70 were considered too large (Tabachnik & Fidell, 2001). None of the variables included in the analyses exceeded this limit. To ensure that the randomisation process had not created any conditional bias, the three groups were compared across various background, presentation and
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demographic variables. There were no significant differences between the three groups in the distribution of: gender; previous exposure to similar styles of video; history of trauma; the extent to which they physically and mentally distracted themselves while viewing the video; blood phobia; history of consultation for emotional problems; the seriousness with which they rated the accident; levels of participant empathy with either the accident victims or the emergency workers; word memory recall ability ( F(2, 58)=.94, ns ); and group allocation sizes (see Table 1). Overall, these results suggest that the randomisation process did not lead to any systematic bias on core criteria within the group compositions (Debriefed vs Confederate vs Non-Debriefed) before the experimental phase.
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Table 1 Demographic Characteristics of the Sample (Study 1)* Debriefing Debriefing with Non- Total n=18 (%) Confederate Debriefed N=61 (%) n=22 (%) n=21 (%) Gender Male 12 (66.6) 11 (50) 11 (52.3) 34 (55.7) Female 6 (33.3) 11 (50) 10 (47.6) 27 (44.3) History of trauma Yes 5 (27.7) 3 (13.6) 5 (23.8) 13 (21.3) No 13 (72.2) 19 (86.4) 16 (76.2) 48 (78.7) Exposure to similar video Never seen similar 11 (61.1) 13 (59.1) 11 (52.3) 35 (57.4) Seen similar / same 7 (38.8) 9 (40.9) 10 (47.6) 26 (42.6) Mean (SD) history of 1.94 (1.1) 1.59 (1.1) 2.20 (1.0) 1.90 (1.1) emotional problems Means (SD) blood 2.22 (1.1) 1.95 (1.3) 2.29 (1.0) 2.15 (1.1) phobia Mean (SD) physical 2.11(.8) 1.77 (.8) 1.70 (1.0) 1.85 (.9) distraction Mean (SD) mental 2.17 (1.2) 2.09 (1.0) 1.95 (.9) 2.06 (1.0) distraction Mean (SD) accident 4.61 (.5) 4.5 (.5) 4.24 (.8) 4.44 (.6) seriousness Mean (SD) empathy for 4.44 (.8) 3.91 (1.1) 4.00 (1.1) 4.09 (1.0) accident victims Mean (SD) empathy for 3.72 (1.2) 3.36 (1.0) 3.29 (1.3) 3.44 (1.2) emergency workers Mean (range) group size, number of 4.5 (3-8) 4.5 (4-5) 5.5 (3-8) 4.8 (3-8) participants Mean (SD) age, years 27.5 (12) 29.7 (11.4) 34.6 (12) 30.7 (11.7) * Unless otherwise indicated, data are given as number (percentage) of subjects. Percentages have been rounded.
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The internal reliability of each of the measures used in Study 1, using the present sample, was calculated using Cronbach’s Alpha (see Table 2). Each of these co- efficients are within acceptable parameters. A series of repeated measures ANOVAs were conducted to investigate the effect of debriefing (or no debriefing) on each of the major variables of the study. Post-hoc univariate tests were performed for all significant findings to investigate how the major variables changed from pre- to post intervention and from pre- to follow-up of the intervention. Effect sizes were calculated using Hedges ĝ and are reported so as to contribute to the meaningfulness of the findings. Where appropriate effect sizes in this thesis will be estimated by Hedges ĝ, and calculated using ClinTools Version 4.1 (Devilly, 2007a). Unlike Cohen’s d, which systematically overestimates effect when used with small samples, Hedges ĝ includes a mathematical adjustment for small sample bias, uses a pooled standard deviation (sigma) and is the gold standard recommended by the International Society for Traumatic Stress (ISTSS; Devilly, McGrail, & McFarlane, In press). An effect size is the strength of the difference between two groups (for example, treatment and placebo) or between two time points of the same group (for example, before and after an intervention programme). Cohen (1992) provides guidelines to interpret effect sizes for Hedges’ ĝ and suggests that an effect size of .2 indicates a small effect size, .5 a medium effect size and .8 a large effect size. Pearson product-moment correlation coefficients (two-tailed) were computed using Statistica. For reasons of consistency, descriptions of correlations were based on the guidelines for conventional practice outlined by Cohen and Cohen (1983). According to these guidelines effect sizes for correlations are as follows: r = .10 (classified as weak), r = .30 (classified as moderate), r > .50 (classified as strong).
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Table 2 Internal Reliability Coefficients of all Measures at Time 1 and Time 2 (Study 1; N = 61) Time 1 Time 2 Measure Cronbach’s α Cronbach’s α DASS-21 Depression .92 .89 Anxiety .82 .77 Stress .83 .84 ISEL-12 Appraisal .77 n/a Belonging .75 n/a Tangible Support .79 n/a PSS-SR n/a .84
3.3.2 Hypothesis 1
Part (a) To examine the efficacy of group debriefing
Hypothesis 1 : H0: That there will be no differences between the three groups for emotional distress, over time. A 3 (Condition) x 2 (Time) repeated measures ANOVA was conducted on participants’ affective distress (as measured by indices of depression, anxiety and stress), in order to address hypothesis (1). As can be seen in Table 3, passage of time was found to have a significant effect upon affective distress with distress significantly greater in session 1 than at follow-up. Looking at a post-hoc univariate test for Time, a significant main effect was found for Stress using Tukey’s HSD ( p < .01), and Anxiety ( p < .01), but not for Depression. Generally participants reported less stress in the follow-up phase ( M=10.03, SD =8.31) than in session 1 ( M=13.50, SD =7.60), and less anxiety at the follow-up (M=2.60, SD =5.75) than in session 1 ( M=7.87, SD =6.84). The effect size for both stress and anxiety were estimated using Hedges’ ĝ, with a moderate effect size found for both stress ( Hedges’ ĝ=.40; 95% CI : .04,.77) and anxiety ( Hedges’ ĝ=.42; 95% CI : .06,.78).
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Further exploratory analyses were conducted to investigate the effect of group debriefing upon several other types of behavioural and emotional response. Specifically, the effect of group debriefing upon people’s perceptions of their own anxiety, participants’ distress, participants’ desire to discuss the video, and participants’ desire to have discussed the video with a professional were all examined. A 3 (Condition) by 2 (Time) repeated measures ANOVA was conducted upon people’s perceptions for how anxious they were to participate in the study. People were asked to rate how anxious they were about watching the video immediately before watching the video. At follow-up participants were asked to estimate how anxious they had been (during session 1), immediately before watching the video. As can be seen in Table 3, no significant effects were found. Participants were asked to rate ‘how distressing’ they found the video on a 5- point Likert type scale (1-5), both directly after watching the video and at follow-up. As can be seen in Table 3, there were no significant differences between the conditions, nor was there a significant effect for the passage of time.
None of the three groups displayed a significant difference in the desire to have discussed the video directly after viewing it, in the session 1 assessment (see Table 3). However there was a significant effect for Condition ( F(2,58)=4.55, p < .02), with those in the Debriefed group expressing a significantly greater desire to have wanted to discuss the video directly after viewing (M=3.50, SD=.92) than those in the Non- Debriefed group (M=2.38, SD=1.02) at follow-up. No significant difference was found for the three groups desire to discuss the video with a friend during the month following the video viewing, nor their desire to discuss the video with a professional in the month following the video. Means and standard deviations for emotional responses, by condition, are presented in Table 4.
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Table 3 3 (Condition) x 2 (Time) Repeated Measures ANOVA for Emotional Responses to the Video (Study 1) Time Analysis Session 1 Follow-up (df) F p Hedges’ ĝ M (SD) M (SD) (95% CI) (1)*Affective 30.90 23.33 T1 (1, 57) 5.66 <.03 .40 distress** (.04,.75) (19.13) (18.85) C2 (2, 57) 1.65 ns T x C (2, 57) 1.62 ns Anxiety for 2.23 2.28 T (1, 57) .17 ns participation (.89) (.90) C (2, 57) 1.36 ns T x C (2, 57) .45 ns Distress caused by 3.39 3.26 T (1, 57) 1.86 ns video (1.14) (1.03) C (2, 57) 1.78 ns T x C (2, 57) .87 ns Desire to discuss video 2.87 2.95 T (1, 57) .48 ns after viewing (1.18) (1.13) C (2, 57) 4.55 <.02 -.07 (-.42-.27) T x C (2, 58) .64 ns Note: *Number denotes hypothesis being tested; **One case was removed from analyses involving the DASS; 1‘T’ denotes Time; 2‘C’ denotes Condition.
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Table 4 Means and Standard Deviations for Emotional Responses to the Video, by Condition (Study 1)
Debriefing Debriefing with Non-Debriefed Total n=18 (%) Confederate n=22 n=21 (%) N=61 (%) (%) Session 1 Follow- Session 1 Follow- Session 1 Follow- Session 1 Follow- M (SD) up M (SD) up M (SD) up M (SD) up M (SD) M (SD) M (SD) M (SD) Affective 27.56 27.33 26.91 19.27 42.19 23.05 32.36 22.95 distress* (17.96) (22.34) (20.30) (16.60) (24.66) (18.14) (22.13) (18.93) Anxiety for 2.41 2.22 2.32 2.50 2.00 2.05 2.23 2.26 participation (1.00) (0.88) (0.89) (0.96) (0.77) (0.86) (0.89) (0.91) Distress 3.72 3.39 3.50 3.41 3.00 3.00 3.39 3.26 caused by video (1.07) (0.98) (1.14) (1.05) (1.14) (1.05) (1.14) (1.03) Desire to 3.22 3.50 2.95 3.05 2.48 2.38 2.87 2.95 discuss video after viewing (1.22) (0.92) (1.00) (1.17) (1.25) (1.02) (1.18) (1.13) Note: *One case was removed from this analysis
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3.3.3 Hypothesis 2
Hypothesis 2: H0: That there will be no differences between the three groups for trauma symptomatology Trauma symptomatology scores were not found to differ significantly between the three groups, as measured by the PSS-SR ( F(2, 58)=1.49, ns ). The PSS-SR data within the three symptom clusters for each condition are displayed in Figure 3.1. A chi- square analysis was performed to determine whether there were any significant differences between the groups for trauma symptomatology. The Pearson chi-square test evaluates the null hypothesis that the frequency distribution of certain events observed in a sample is consistent with a certain theoretical distribution (Tabachnik & Fidell, 2001). The chi-square test can also be used to evaluate whether the frequency of certain events is greater for one group than another. Chi-square analysis did not reveal any significant differences between the groups in the level of trauma symptomatology when symptom categories were applied (i.e., mild, moderate, moderate to severe and severe), however one participant in the Debriefed group met symptomatic criteria for a diagnosis of PTSD. Overall, participants in the Control group showed low levels of trauma symptomatology ( M=5.95, SD =5.95), as did those in the Debriefed with a Confederate ( M=6.36, SD =5.04). The Debriefing group displayed slightly higher levels of trauma symptomatology ( M=9.06, SD =7.11), although as reported earlier, these differences were not significant.
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6
5
4
3
Symptom Rating 2
1
Intrusions 0 Avoidance Non-Debriefed Confederate Arousal Debriefed
Note: Vertical bars denote 0.95 confidence intervals
Figure 3.1. Post-traumatic Stress Symptomatology Cluster Severity by Condition at Follow-up (Study 1)
3.3.4 Hypothesis 3
Part (b) To examine the effect of group processes upon memory for emotionally laden events
Hypothesis 3: H1: That irrespective of condition, memory would be better for central rather than peripheral details of the video Paired samples t-tests revealed that, overall participants recalled significantly more correct central details of the video than peripheral details in both session 1 (t(60)=8.21 , p <.001; Hedges’ ĝ = 1.1; 95%CI: .72, 1.48), and at follow-up (t(60)=10.37 , p <.001; Hedges’ ĝ = 1.74; 95%CI: 1.32, 2.15).
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3.3.5 Hypothesis 4
Hypothesis 4: H1: That irrespective of condition, confidence would be greater for incorrect memories than for correct ones Paired samples t-tests were also conducted for hypothesis (4), with confidence greater, at follow-up, for those details of the video that were recalled incorrectly than those details of the video that were recalled correctly ( t(60) = -10.19, p < .001; ĝ = - 1.68; 95% CI : -2.09, -1.27). However, when looking at session 1 (directly after having watched the video) a two-tailed dependent t-test did not quite reach significance (t(60)=1.89, p < .07). Interestingly, this trend at session 1 was in the reverse direction, with more confidence in correct memories.
3.3.6 Hypothesis 5
Hypothesis 5: H1: That irrespective of condition, those provided with misinformation by the confederate would make more errors than those who did not receive this misinformation To test hypothesis (5) a repeated measures ANOVA was used to look at the number of correct responses to misinformation items. There was an effect for condition (F(2,58)=3.37, p<.05) with the Confederate group making fewer correct responses to the misinformation items overall. There was not a significant effect for Time (F(1,58)=2.63, p<.12), and only a trend for an interaction effect (F(2,58)=2.88, p< .07). It appears that those who were debriefed with misinformation were more likely to recall these items incorrectly later. This effect did not change over time. However, there was a trend for the Non-Debriefed group to demonstrate memory degradation over time but not for the Debriefed group. Looking in more detail, chi-square analysis revealed that it was the complete misinformation item (i.e., where the confederate said she observed two helicopters) which particularly differentiated the groups, with the Confederate group more likely to report seeing a helicopter than both the straight Debriefed and Non-Debriefed groups at session 1 ( χ 2 (2)=7.75, p< .02; Cramer’s Phi = .36) and at follow-up ( χ 2 (2)=8.02, p<.01; Cramer’s Phi =.36). At follow-up the Non-Debriefed group increased their number of incorrect responses to this item. The other two items
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did not show a differential memory effect in session 1 or follow-up.
2.0
1.8
1.6
1.4
1.2
1.0
Number Correct Number 0.8
0.6
0.4
0.2 Non-Debriefed Debriefed 0.0 Confederate Session 1 Follow -up
Note: Vertical bars denote 0.95 confidence intervals
Figure 6.2 Number of Correctly Answered Misinformation Items between the Three Groups over Time
3.3.7 Hypothesis 6
Hypothesis 6: H0: That there will be no differences in the three conditions over time for: (a) central memory for the event; (b) peripheral memory for the event; (c) central memory confidence; (d) peripheral memory confidence; (e) confidence for correct memories; and (f) confidence for incorrect memories. A series of 3 (Condition) x 2 (Time) repeated measure ANOVAs were conducted on participants’ video memory scores and confidences for these memories in order to address hypothesis (6). Means and standard deviations are presented in Table 6.
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As can be seen in Table 5, passage of time was found to have a significant effect upon both central and peripheral memory with recall significantly better in session 1 than at follow-up. Similarly, passage of time had a significant effect for central and peripheral memory confidence, and correct and incorrect response confidence, with confidence significantly greater in session 1 than at follow-up in all conditions except for confidence in incorrect memories – which increased over time. Testing hypothesis (6b), Condition was found to have a significant effect ( F(2,58)=4.77, p< .02). Post Hoc analysis using an unequal N HSD revealed a significant difference ( p< .02) between the Debriefed and Confederate condition, with the Confederate group recalling fewer correct peripheral details overall. However, as predicted, this effect did not apparently interact with Time (session 1 to follow-up).
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Table 5 3 (Condition) x 2 (Time) Repeated Measures ANOVAs for Video Memory and Confidence Scores (Study 1) Time Analysis Session Follow- (df) F p Hedges’ ĝ 1 up (95% CI) M M (SD) (SD) (6a)* Central 6.79 5.84 T1 (1, 58) 20.48 <.001 .46 memory for the (.10, .82) event (2.11) (2.00) C2 (2, 58) .07 ns T x C (2, 58) .28 ns (6b) Peripheral 4.57 2.85 T (1, 58) 49.0 <.001 1.18 memory for the (.80, 1.57) event (1.51) (1.36) C (2, 58) 4.77 <.013 T x C (2, 58) .23 ns (6c) Central 38.31 31.23 T (1, 58) 73.45 <.001 1.03 memory (.66,1.42) confidence (9.18) (9.47) C (2, 58) .16 ns T x C (2, 58) .31 ns (6d) Peripheral 35.31 28.46 T (1, 58) 72.15 <.001 .74 memory (.37, 1.11) confidence (9.26) (9.17) C (2, 58) .00 ns T x C (2, 58) .24 ns (6e) Confidence 40.56 20.31 T (1, 58) 239.4 <.001 1.57 for correct (1.16,1.98) memories (14.39) (10.95) C (2, 58) 1.04 ns T x C (2, 58) .70 ns (6f) Confidence 36.11 39.34 T (1, 58) 7.83 <.01 -.29 for incorrect (-.64,.07) memories (10.85) (11.54) C (2, 58) .57 ns T x C (2, 58) .19 ns Note: * Numbers and letter denote hypothesis being tested; 1‘T’ denotes Time; 2‘C’ denotes Condition.
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Table 6 Means and Standard Deviations for Video Memory Scores, in Session 1 and at Follow-up (Study 1)
Non-Debriefed a Debriefed b Debriefed-Confederate c Session 1 Follow-up Session 1 Follow-up Session 1 Follow-up M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) (6a)* Central memory for the event 6.90 (2.07) 5.95 (1.94) 6.78 (2.05) 5.61 (1.72) 6.68 (2.27) 5.91 (2.33) (6b) Peripheral memory for the event 4.67 (1.56) 2.81 (1.33) 5.17 (1.20) 3.33 (1.50) 4.00 (1.54) 2.50 (1.22) (6c) Central memory confidence 39.29 (9.65) 31.33 (10.88) 38.61 (8.84) 31.78 (9.55) 37.14 (9.78) 30.68 (8.32) (6d) Peripheral memory confidence 35.81 (10.39) 28.19 (10.17) 35.06 (9.14) 28.61 (11.53) 35.05 (8.62) 28.59 (5.85) (6e) Memories correctly recalled 11.57 (3.11) 8.76 (2.70) 11.94 (2.6) 8.94 (2.53) 10.68 (3.20) 8.69 (2.59) (6f) Memories incorrectly recalled 13.43 (3.11) 16.24 (2.70) 13.06 (2.60) 16.06 (2.53) 14.32 (3.20) 16.59 (2.61) (6g) Confidence for correct 43.33 (15.43) 21.24 (11.37) 41.94 (14.09) 21.61 (13.45) 36.77 (13.42) 18.36 (8.16) memories (6h) Confidence for incorrect 35.24 (10.58) 38.19 (13.87) 34.44 (10.34) 38.78 (9.58) 38.32 (11.61) 40.91 (10.90) memories
Note : a n = 21, b n = 18, c n = 22; * Numbers and letter denote hypothesis being tested
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3.3.8 Hypothesis 7
Hypothesis 7: H0: That there will be no relationship between memory for the event and distress To test the relationship between memory for the event and distress, Pearson correlation coefficients (two-tailed) were computed using Statistica. Examination of the relationship between the measures of Affective Distress (i.e., the DASS) and Trauma Symptomatology (i.e., the PSS-SR), and memory for the video revealed no significant correlations between distress and memory at follow-up. There was, however, a significant moderate correlation in session 1 between Affective Distress as measured by the DASS, and memory for the video ( r s (61)=-.28, p < .05), with those who reported less affective distress before viewing the video recalling a greater number of correct details from the video. There were no significant correlations in session 1 or at follow- up, between either affective distress or trauma symptomatology and (a) the number of correct central or peripheral details recalled, and (b) participants’ confidence for correct and incorrect responses.
3.3.9 Subsidiary Analyses As previously mentioned, perceived social support was assessed to see whether there were any differences between the three groups that may explain the results and need to be entered as a covariate in the calculations. Significant differences were found for “belonging”, with the Debriefed group reporting significantly higher levels than both the controls ( t(37)=-4.95, p < .05), and the Debriefed with Confederate group (t(38)=2.84, p < .01). The Debriefed group also reported significantly higher levels of “tangible support” than the controls ( t(37)= -2.8, p < .01), and the Debriefed with a Confederate group ( t(41)=-.88, p < .05). However, perceived social support did not correlate with outcome for the intrusions ( r = -.05), avoidance ( r= -.07) or hyper-arousal (r =-.07) subscales of the PSS-SR, nor the functioning subscale of the PSS-SR ( r =.09), and as such was not included as a covariate in the calculations. Perceived social support correlated significantly with stress ( r = -.34, p < .01) and anxiety ( r = -.51, p < .01) in session 1, but not at follow-up. Participants’ level of satisfaction was analysed using a repeated measures ANOVA, and a significant effect for Satisfaction was found ( Wilks Lambda (1, 58)=
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.86, p <.01) with participants tending to have greater satisfaction in session 1 than at follow-up. There was no significant effect found for Condition ( F(2, 58)=.90, ns ), and there was no significant interaction between Condition and Satisfaction ( F(2, 58 = .04, ns ). A high level of satisfaction was reported by participants across the groups both in session 1 ( M=4.52, SD =.62) and follow-up ( M=4.28, SD =.71). All participants were asked to rate the appropriateness of a television road safety advertisement using material similar to that shown on the video, for commercial television. No significant difference in appropriateness rating was found between the three groups ( F(2, 58)=.09, ns ). The mean participant satisfaction rating with the debriefing (both conditions combined) was 4.52, with a median of 5 and a mode of 5, with 5 being the highest possible score. The mean therapist fidelity rating was 5.13, with a median of 5 and a mode of 5, with 6 being the highest possible score.
3.4. Study 1: Discussion
3.4.1 Introduction PD is an intervention that has caused controversy in recent times (see Devilly et al., 2006). There have been relatively few RCTs conducted using this intervention, and for the few studies that have been published, debriefing has been found to have either no effect, or a harmful effect (Rose et al., 2004). Despite this lack of empirical support, PD remains to be a commonly used intervention, applied directly after individuals have been exposed to a traumatic event. Eyewitnesses to traumatic events are commonly provided with group PD. Often this group debriefing occurs before the eyewitnesses have been interviewed individually by police. There has never before been a RCT of the impact of group debriefing upon eyewitness memory. This analogue study aimed to investigate both the efficacy of group PD and the effect of group dynamics upon memory for an event following the viewing of an emotionally stressful video. Participants were shown a graphic video of paramedics attending the scene of a real life car accident where victims had been both injured and killed. One third of the sample were debriefed using the Critical Incident Stress Debriefing model (CISD; Mitchell, 1983), one third of the sample was debriefed using
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CISD in the presence of a confederate, and one third of the sample did not receive debriefing. All three groups were followed-up 1 month later.
3.4.2 Evaluation of Study 1 Descriptive Statistics There were no significant differences between the 3 groups for any of the demographic variables, and for group allocation sizes. Thus, these results suggest that the randomisation process did not lead to any systematic bias on core criteria within the group compositions (Debriefed vs Confederate vs Non-Debriefed) before the experimental phase.
Part (a) To examine the efficacy of group debriefing There were no differential reactions noted between the three groups for affective distress, and all three groups reported less affective distress at follow-up than in session 1. Trauma symptomatology was not found to differ between the 3 groups. At follow-up those in the debriefing group remembered wanting to discuss the video, directly after viewing it, more than those in the non-debriefing group. These results suggest that group debriefing has no obvious effect on distress following the viewing of this stressful video. People in all three conditions reported very few trauma symptoms (i.e., intrusions, avoidance and arousal) in relation to the video and there were no differences between the three groups for affective distress. These results replicate the findings of Devilly and Annab (2008), and are similar to the results of individual debriefing trials conducted with individuals who have personally experienced stressful events (e.g., Conlon, Fahy, & Conroy, 1999; Lee, Slade, & Lygo, 1996). A further examination of the debriefing data presented here was also conducted, although this examination is beyond the realms of the current thesis. This study reported data on the efficacy of group debriefing in the mitigation of distress for a stressful video, which had two levels of severity (for full article see Devilly, G. J., & Varker, T. (2008). The effect of stressor severity on outcome following group debriefing. Behaviour Research and Therapy, 46, 130-136). One hundred and nineteen participants were shown one of two stressful videos and, subsequently, 67 participants received group debriefing whilst 52 participants acted as a control. A statistical difference was
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found between the two groups for level of distress at follow-up, with those who had watched the more stressful video scoring higher on video distress and trauma-type symptomatology than those who watched the less stressful video. This was particularly the case for those who received debriefing—adding further caution to the longer-term effects of systematised group interventions following harrowing events. In a study conducted several years ago, Mayou, Ehlers and Hobbs (2000), found that there was no significant effect for individual debriefing 4 months post-injury, but at 3 years post- injury those in the debriefing group were more symptomatic. Those who were most distressed following the event appeared to be most negatively affected by debriefing. The results of the video severity study suggest that effects upon affective and trauma- type symptoms take time to incubate to the point where differences are apparent, a result which parallels the results of Mayou et al. (2000).
Part (b) To examine the effect of group processes upon memory for emotionally laden events The effects of group PD upon memory for an event, following viewing of an emotionally stressful video were assessed in this analogue experiment. It was found that memory for both central and peripheral details of the video was better in session 1 than at follow-up, with no apparent effect from debriefing – whether provided misinformation or not. Participants in all groups recalled more central details correctly than peripheral details, in both session 1 and at follow-up, although there were again no differences between the groups. At follow-up, participants in all three groups were found to be more confident of memories for incorrect details of the video than for memories of correct details. As expected, those in the debriefing group with a confederate providing misinformation were more likely to report seeing phenomenon that they did not in fact observe (i.e., two helicopters circling overhead) than those in the debriefing or non-debriefing group. Recollection of this incorrect information was stable over time for the confederate group, with individuals who recalled the misinformation incorrectly in session 1 likely to recall this information incorrectly at follow-up also. Overall, these results suggest that misinformation supplied by another member of a debriefing group can affect individuals’ memories of a stressful event. This is consistent with findings of memory conformity studies in non-clinical scenarios (e.g.,
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Gabbert et al., 2003; Memon & Wright, 1999). The results also suggest that individuals have greater confidence for memories that are incorrect than for memories that are correct, a finding which adds further weight to the results of other research examining confidence following the presentation of misinformation. The current results fall directly in line with the work of Gerrie and colleagues (2006), who found that subjects confidently, but falsely, remember unseen information from an event. Together with past studies, this suggests that incorrect memories may be built upon stable, stereotyped ideas whilst the correct responses are built upon unstable narratives (e.g., Brainerd et al., 1995; Loftus et al., 1989; Ryan & Gesiselman, 1991; Weingardt et al., 1994). The finding that debriefed group members are susceptible to the effects of misinformation has important implications in relation to eyewitness testimony. It is common for individuals who have experienced a traumatic event to receive group debriefing immediately after the incident, often before even speaking to police officers. The current research suggests that it may be possible for debriefing group members to inadvertently alter other debriefing group members’ memories of the event during the debriefing session. The results also suggest that once an incorrect memory is planted, this remains intact across time. Such memory alteration could in turn lead to inaccurate statements to the police and have consequences for police investigations. This is particularly problematic because an errant consensus, which can arise from a single source, may be taken by police or jurors as a sign of accuracy (Wright, Self & Justice, 2000). As one would expect, the debriefed group remembered more accurate peripheral material than the confederate group. This is expected since two of the misinformation items counted towards the peripheral score.
3.4.3 Limitations of Study 1 It is acknowledged that this research has limitations. A small amount of deception was involved in the research, with participants unaware that a confederate was present in the groups. However, this deception was necessary in order to investigate the effects of misinformation, the deception did not have any harmful consequences for participants, and all participants were made aware at the completion of the research that a confederate had been present during the initial session. In addition, only one therapist provided the debriefing. Although some may argue that it is desirable to counterbalance therapist effects by using many therapists, the use of a single therapist ensured that there
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was a systematic and consistent delivery of the intervention. The high satisfaction rating given by the participants tends to suggest that debriefing was conducted sensitively (and conforms to past research which found high satisfaction ratings with debriefing, e.g., Matthews, 1998 ). There was only one confederate used for all of the debriefing, and again it may be argued that it is desirable to weigh confederate effects. However, it was considered that using a single confederate controlled for more extraneous variables than would be introduced using a different confederate for each group. Finally, this study is an analogue study, and as such the generalisability of the findings to other populations will not be known until further field-based research is undertaken.
3.4.4 Areas for Future Research The results of Study 1 add to the growing body of literature which suggests that PD may be an ineffective technique for mitigating stress reactions. Further RCTs of group PD must be conducted using “real-life” situations. Furthermore, given that this is the first RCT to examine the effect of group debriefing upon eyewitness memory, it is important that studies are conducted on this new area of research. Such research can be conducted using both analogue studies and “real-life” situations. Given the underwhelming results that have been produced in relation to both individual debriefing and group debriefing in recent years, the next logical step is to find alternate methods for mitigating stress reactions. The theoretical and scientific questions now go beyond PD and immediate intervention after the incident, and instead turn to what may be done before the incident. We now look to see whether it is possible to prepare individuals for traumatic events, and thus circumnavigate the “feeling of intense fear helplessness or horror” that may then go on to lead to PTSD. One technique which may provide such a possibility is resilience training. Rather than attempting to mitigate trauma reactions immediately after a traumatic event has occurred, individuals can be provided with resilience training, which is designed to inoculate them for possibly traumatic events. By being prepared, the “unexpected” element of the event is removed. In Chapter 1 of this thesis, the literature was reviewed for the theoretical models which are currently used to explain trauma symptomatology. Potentially, these same theoretical models can also be applied to develop strategies which can prevent an individual from going on to develop a stress reaction after being exposed to a traumatic event. These strategies could be used to form a resilience
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programme, which would be designed to prepare individuals for stressful situations. In light of the results of the current study, which suggest that people who are involved in organised psychological interventions may be at risk of having their memory for the event compromised, it is important for researchers to ascertain whether resilience training is likely to impact upon individuals’ memories for traumatic events. This suggestion is undertaken in Study 2 of the current thesis, whereby resilience training is trialled in a proof of concept study. Resilience training will be given to individuals who will then be shown the same stressful video that was used in Study 1. The efficacy of the training will be evaluated via a RCT - the first such trial of resilience training that has ever been conducted. In addition, the impact of resilience training upon individuals’ memories for a stressful event will also be evaluated. A review of the literature related to the prevention of stress reactions is presented in Chapter 6, followed by an evaluation of the resilience training in Chapter 7.
3.4.5 Summary of Study 1 The results of Study 1 suggest that participation in group debriefing may alter group members’ recollections of the event when one group member utters untrue memories of the events in front of the other group members. Furthermore, untrue recollections persisted and the eye witnesses reported increased confidence in these erroneous recollections than in memories which were accurate. The effect of such misinformation upon the long term stress levels of the witness is yet to be examined in full.
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Chapter Four: Is it Possible to Prevent Stress Reactions? Stress, Appraisal, Coping and Resilience
4.1 Introduction The way in which one interprets and reacts to events is unique to each individual. Whilst in a given situation one person may respond with anger, another person may react with anxiety, whilst yet another may feel threatened. To understand variations among individuals, the cognitive processes that intervene between an encounter and an individual’s response must be considered (Lazarus & Folkman, 1984). In the following chapter, the theories relating to stress, appraisal, coping, hardiness and resilience are reviewed. In addition, whether it is possible to prevent stress reactions is canvassed and supportive evidence is presented. This evidence provides the background and rationale for Study 2 of this thesis.
4.2 Overview of Psychological Theories of Stress Related to Resilience
4.2.1 Stress Lazarus and Folkman (1984) conceptualise stress as a relationship between a person and the environment that is appraised by the person as being taxing or exceeding his or her resources and endangering his or her well-being. When a person appraises a situation as potentially stressful, they then assess their own resources for dealing with it (i.e., their ability to cope). Coping under stress involves an active, adaptive process in which an individual employs strategies to manage a specific environment. Inadequate coping is conceptualised as occurring when an individual perceives a failure in dealing with the situation, thus resulting in stress (Biggam, Power, & Macdonald, 1997). The literature related to stress and coping will be discussed in greater detail in Section 4.4. The stressful situation, or source of the stress, is known as the ‘ stressor ’. The relationship between the stressor and an individual is also mediated by ‘ appraisal ’. Appraisal is a cognitive process through which a person evaluates the consequences of an encounter on his or her well-being (primary appraisal), and what can be done about those consequences (secondary appraisal; Hart, Wearing, & Headey, 1993). According
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to Lazarus and Folkman (1984) there are three types of primary appraisal: (a) irrelevant, where the individual has no vested interest in the transaction or the results; (b) benign positive, when the individual assumes that the situation is positive with no potential negative results to his or her well-being; and (c) stressful, where the individual only perceives negative results or that the circumstance is detrimental to his or her well- being. Lazarus and Folkman (1984) suggest that people use both primary and secondary cognitive appraisals to evaluate adverse events. Primary appraisal involves evaluation of the threat represented by the event, whilst secondary appraisal involves the assessment of one’s ability to cope with the threat. Subsequently, the individual evaluates his or her coping responses for their effectiveness in reducing or removing the threat (Lazarus & Folkman, 1984). Stressors can range from something minor such as starting a new job or having to perform a speech, through to something major such as the death of a loved one. Some short-term stress is often good for us, providing us with increased energy and tension and improving our ability to concentrate. It allows us to make an extra effort, keeps us motivated and provides us with a sense of achievement once the stressful situation is successfully dealt with. However, if stress is intense and long-term, it can lead to exhaustion and mental and physical ill health. The stress response of an individual is a combination of physical reactions, thoughts (cognitions), emotions, and behaviours (Vlisides, Eddy, & Mozie, 1994). Commonly noted physical symptoms of stress are: fatigue and physical weakness; migraine and tension headaches; backaches including lower back pain; increased heart rate; a rise in blood pressure; and diarrhoea or constipation (Rice, 1999). Behavioural symptoms include procrastination, avoidance, loss of appetite and energy, absenteeism, changes in sleep patterns, and an increase or change in drug and alcohol use (Hamberger & Lohr, 1984). Some of the many emotive symptoms are anxiety, dread, irritability, depression and frustration, whilst the most common cognitive symptoms are loss of motivation and concentration (Berkowitz, 1990). Over the years, researchers have found links between chronic stress and a number of illnesses including: asthma, allergies and autoimmune disease (Plaut & Friedman, 1981); sleep disorders (Waters, Adams, Binks, & Varnado, 1993); migraine (Wilkins & Beaudet, 1998); skin conditions (Al' Abadie, Kent, & Gawkrodger, 1994); heart problems (Anderson, 1989) and peptic ulcers (Pinkerton, Hughes, & Wenrich, 1982).
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4.2.2 Stress Inoculation Training Stress Inoculation Training (SIT), developed by Cameron and Meichenbaum (1982), is an approach that teaches self-understanding and general coping skills that can be used to prepare people for conditions of high stress. The SIT protocol consists of three phases: conceptualisation; skills acquisition and rehearsal; and application. During the initial conceptualisation phase, the client is educated about the nature and impact of stress and the role of both appraisal processes and the transactional nature of stress (i.e., how clients may inadvertently exacerbate the level of stress that they experience, Meichenbaum, 1996). Clients are taught to consider threats as problems-to-be-solved and to identify those aspects of both the situation and the clients’ reaction which are amenable to change. They are taught how to apply either problem-focused or emotion- focused coping strategies to deal with the perceived demands of the stressful situation. The second phase of SIT is the skills acquisition and rehearsal phase, during which coping skills are taught to the clients (Meichenbaum, 1996). These skills include: relaxation training; self-instructional training; emotional self-regulation; self-soothing and acceptance; interpersonal communication skills training; cognitive restructuring; problem-solving, attention diversion procedures using social support systems; and fostering meaning-related activities (Meichenbaum, 1996). This practice occurs both in the training setting, and in vivo (where possible), and is tailored to the specific stressors the client will have to deal with. The third and final application phase of SIT, is the time in which clients are provided with opportunity to apply and practice the variety of coping skills learnt in the skills acquisition and rehearsal phase, across increasing levels of stressor (Meichenbaum, 1996). This process is analogous to a medical immunisation, with a relatively small, controlled amount of stress being applied as a tool for increasing the clients’ resistance to stress. In order to create stressors, techniques such as imagery and behavioural rehearsal, role-playing, modelling, and graded in vivo exposure are applied. An early study by Veronen and Kilpatrick (1982) provided rape victims who reported persistent anxiety and avoidance, with 20 sessions of SIT. Although positive results were reported, i.e., a marked decrease in fear, avoidance, and depression, the study did not include a control group. A second study by Veronen and Kilpatrick (1983) assigned rape victims to either SIT, peer counseling or systematic desensitisation conditions. SIT was found to lead to a reduction in rape-related anxiety. The first
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controlled study of SIT was conducted by Resick, Jordan, Girelli, Hunter and Marhoefer-Dvorak (1988), who assigned 37 rape victims to either SIT, assertion training, supportive counseling, or a wait-list control group. At the post-treatment assessment all three treatments led to more improvement in fear and anxiety than the untreated control group. SIT produced a 27% reduction compared to a 14% increase in the wait-list controls, however it is difficult to draw inferences because the SIT included in vivo exposure. Foa and colleagues (1991) conducted a study in which female assault victims were allocated to either SIT, prolonged exposure or a wait-list control group. The SIT and prolonged exposure patients showed improvement in PTSD symptomatology post-treatment, but at the six-month follow-up prolonged exposure showed a superior outcome. In yet another study of 96 female assault victims, Foa and colleagues (1999) compared four treatments: prolonged exposure (PE), SIT, combined treatment (PE + SIT), and wait-list control. At the post-treatment assessment all three active treatments reduced PTSD severity, and did not differ significantly from each other. It should be noted, however, that there was a dosage effect, with those in the PE condition having longer sessions than those in the other conditions. In addition, in order for SIT to be most effective, the patient must be provided with time to go away and practice the techniques that they have been taught, and to consolidate the new information that they have learned. Due to the fact that therapy sessions were held twice a week, those in the SIT condition did not have the time that was required for them to practice and consolidate. SIT has been found to be effective in decreasing PTSD symptoms, especially in rape victims (as mentioned above). Consequently SIT is often used as an adjunct to exposure treatment, with the assumption being that learning to cope with daily stressors as well as with the trauma symptoms will increase a patients sense of control and reduce avoidance behaviour (Solomon & Johnson, 2002). In Study 3 of this thesis, a resilience programme has been developed and trialled, and this programme draws upon the SIT literature. The development of this resilience programme is detailed in Section 9.2.1.
4.2.3 Serial Approximation and Desensitisation Serial approximation and desensitisation are exposure based approaches that originate from conditioning theory of fear and anxiety. Exposure based approaches were developed originally for the successful treatment of specific anxiety disorders such as
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obsessive-compulsive disorder (Kozak, Foa, & Steketee, 1988; Rabavilas, Boulougouris, & Stefanis, 1976), panic disorder (Agras, 1985; Barlow, 1988; Leskin et al., 1998) and phobia (Heimberg & Barlow, 1988; Steketee, Bransfield, Miller, & Foa, 1989). They involve helping the patient confront fears and are based on the premise that direct therapeutic exposure to feared, but relatively harmless stimuli, will result in a reduction of PTSD symptoms (Solomon & Johnson, 2002). When serial approximation and desensitisation are applied before a traumatic exposure has occurred, it is an opportunity for an individual to emotionally process stressful or traumatic stimuli (i.e., photographs, videos) in an environment that is safe and supportive. In the field of dental anxiety, classical conditioning has been proposed to explain dental anxiety (e.g., Lautch, 1971). According to this principle, neutral stimuli acquire painful properties and become conditioned stimuli (CS) through being paired with unconditioned stimuli (UCS) that naturally evoke anxiety (DeJongh, Muris, Ter Horst, & Duyx, 1995). Davey (1989) provided further evidence for this contention, finding that the dental history of anxious patients was marked by a higher proportion of painful treatments than those who reported feeling relaxed about dental treatment. His results showed that people who did experience painful events but did not acquire anxiety, reported a history of dental treatments which is characterised as ‘latent inhibition’ (Lubow, 1973). Latent inhibition refers to a retardation of conditioning as a result of prior exposure to the to-be-CS (Siddle, Remington, & Churchill, 1985). In two experiments which investigated the effects of conditioned stimulus (CS) preexposure on Pavlovian differential conditioning and extinction of the skin conductance response, Siddle, Remington and Churchill (1985) found that preexposure to the to-be-CS retards subsequent conditioning. When participants did not receive preexposure they displayed more differentiation for both positive and negative CS than preexposure groups during acquisition and more resistance to extinction. Latent inhibition predicts that where individuals have received a number of relatively painless treatments prior to the conditioning event, they are less likely to acquire dental anxiety. In a replication and extension of Davey’s (1989) study, DeJongh and colleagues (1995) found that both the extent to which earlier dental treatments were perceived as painful and the extent to which these incidents were reported as traumatic were significantly related to dental anxiety. Based on these results, DeJongh and colleagues
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suggest that non painful, aversive or frightening situations may serve as powerful conditioning experiences. Based upon the research discussed above and using the principles of classical conditioning, for the current study individuals will be shown a stimulus that elicits a fear or anxiety response repeatedly, until habituation occurs (i.e., there is a decline in the strength of the anxiety response that is elicited). By presenting CS in an environment that is non aversive or frightening, it is proposed that latent inhibition will occur. In keeping with the protocol typically used to deliver exposure therapy to patients, recruits will be shown a hierarchical series of stimuli (i.e., photographs). The first stimulus that is shown will be the least anxiety provoking, and the stimuli will sequentially become more severe, and the final stimulus shown is the most anxiety provoking stimulus (Hembree & Foa, 2003).
4.2.4 Occupational Stress Occupational stress has been defined by many researchers (e.g., Cox, 1978; Cummings & Cooper, 1979; Quick & Quick, 1984) as work demands or expectations that a worker perceives to be beyond their skills, abilities and coping strategies, and which also have negative mental and physical health consequences. While some forms of stress may actually increase worker productivity, if the burden is too great, job performance will be impaired. The major sources of occupational stress (or stressors) have been divided into seven categories: work control; job-intrinsic factors (e.g., work overload, job variety); interpersonal relationships; career development (e.g., under- or over-promotion); organisational climate; and home/work interface (Sparks & Cooper, 1999). In the past, occupational stress has been conceptualised in terms of stressors and strain, presuming that adverse work experiences (stressors) cause psychological and behavioural strain (e.g., Greller, Parsons, & Mitchell, 1992). However, more recently, evidence is emerging that the organisational context may exert a much stronger influence on outcomes related to employee well-being than has previously been recognised. Hart and Cooper (2001) proposed the organisational health framework as an alternative to the stressors and strain approach. In this framework, both the occupational well-being of employees and organisational performance are considered. It is insufficient to be concerned with occupational well-being solely; occupational well-
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being must also be linked to outcomes that affect organisational performance. The symptoms of occupational stress are the same as for stress (detailed above). The consequences differ, however, with occupational stress frequently resulting in job dissatisfaction (Jackson & Schuler, 1985), reduced productivity (Braham, 1991), premature retirement (Kendell & Pearce, 1997), absenteeism (Fagin, Brown, Bartlett, Leary, & Carson, 1995; Gray-Toft & Anderson, 1985), workplace accidents (Cain, 1987), lower organisational commitment (Jamal & Baba, 2000), and work/family conflict (Voydanoff, 2002). A number of studies have also found that occupational stress is related to impaired physical and psychological well-being (e.g., Adler & Matthews, 1994; Beehr, 1995; Cooper, Rout, & Faragher, 1989; Newbury-Birch & Kamali, 2001). Whilst it is impossible to calculate the full personal and economic costs of each of these problems, a recent report produced by the Australian Government provides us with some indication of the cost of workplace ‘psychological injuries’ (a classification that includes stress, depression and post-traumatic stress disorder) to the Australian community each year. The report revealed that psychological injuries make up 8.0% of workers’ compensation claims in Australian Government agencies, but 29.1% of total claim costs (Australian Government Comcare, 2007). In 2003-2004, psychological injuries were the most costly of all the types of injury (Australian Government Comcare, 2005), and the average lifetime cost of claims for psychological injuries sustained in 2005-2006 for Australian Government premium paying agencies was $115, 000, compared to $27, 000 for a non-psychological claim (Australian Government Comcare, 2006).
4.3 Burnout The phenomenon of burnout was first identified by Bradley (1969) in a paper on probation officers, and was characterised as feelings of failure and being worn out. The concept was further elaborated upon by Freudenberg (1974), who considered burnout to be a malaise of human service professionals, such as social workers mental health workers, teachers and nurses, which is characterised by feelings of ‘wearing out’. Over the years there have been many varying definitions of burnout, however the first widely accepted definition was that proposed by Maslach (1982). Maslach defined burnout as ‘emotional exhaustion, depersonalisation, and reduced personal accomplishment that
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can occur among individuals who do ‘people work’ of some kind’ (p. 3). According to this definition, burnout consists of three core components; emotional exhaustion, depersonalisation and (reduced) personal accomplishment. Emotional exhaustion refers to feelings of being depleted of one’s emotional resources, and may be linked to physical fatigue and weariness. Depersonalisation refers to a negative, cynical or excessively detached response to other people at work. Diminished personal accomplishment refers to a tendency to evaluate one’s behaviour and performance negatively. This results in feelings of decline in one’s competence and productivity and to a lowered sense of self-efficacy. Subsequently, Maslach and her colleagues modified this definition (c.f., Maslach, Schaufeli, & Leiter, 2001, p. 399). Depersonalisation was replaced by cynicism, representing an indifferent or ‘distant’ attitude toward work generally, which may (or may not) include people encountered in the context of the job. The cynicism construct does not directly refer to personal relationships at work, nor does it exclude such a reference (Schaufeli, Leiter, Maslach, & Jackson, 1996). The dimension of (diminished) personal accomplishment was relabelled as (diminished) professional efficacy. This construct is similar to the original, but has a broader focus, encompassing self-assessments of low self-efficacy, lack of accomplishment, lack of productivity and incompetence (Leiter & Maslach, 2001). There is current controversy, however, over the diversity of the symptoms encompassed by the professional efficacy dimension, and the theoretical reasoning behind the grouping of these concepts together (Cooper, Dewe, & O' Driscoll, 2001). Previous reviews of the burnout literature (i.e., Burke & Richardson, 2000; Cordes & Dougherty, 1993; Moore, 2000; Schaufeli & Enzmann, 1998; Wisniewski & Gargiulo, 1997) consider it to be a consequence of one’s exposure to chronic job stress. The chronic stresses that may lead to burnout include qualitative and quantitative overload, role conflict and ambiguity, lack of participation, and lack of social support (Shirom, Melamed, Toker, Berliner, & Shapira, 2005). The array of symptoms associated with burnout is extensive, and not every individual exhibits the same symptoms, however symptoms commonly cited in the literature are: low job performance/low job satisfaction, physical exhaustion/fatigue, rigidity to change/loss of flexibility, decreased communication / withdrawal, physical symptoms, apathy/ loss of concern, cynicism, and emotional exhaustion (James & Gilliland, 2001). These findings
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suggest that job stressors are more often to be found in the job context rather than the job content (Evans & Coman, 1993). Job related burnout may result in several negative organisational outcomes, including increased turnover and absenteeism (Jackson, Schwab, & Schuler, 1986; Parker, 1995; Parker & Kulik, 1995), lower organisational commitment (Maslach & Leiter, 1997) and the self-reported use of violence by police officers against civilians (Kop, Euwema, & Schaufeli, 1999). Burnout may also result in diminished physical and mental health (Belcastro & Hays, 1984; Burke & Greenglass, 1995; Pierce & Molloy, 1990; Seidman & Zager, 1991) and increased use of drugs and alcohol (Farber & Miller, 1981; Lowenstein, 1991; Maslach & Jackson, 1981b). The majority of studies that have examined burnout have utilised the Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981a), which was developed to assess the three dimensions of burnout identified by Maslach (1982): emotional exhaustion, depersonalisation and (reduced) personal accomplishment. In Study 3 of this thesis, burnout (along with many other constructs), is examined in relation to police officers. As such, the literature relating to burnout and police officers is reviewed below. Several studies have been conducted using the MBI, to examine burnout in relation to police officers. In a sample of Canadian mounted police, Stearns and Moore (1990) found that psychological well-being was correlated with emotional exhaustion, depersonalisation and total burnout scores of the MBI. Health concerns were also highly correlated with burnout. In another study of Canadian police (both mounted officers and regular officers) Kohan and Mazmanian (2003) found that burnout was more strongly related to organisational issues, than operational ones. It was also found that organisational hassles had a stronger relationship with distress measures than operational ones. Using the MBI, Jackson and Maslach (1982) examined 142 police officers and their wives, and found that those officers experiencing burnout were more likely than those who were not experiencing burnout to report that they got angry at their wives and their children. Those with high scores on the emotional exhaustion scale were more likely to report having a drink to cope with stress and to report taking tranquillisers if they scored low on personal accomplishment. However, not all studies conducted with police officers have found them to suffer from aspects of burnout, with Kop and colleagues (1999) finding that their sample of Dutch police officers reported a low level
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of emotional exhaustion, average level of depersonalisation, and a high level of personal accomplishment.
4.4 Coping Following on from Section 4.2.1, which briefly introduced the concept of coping, in this section coping will be discussed in greater detail. Coping refers to the cognitive and behavioural efforts one uses to manage (reduce, minimise, master, or tolerate) the internal and external demands of a stressful situation (Lazarus & Folkman, 1984). The way in which someone appraises an event will have a powerful influence in determining the level of stress reactions (Lazarus & Folkman, 1984). It is the use of coping mechanisms, however, which account for the major differences in outcome (Roskies & Lazarus, 1979) and that influence a person’s subsequent appraisal of the transaction (Lazarus, 1990). According to Lazarus and Folkman (1984), people use both primary and secondary cognitive appraisals to evaluate adverse events. Primary appraisal involves evaluation of the threat represented by the event, while secondary appraisal involves the assessment of one’s ability to cope with the threat. Subsequently, the individual evaluates his or her coping responses for their effectiveness in reducing or removing the threat. Lazarus and Folkman (1984) consider that there are two primary functions of coping: dealing with the problem that is causing the distress (‘ problem-focused coping’) ; and regulating the emotional reaction caused by the situation (‘ emotion- focused coping ’). Problem-focused coping involves activities that focus on directly changing elements of the stressful situation (e.g., focusing on the task at hand, goal- setting, information gathering, and problem-solving), whereas emotion-focused coping involves techniques that focus more on modifying one’s internal reactions resulting from the stressful situation (e.g., distancing, denial, seeking social support, self- controlling, accepting responsibility and positive reappraisal). Research has shown that people use both forms of coping in almost every type of stressful encounter (e.g., Folkman & Lazarus, 1988). In several studies of trauma, however, victims’ greater use of emotion-focused coping such as avoidance and distancing strategies, and less use of problem-focused coping has been consistently associated with greater levels of post-traumatic symptomatology (e.g., Morgan & Matthews, 1995; Norvell, Cornell, & Limacher, 1993; Solomon, Avitzur, & Mikulincer,
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1990; Weisenberg, Schwarzwald, Waysman, Solomon, & Klingman, 1993). Emergency services personnel frequently have to cope with a wide range of work-related traumatic events. As such, a number of studies have been conducted to identify which coping techniques are most commonly used by people in these professions, and which techniques are most helpful. In a study of the stress-coping strategies used by Australian police personnel, Evans, Coman, Stanley and Burrows (1993) found that officers typically use problem-focused coping strategies, using emotion-focused coping less often. Likewise, in an investigation of coping strategies used by Scottish police officers, Biggam and colleagues (1997) found that the officers displayed a preference for problem-focused strategies. A study by Patterson (2003), however, examined the effect of coping on degree of psychological distress in American police officers that had been involved in stressful events. He found that problem-focused coping resulted in a ‘reverse buffering effect’, i.e., greater use of problem-focused coping was associated with higher levels of distress, and that emotion-focused coping resulted in a buffering effect, i.e., greater use of emotion-focused coping was associated with lower levels of distress. In accordance with this finding, a study of the coping techniques of Israeli bus commuters who face the threat of terrorism found that those commuter’s who used problem-focused coping more than denial or emotion-focused coping, were more likely to suffer anxiety regarding terrorism (Gidron, Gal, & Zahavi, 1999). Thus, although police officers appear to prefer problem-focused coping, the evidence suggests that this may not be the most effective strategy for reducing psychological distress. In an alternative to Lazarus and Folkman’s (1984) theory of coping, Suls and Fletcher (1985) conceptualise coping as comprising the two dimensions approach coping and avoidance coping . Approach coping refers to the use of strategies that focus on both the source of the stress and reactions to it, with the individual dealing directly with the event. Avoidance coping refers to the use of strategies that place focus away from both the source of the stress and the reactions to it, with the individual avoiding dealing with the event by not facing reality and disrupting the coping process. Avoidance coping has repeatedly been found to be associated with post-traumatic symptomatology, with those that employ more avoidance strategies likely to be more symptomatic than those that use more active forms of coping (e.g., Sutker et al., 1995; Wolfe, Keane, Kaloupek, Mora, & Wine, 1993).
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As with the emotion-focused, problem-focused coping literature, a number of avoidance-approach coping empirical studies have been conducted using cancer patients. For example, Friedman and colleagues (1992) noted that women with breast cancer who exhibited a fighting spirit (viewed as active coping) adjusted more positively to their illness, whereas women who used avoidance coping did not adjust as well. Similarly, in a study of women diagnosed with breast cancer, Holland and Holahan (2003) found that avoidance coping strategies were negatively related to psychological well-being, whilst approach coping strategies were related to positive adjustment. Furthermore, a study by Carver and colleagues (1993), of women diagnosed with breast cancer found that the following three coping responses had a positive effect, reducing the woman’s level of distress: acceptance - an acceptance strategy was consistently linked to low levels of distress and was also a prospective predictor of low distress post-surgery; denial - was consistently related to high levels of distress; and behavioural disengagement (thoughts of giving up)- was also consistently related to high levels of distress. Approach-avoidance coping strategies have also been examined in relation to emergency services personnel. In a survey of police officers that had been involved in the LA Riots, it was found that the 17% of officers that reported post-traumatic symptomatology were almost twice as likely to use avoidance coping strategies as those without symptoms (Harvey-Lintz & Tidwell, 1997). Those that made more use of cognitive avoidance, acceptance or resignation, and emotional discharge had greater levels of PTSD symptomatology, whilst those that had greater levels of seeking support and information and seeking alternative awards (e. g. exercise) had lower levels of PTSD symptomatology. The finding of a link between seeking alternative awards (an avoidance strategy) and lower levels of PTSD symptomatology is inconsistent with the literature, however, the authors theorise that due to the unique circumstances that confronted Los Angeles Police Department officers at the time, this strategy may have helped the officers with a perceived ambiguous situation and thus, helped the officers deal with their stress. Coping has been consistently found to mediate the relationship between optimism and psychological distress (e.g., Aspinwall & Taylor, 1992; Long & Sangster, 1993). For example, in a study of maternal optimism, coping, and psychological distress following an infants’ hospitalisation to the Neonatal Intensive Care Unit, it was found
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that the relationship of optimism and psychological distress was mediated by the mothers’ use of use cognitive and avoidant coping strategies (McIntosh, Stern, & Ferguson, 2004). Those mothers that were optimistic, employed more cognitive and fewer avoidant coping strategies, and also experienced less psychological distress both during and after their infants’ hospitalisation. In a well-designed prospective study, Carver and colleagues (1993) found that pessimism was significantly but indirectly associated (through coping responses) with the experience of greater distress at each time point of the follow-up, even after controlling for initial levels of distress. Carver and colleagues (1993) also found that optimistic women who were diagnosed with breast cancer were more likely than women who were less optimistic to accept the reality of the situation they were facing. The relationship between optimism and PTSD symptomatology is reviewed in Section 8.4.3 of this thesis. A general characterisation of the aforementioned research is that those higher in optimism tend to use more approach-focused coping strategies (i.e., overt efforts to deal directly with the stressful event) and less avoidance coping (i.e., avoidance of the stressful event). In turn, these coping strategies and positive expectations seem to promote greater psychological well-being (Friedman et al., 1992). According to self- regulatory theory (Scheier & Carver, 1992) individuals who generally expect positive outcomes (i.e., are optimistic), also expect their coping efforts to be effective. McIntosh and colleagues (2004) suggest that optimists are more likely to persist in the use of coping behaviours such as information-seeking and cognitive reappraisal. They suggest that individuals who generally expect negative outcomes tend to avoid the stressful situation and withdraw from continued coping efforts based on their presumed futility, thus decreasing the likelihood of positive outcomes. Although there is evidence to suggest that some coping strategies are more effective than others, and that an optimistic disposition may be advantageous, the ultimate issue remains that a person should be capable of using a wide range of coping styles in any given situation (Biggam et al., 1997). What works in one situation may not work in another, and what works at one point in time may not at another (Norris, 2001). Rather than one type of coping response being better than another, conflicting results in the literature may be explained by the fact that certain strategies suit certain situations. In order to succeed, one’s coping must match the circumstances of the event and the individuals’ resources (Shalev & Ursano, 2003). Acceptance, cognitive re-framing or
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denial may be more appropriate in situations that are uncontrollable (e.g., captivity), whilst taking action to reduce the stressor or seeking help may be more appropriate in other circumstances (e.g., injury from a car accident).
4.5 Hardiness Hardiness is a dispositional construct proposed by Kobasa (Kobasa, 1979; Kobasa, Maddi, & Kahn, 1982) to explain personal resilience to stress and adversity. It is defined as “the use of ego resources necessary to appraise, interpret, and respond to health stressors” (Pollock, 1989, p. 53). The construct is described in terms of three traits: (a) commitment, or sense of meaning, purpose, and perseverance attributed to one’s existence; (b) control, or sense of autonomy and ability to influence one’s destiny and manage experiences; and (c) challenge, or perceptions of change as exciting growth opportunities (Maddi & Kobasa, 1984). According to Maddi and Kobasa (1984), these traits should protect the individual against potentially traumatic events. Those with a ‘hardy’ personality view such events as being under their control, as meaningful rather than random or pointless, and as a challenge rather than a threat. High levels of hardiness have been associated with less post-traumatic symptomatology in Persian Gulf troops (Bartone, 1999; Sutker et al., 1995), army family assistance workers (Bartone, Ursano, Wright, & Ingraham, 1989), Israeli Prisoners of War (Waysman, Schwarzwald, & Solomon, 2001) and Vietnam veterans (King, King, Fairbank, Keane, & Adams, 1998). Similar results have also been found in research with emergency services personnel, with Alexander and Klein (2001) finding that for those ambulance workers who experienced a personally disturbing incident in the previous 6 months, those high in commitment reported less post-traumatic symptomatology. Those with a more hardy personality displayed significantly less burnout than those with a less hardy one. Hardiness has been found to have an indirect effect on PTSD symptomatology, through functional social support (King et al., 1998). It has been hypothesised that hardy individuals are more likely to seek out available others for realistic help in times of stress (Kobasa & Puccetti, 1983). People high in hardiness may be better able to build for themselves a larger or more complex support network than a person low in hardiness (King et al., 1998). Choice of coping strategy in a stressful situation has also been linked to hardiness. Those people high in hardiness have been shown to use more
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problem-focused coping and less emotion-focused coping than do less hardy people (Florian, Mikulincer, & Taubman, 1995; Kobasa & Puccetti, 1983; Williams, Wiebe, & Smith, 1992). Limited research suggests that hardiness is amenable to change under certain conditions, with it possible to increase levels in adults. Using a structured intervention program, Maddi (1987) successfully increased hardiness levels in corporate managers, and at the same time found that their physiological responses were attenuated and healthier. Likewise, Maddi, Kahn and Maddi (1998) increased self-reported hardiness in corporate managers, while decreasing self-reported strain and illness severity. Maddi and colleagues (1998) achieved this by creating a more refined ‘hardiness induction’ programme, which involves facilitating the adoption and application of new strategies for interpreting and making sense of experiences, especially highly stressful ones. Trainees were taught ‘transformational coping’ skills, and were motivated to use these skills (Maddi et al., 1998). Organisational groups such as the military and emergency services are team oriented and highly interdependent. It is suggested that in such groups, this ‘meaning-making’ is a process that leaders can influence through the policies and priorities they establish, the directives they give, and the advice and counsel they offer (Bartone, 2003). There are, however, several concerns regarding the concept of hardiness which have been noted by Lambert and Lambert (1999) and Funk (1992). For example, it is not clear if hardiness is a concept on its own, or an amalgamation of the three separate components of commitment, control and challenge. The various studies measuring hardiness often use different measures and therefore it is unclear whether the same concept is being measured. In addition, it is unclear whether hardiness is an innate or a learnt trait or even a by-product of a strong social support network. Furthermore, in recent times, the construct of hardiness has received much less attention, and the construct of ‘resilience’ has come to the forefront. Seemingly, there are a number of similarities between the two constructs, and differentiating hardiness and resilience has proven to be somewhat difficult. Maddi and Khoshaba (the creators of the HardiAttitudes® programme) (2003) claim that three traits that make-up hardiness, i.e., commitment, control and challenge, and that these three traits in turn facilitate resilience in two ways. The first involves being proactive in interactions with people and events, while the second concerns the skills that facilitate turning adversity
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into opportunity (Khoshaba & Maddi, 2001, cited in Maddi & Khoshaba, 2003). It has been suggested that ‘cognitive hardiness’ can be used to describe the adaptive behaviours of resilient individuals (Beasley, Thompson, & Davidson, 2003). Druss and Douglas (1988) suggest that the term resilience describes both the particular cognitive style of ‘hardiness’ and the ‘ego strength’ that characterise people that show unusual courage. However, in a study conducted by Foster and Dion (2004) which claimed to examine resilience, the definition of hardiness was used to represent resilience in their study, meaning that in this case the terms hardiness and resilience were used interchangeably. Similarly, in King and colleagues (1998) study of factors associated with PTSD among Vietnam Veterans, the study title claimed that ‘Resilience-recovery factors’ would be explored. Yet no measure of resilience was included in the study, while a measure of hardiness was included. Studies such as these add to the confusion surrounding hardiness and resilience.
4.6 Resilience Although the bulk of resilience research has been conducted in recent years, the term ‘resilience’ was first used in the 1950s to describe individuals who survived stressful environments (for review see Kaplan, 1999; Masten, Best, & Garmezy, 1990). The foundation of the concept of resilience is the possession of selective strengths or assets that help an individual survive adversity (Richardson, 2002). Over the last two decades, various models of resilience have been proposed, each emphasising various ecological and psychological contexts. Garmezy and colleagues defined resilience as a ‘capacity’ for successful adaptation in face of hardship (Garmezy, 1993; Masten et al., 1990) whilst Rutter (1987) described it as a positive response to stress and adversity. Much of the original theorising in this area emerged in the 1970’s from within the fields of developmental psychology and psychiatry. Garmezy (1971; 1974) observed and documented that contrary to expectations, many children growing up in caustic socioeconomic circumstances followed healthy development trajectories. Prompted by the finding that this unexpected resilience in at-risk children was in fact quite common, Masten (2001) described resilience as an “ordinary magic”. Recently adult resilience to trauma has become a focus, and definitions of resilience have included: “a dynamic process encompassing positive adaptation within the context of significant adversity” (Luthar, Cicchetti, & Becker, 2000, p. 543); “the possession and sustaining of key
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resources that prevent or interrupt loss cycles” (Hobfoll, Ennis, & Kay, 2000, p. 277); and “the individual’s capacity for adapting successfully and functioning competently despite experiencing chronic stress or adversity, following exposure to prolonged or severe trauma”(Cicchetti & Rogosch, 1997, p. 797). More recently, resilience was defined as “the capacity of a given system to implement early, effective adjustment processes to alleviate strain imposed by exposure to stress, thus efficiently restoring homeostatic balance or adaptive functioning within a given psychological domain following a temporary perturbation therein” (Layne et al., 2007, p. 500). Following this definition, an individual may experience resilience in one life domain (e.g., maintaining healthy family relationships following involvement in a police shooting), whilst they may not experience resilience in another domain (e.g., maintaining workplace functioning) (Layne et al., 2007). A key point is that although resilient individuals may experience some short term dysregulation and variability in their emotional well-being (Carver, 1998) , their reactions to a traumatic event tend to be relatively brief and do not impede their functioning to a significant degree. Therefore one would expect resilient individuals among a trauma exposed population to report few or no psychological symptoms, to continue fulfilling their personal and social responsibilities and be able to embrace new tasks and experiences (Westphal, Bonanno, & Bartone, 2008). It is suggested that resilience is not a fixed attribute but rather a transactional process between the circumstances defining the risk situation and individual variations (e.g., vulnerability, protective mechanisms, affective and coping style; Rutter, 1987) The mechanism by which resilience facilitates adaptation has been described as the ability to identify what is stressful, appraise realistically one’s capacity for action, and problem-solve effectively (Beardslee, 1989; Caplan, 1990). Similarly, Mrazek and Mrazek (1987) posit a cognitive appraisal theory of resilience, whereby responses to stress are influenced by appraisal of the situation and by the capacity to process an experience, attach meaning to it, and to incorporate the experience into one’s belief system. Resilience is seen as an attribute that may alter depending upon the circumstance. A person may cope successfully with difficulties at one point in their life, yet may react adversely to other stressors when their situation is different (Jew, Green, & Kroger, 1999). In the theoretical literature, three groups of resilient phenomena have been
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distinguished: those where (1) at-risk individuals show better than expected outcomes; (2) despite the occurrence of stressful experiences, positive adaptation is maintained; and (3) there is a good recovery after a traumatic incident (Masten et al., 1990; Masten, 1994). Resilience represents an outcome trajectory distinct from the type of responses typically associated with recovery from trauma (Bonanno, 2004). Many individuals who experience a traumatic event and go on to recover without developing PTSD, often experience subthreshold levels of psychological symptoms together with significant disruption to daily functioning. In contrast, however, resilient individuals experience mild disruption in physical and emotional well-being (e.g., sleeplessness, negative affect, difficulty concentrating), but these reactions are only transient with relatively stable levels of adjustment exhibited across time (Bonanno, Rennicke, & Dekel, 2005). Although resilience is an oft-cited outcome after exposure to a traumatic event, very few empirical measures of resilience exist. Instead indicators of adaptive outcomes are described as evidence of resilience, usually in the realm of social and psychological competence (Byrne et al., 1986). Wagnild and Young (1993) developed one of the earliest measures of resilience, the Resilience Scale, and in doing so identified two resilience factors: (a) personal competence; and (b) acceptance of life and self. This scale includes 25-items and evaluates qualities of personal competence and acceptance of self and life. One of the few other measures of resilience, and perhaps the most widely used, is the 25-item Connor-Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003). Connor and Davidson (2003) identified five factors of resilience in the development of this scale: (a) personal competence, high standards and tenacity; (b) trust in one’s instincts, tolerance of negative affect, and strengthening effects of stress; (c) positive acceptance of change, and secure relationships; (d) control; and (e) spiritual influences. The CD-RISC incorporates items from earlier resiliency research, including those corresponding to Kobasa’s hardiness model and Rutter’s list of resilient characteristics from his 1985 review (Hoge, Austin, & Pollack, 2007). Whilst being developed by Connor and Davidson (2003), the CD-RISC was administered to a number of different populations, including patients who were being treated for PTSD, samples of the general population, psychiatric outpatients, and patients with generalised anxiety disorder. It was found that an increase in CD-RISC score, i.e., an increase in resilience, was associated with greater improvement during PTSD treatment. Using an abbreviated 11-item version of the CD-RISC, Connor,
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Davidson and Lee (2003) examined resilience in survivors of violent trauma. They found that those who scored more highly on the resilience measure, i.e., that were more ‘resilient’, had less post-traumatic symptomatology and better general health than those that were ‘non-resilient’. Recently, researchers have become increasingly interested in the concept of resilience in regards to post-traumatic stress symptomatology. However, as noted by Bonanno, Rennicke and colleagues (2005), there have been few attempts in the trauma literature to distinguish sub-groups within the broad category of individuals who are exposed to a traumatic incident but who do not go on to develop PTSD. Most studies of resilience have focused on children, with fewer studies examining resilience among adults. Many of these studies have been efforts to understand how children growing up in adverse circumstances successfully avert later psychiatric disorder (Elder, 1986; Smith, Smoll, & Ptacek, 1990; Werner, 1990; Zoccolillo, Pickles, Quinton, & Rutter, 1992). In one of the very few studies to examine resilience in adults, Manhattan residents were randomly surveyed by phone following the September 11 terrorist attack (Bonanno, Galea, Bucciarelli, & Vlahov, 2006). With mild to moderate PTSD defined as two or more PTSD symptoms, and resilience defined as one or no PTSD symptoms in the first 6 months after the attack, over 65% of the residents were classified as being resilient. Resilient outcomes have also been documented in studies that utilised structured clinical interviews, and anonymous ratings from participants’ friends or relatives (e.g., Bonanno, Moskowitz, Papa, & Folkman, 2005; Bonanno, Rennicke et al., 2005). In contrast to childhood resilience, which is identified in situations where typically a child has been exposed to an abusive or poverty stricken environment over a long period of time, Bonanno (2005) notes that resilience in adults typically occurs as the result of an isolated and usually brief traumatic event. At this time, rather than adapting long-term coping strategies, the individual instead utilises pragmatic forms of coping which are often less effective or maladaptive in other contexts. For example, in an examination of individuals exposed to a traumatic event Bonanno, Field, Kovacevic and Kaltman (2002) found trait self-enhancement (i.e., overestimating one’s own positive qualities) to be positively associated to ratings of functioning made by mental health experts. Those high in self-enhancement tend, however, to be regarded as narcissistic, and for the study untrained observers rated those high in self-enhancement
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as being high on negative traits such as ‘self-centredness’. Furthermore, in a study of September 11 high-exposure survivors, it was found that trait self-enhancement was more prevalent amongst those who exhibited a resilient trajectory (defined as good levels of mental and physical health), through either self- report or ratings by family and friends (Bonanno, Rennicke et al., 2005). However, self- enhancers friends and family as rated them as decreasing in social adjustment and honesty, whilst the self-enhancers themselves rated their social relationships more positively than non self-enhancers. Analysis revealed that this positive rating by the self-enhancers fully mediated their low levels of PTSD symptomatology, a finding which Bonanno, Rennicke and colleagues (2005) suggest indicates that self-enhancers are completely unaware of the negative reaction they can cause in others, with their self- serving bias playing an important role in maintaining healthy, stable levels of functioning. Resilience is a construct that has received increased attention in recent years. However, theories that explain the method in which resilience interacts with the perception, processing and adaptation to traumatic events are yet to be developed. As it has been detailed in this section, resilience has been conceptualised in a number of different ways, which are often dependent upon the context in which resilience is being measured. Some researchers have chosen to define resilience as the absence of PTSD symptomatology following exposure to a potentially traumatic event (e.g., Resnick, Galea, Kilpatrick, & Vlahov, 2004), but other researchers argue that the absence of PTSD symptoms does not equate to resilience anymore than absence of disease equals health (see Almedom & Glandon, 2007). In a study by Bonanno, Rennicke and colleagues (2005) resilience was defined as ‘good levels of mental and physical health’, and for Study 3 in this thesis, this type of holistic approach to resilience will be utilised. Study 3 of this thesis aims to evaluate a resilience training programme with police officers, and therefore one of the key outcome measures of this study is resilience. Layne and colleagues (2007) defined resilience as “the capacity of a given system to implement early, effective adjustment processes to alleviate strain imposed by exposure to stress, thus efficiently restoring homeostatic balance or adaptive functioning within a given psychological domain following a temporary perturbation therein” (p. 500), and this definition will be used for Study 3. In addition, rather than simply considering resilience in terms of PTSD symptomatology, for Study 3 resilience will be
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defined as comprising three life domains, with an individual considered resilient only if they show no change or improvement across all three domains. The first of the domains, ‘Health and Well-being’, will encompass factors associated with general health and well-being. Measures of general health, affective distress (depression, anxiety and stress), drug and alcohol use, and relationship satisfaction will be used for assessment, with resilience in this domain equal to no change or improvement across time, for all four of these measures. The second of the domains, ‘Reactivity to Trauma’, will reflect the amount of self-reported PTSD symptomatology experienced by the individual following exposure to potentially traumatic policing events. A measure of PTSD symptomatology will be used to assess this domain, and resilience will equal a score on this measure which is below a clinical cut-off point. The third of the domains, ‘Workplace Functioning’ will reflect the individual’s ability to work and function in a stressful occupation. A measure of burnout will be used to assess this domain, and in addition the individual’s use of both police and community mental health services will be measured. Resilience in this domain will equal a score on the burnout measure which is below a clinical cut-off point. In Study 2 of this thesis a resilience training study will be trialled, and the impact of this training upon eyewitness stress reactions and eyewitness memory will be assessed. This study aims to assess the impact of resilience training upon individual reactions, and does not seek to measure personal resilience. As such, the above definition will not used for Study 2. In Study 3, however, a resilience training programme will be delivered to new recruit police officers, and resilience will then be assessed once the officers have been working for 6 months. For this study, resilience will be considered in terms of the above definition.
4.7 Preventing Stress Reactions Although a great deal of research has examined the nature and aetiology of adverse stress reactions (e.g., Kessler et al., 1995; Kulka et al., 1990), the pre-trauma, peri-trauma and post-trauma risks associated with the development of stress reactions (e.g., Breslau, Davis, & Andreski, 1995; Bromet, Sonnega, & Kessler, 1998; Green et al., 1990; Lauterbach & Vrana, 2001), and the most efficacious ways to treat stress reactions (e.g., Bryant & Harvey, 2000; Cooper & Clum, 1989; Devilly & Spence, 1999; Foa et al., 1999; Foa et al., 1991), no-one has ever examined whether it is
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possible to prevent stress reactions. One of the primary reasons for this is because in the general population, exposure to a traumatic event happens so infrequently during a persons’ lifetime, that its occurrence is usually impossible to predict. The intensity of stress reactions, and the ability to cope emotionally with a traumatic or stressful event can be influenced by the extent to which an individual is prepared for the experience (Paton, 1994). Lack of preparation, suddenness of onset, unrealistic expectations and a tendency to deny or suppress feelings can heighten the subjective experience of loss of control and result in the process of re-establishing control becoming more difficult (Eränen & Liebkind, 1993). Under these circumstances, when faced with events that threaten psychological integrity, individual’s become unable to draw on their previous learning, training, or experience to guide their response or to appreciate their reactions, increasing their vulnerability to traumatic stress reactions (Pollock, Paton, Smith, & Violanti, 2003). In the case of Posttraumatic Stress Disorder (PTSD) it has been established that the severity of PTSD experienced by an individual is associated with uncontrollability and unpredictability (Foa & Rothbaum, 1998). In Section 1.7.2.3 of this thesis Davey’s Two-component Conditioning Model was reviewed. Davey (1993) adopts the view that an individual’s expectancy is directly related to their fear response to fear relevant stimuli. One important aspect of pre- incident preparation is the provision of information. Many traumatic experiences result from a violation of expectancy, thus setting realistic expectations serves to protect against violated assumptions (Everly & Mitchell, 2000). Mastery of a situation refers to ones’ perception of an event as being under control, which in turn reduces the deleterious effects of the resulting stress (Mandler, 1982). (Janis, 1982) argues that the most promising approach to intervening and countering the disruptive consequences of the stress from an incident is to prepare individuals by providing them vivid information as to what they are likely to experience during and after a stressful incident while developing skills and strategies for coping. Resilience (pre-trauma inoculation) training may be looked at as a way of activating new pathways for processing traumatic information and increasing an individual’s ability to respond to a variety of situations with greater flexibility (Byatt, 1997; Garrison, 1991). Within the stress management literature, attention has been directed at resilience training as a way of providing individuals with the necessary skills to deal with a
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stressful event (Meichenbaum, 1974). This process is analogous to a medical immunisation, with a relatively small, controlled amount of stress being applied as a tool for increasing the clients’ resistance to stress. In order to create stressors, techniques such as imagery and behavioural rehearsal, role-playing, modelling, and graded in vivo exposure are applied. Using the theoretical framework of SIT (detailed in Section 1.5.2.1), Keyes and Dean (1988) successfully developed a programme to reduce and prevent maladaptive stress in individuals who worked in direct contact with mentally retarded clients at three residential facilities. After training, the SIT group had significantly lower scores on an anger inventory, and used emergency restraint less frequently than those that did not receive SIT training. Using the same SIT programme as that used by Keyes and Dean (1988), Keyes (1989) once again trained staff that worked in direct contact with the mentally retarded at a residential facility. He found that during the 12-month training period, 28 cases of suspected abuse by staff members were reported. In the 12 months following the training, this figured dropped to 15 cases. In addition, during the 12-month period before SIT training a direct-contact staff turnover rate of 60% was reported. During the 12-month period following SIT a direct- contact staff turnover rate of 35% was reported. These results suggest that SIT can be successful in reducing intra-personal stress. Sarason, Johnson, Berberich and Siegel (1979) developed a stress management programme for police academy trainees, based heavily upon the early work of Meichenbaum (1973; 1975). The programme was designed to make trainees aware of their cognitive and physiological responses to anger-provoking and threatening situations. Academy personnel rated the trainees that received the stress management training as performing at a superior level in several simulated police activities, compared to those trainees that did not receive the training. These results, however, must be treated with caution as the observers were not independent, and there were only nine participants in each of the two conditions. An interesting finding was made regarding the effect of preparedness for people involved in a traumatic incident, in a piece of research that was not specifically designed to measure this outcome. In a study of the psychological impact of performing body recovery duties after the Piper Alpha oil rig disaster, Alexander and Wells (1991) concluded that preparing police officers for body recovery work, advising them of the personal, emotional and psychological reactions the work was likely to elicit, and
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emphasising the importance of their work for surviving families, contributed to increasing stress resilience. Compared to matched normal controls, the group failed to exhibit any increase in psychiatric morbidity. However, because it was not possible to isolate the effects of preparation from other managerial and support interventions, the specific contribution of training can only be inferred (Bartone, 2003). Paton (1994) compared the experiences of a group of volunteer disaster workers who had received training designed to increase their ability to impose coherence and meaning on disaster experiences with a group of fire-fighters who had received no special training for working in a disaster situation. Training included: increasing awareness of the emotional and psychological consequences of disaster work; creating realistic performance expectations and increasing awareness of the nature of disaster operating environments. It was found that the volunteers were better equipped to deal with the situation, with the fire-fighters more likely to perceive event demands and characteristics as stressors and to report post-traumatic symptoms more frequently and at greater intensity. These results should be treated with caution however, due to the fact that volunteer disaster workers were compared to career fire-fighters, and as such two different populations were compared. In another study with police, Backman, Arnetz, Levin and Lublin (1997) provided police academy trainees with mental imaging training. This training comprised: instruction in stress theory; being taught physical and mental relaxation; learning about problem management, setting goals, triggers and self-image; and practical training. Those trainees that received training were found to experience their daily situation more positively than those trainees who did not receive the training. The training group also reported better health, experiencing fewer intestinal and sleep problems. In an attempt to address shortcomings in the area of preparedness training, Mitchell and Dyregrov (1993) proposed a six-step programme that may assist in preparing an individual to cope with a traumatic event. This programme comprised: (1) giving emergency workers education about the nature of stress responses, their causes and their effects on the average person; (2) providing information about “critical incident stress” or emergency stress reactions; (3) explaining the differences between the routine stress of everyday and the acute stress of an emergency situation; (4) teaching individuals to identify the specific behavioural, emotional, physical, and
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cognitive symptoms that may appear at the acute phase; (5) presenting material which described survival strategies to be used whilst at the scene of an emergency situation; (6) presenting material to spouses and significant others in stress workshops. The efficacy, however, of this programme was not empirically assessed. In one of the earliest studies of its kind, Clarke and colleagues (1995) conducted a RCT of targeted cognitive-behavioural intervention for the prevention of depressive disorders in adolescents. The intervention was ‘targeted’ because adolescents at an elevated risk of depression were selected to participate. It was found that the intervention significantly prevented depressive disorders through 1-year follow-up. Self-reported depressive symptoms were significantly reduced at post-intervention, but not over the follow-up period. There was also no reduction in clinician-rated depressive symptoms. Similarly, Peden, Rayens, Hall and Beebe (2001) found that a brief targeted cognitive-behavioural group intervention significantly prevented depressive symptoms in female college students who were at risk of depression. More recently, Bearman, Stice and Chase (2003) applied a brief targeted cognitive behavioural group intervention to women identified as being at risk of depression and bulimia. There was a reduction in depressive symptoms at the 3-month follow-up, but the effect faded at 6-months. In a study similar to that which was conducted in 1995, Clarke and colleagues (2001) used a brief targeted intervention with adolescents at high risk of depression (the adolescents parents were all treated for clinical depression). A significant preventative effect was found for both self-reported depressive symptoms and clinician-rated major depressive symptoms at the 1-year follow-up, however, at the 2-year follow-up the preventative effects had faded. In another study that followed participants over 2 years, Gillham, Hamilton, Freres, Patton and Gallop (2006) delivered a cognitive behavioural prevention programme to 11 and 12 year old children. The intervention produced a significant preventative effect for those children who had high symptoms at intake. Significant prevention of depression was also found in a study by Seligman, Schulman, DeRubeis and Hollon (1999), following the use of a targeted cognitive- behavioural intervention. In a sample of college students it was found that the intervention group had significantly fewer moderate depressive episodes through three years of follow-up, although there was no preventive effect for severe depressive episodes. They also found that there were fewer episodes of moderate generalised anxiety disorder in the intervention group compared to the control group. Both severe
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depressive episodes and moderate generalised anxiety disorder episodes were few in the college sample. In a replication and extension of the work by Seligman and colleagues (1999), Seligman, Schulman and Tryon (2007) delivered a targeted cognitive- behavioural intervention programme to college students at risk of depression. For this second study, the classroom workshop that was delivered to the intervention group was supplemented with Web-based materials and e-mail coaching. It was found that those in the intervention group had significantly fewer depressive and anxiety symptoms than those in the control group immediately after the intervention, but there was no significant difference between the conditions at the 6-month follow-up. Although a small number of RCTs have been conducted which indicate that resilience training is able to prevent depression and anxiety symptomatology, a RCT of the efficacy of resilience training for ameliorating stress reactions has never before been conducted. A few studies have used resilience training with the aim of preventing stress reactions, however these studies did not utilise robust, scientific designs. Therefore, in order to address this deficit in the literature, the primary aim of Study 2 was to conduct a RCT of resilience training for the prevention of stress reactions.
4.8 Conclusion In this Chapter, the literature relating to stress, burnout, appraisal, coping, hardiness and resilience has been presented, and the relevant theories have been explored. In Section 4.7 evidence was presented which indicates that it may be possible to provide people with training which will result in the mitigation of depression and anxiety symptomatology. In this section, however, it was also noted that no study has ever been conducted to examine whether it is possible to provide people with training that will mitigate stress reactions. In the next chapter, the results of such a trial are presented.
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Chapter Five: Proof of Concept: Study 2- Resilience Training for Witnessing Stressful Situations
5.1 Study 2: Overview This chapter presents a RCT of resilience training, which was delivered to individuals who were later shown a very stressful video. The aim was to assess the effect of this intervention upon eyewitness stress reactions and eyewitness memory for a stressful event, with a sample drawn from the general community ( n = 80). Participants were randomly allocated to either: resilience training; or control training. All participants received training in session 1, were then shown a very stressful video in session 2 one week later, and were again reviewed after one month. Members of the control training group were more accurate in their recall of peripheral content than those in the resilience group however there was also a greater decline over time for memory of peripheral content for those in the control group than for those in the resilience group. Additionally those in the control group reported a greater decline in confidence for incorrect memories over time, than those in the resilience group. Across all groups, participants were found to be more accurate at central rather than peripheral recall yet more confident for incorrect memories of the video than correct memories. Although the video was rated as being distressing, it was found that there were no significant differences between the three groups on measures of affective distress. These findings are discussed in relation to Study 1 and eyewitness testimony and distress mitigation.
5.1.1 Introduction In Chapter 1 of this thesis the nature and aetiology of trauma symptomatology was discussed, the causes of adverse stressful situations were identified, and the current treatments for PTSD were explored. In Chapter 2 the PD literature was reviewed, and the limitations of this intervention were highlighted. In Chapter 5 the vulnerabilities to the development of trauma reactions were briefly covered, while in Chapter 4 the memory conformity and misinformation effects were discussed. In Chapter 5, a RCT of group debriefing was reported and as expected those who received the group debriefing did not report any significant reductions in trauma
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symptomatology. In addition, those in the confederate debriefing group were found to be susceptible to misinformation. Considering the empirical evidence suggests that the current interventions (which are administered directly after a traumatic event) do not ameliorate stress and trauma symptomatology, the next logical progression is to consider what can be done to prepare individuals before a traumatic event occurs. In Chapter 6 of this thesis, the stress, burnout, appraisal, coping, hardiness, and resilience literature was reviewed. The notion of whether stress reactions can be prevented was considered and the evidence supporting resilience training was presented. In the current chapter, Chapter 7, the findings of Study 2 are presented. There has never been a randomised controlled trial of resilience training. Therefore, Study 2 was designed to use several key aspects of SIT and combine them with education, in order to create a resilience training programme designed specifically to reduce the level of stress experienced by individuals who watch a distressing video. This study represents a proof of the concepts that have been explored both in the limitations section of Study 1 and in Chapter 4. The analogue design of the study overcomes the difficulty of not being able to predict when an individual will be exposed to a traumatic event. It makes it possible to expose individuals to a stressful event in a controlled environment. The effectiveness of resilience training, in mitigating individuals stress reactions, following exposure to a traumatic has never been assessed before. As such, the first aim of the current study was to examine whether resilience training can mitigate an individual’s stress reactions following exposure to a stressful event. It is important to also consider the impact that resilience training may have upon an individual’s memory for a traumatic event. Eyewitness memory for events can often prove to be invaluable, and it is important to make sure that resilience training, which may ultimately be used by those such as the police department, does not impact upon eyewitness memory in a detrimental way. As described in Chapter 4, research has found that certain conditions influence an individual’s memory for an event, when they are applied after the event has been witnessed. The misinformation effect, for example, is a well documented phenomenon whereby an eyewitness’ memory for an event is altered by hearing another person’s account of the same event (e.g., Gabbert et al., 2003; Ost, Hogbin, & Granhag, 2006; Roediger, Meade, & Burgman, 2001). Hearing about someone else’s account can also
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alter a person’s confidence in their own report (Gerrie et al., 2006; Luus & Wells, 1994; Wright et al., 2000). There has been limited research regarding the effect of trauma interventions upon memory. The only published study which has examined the effect of group debriefing upon an individual’s memory for an event, is derived from the data presented in Study 1 of this thesis. Devilly, Varker, Hansen and Gist (2007) found that group debriefing reduces the accuracy for recall of peripheral details related to the video. No published study, however, has ever examined the impact of resilience training individuals’ memory for a stressful event. Therefore, in order to address this deficit in the literature, the second aim of this study was to examine the impact of resilience training upon individuals’ memory. In this analogue study, participants were shown a stressful video of paramedics attending the scene of a car accident. Prior to watching the stressful video participants received one of two types of training: (a) resilience training; or (b) control training. Participants were assessed on the day that they received this training (session 1), one week later, immediately after being shown the stressful video (session 2) and again one- month later (follow-up). A glossary of terms used in Study 2 is provided in Appendix 7.
5.1.2 Project Aims Based upon the psychological theories which were described in Chapter 1, and the stress prevention literature review which was provided in Chapter 6, a resilience programme was developed. The efficacy of this programme in mitigating stress for those who were exposed to a stressful situation was then evaluated using a RCT trial. The overall aims of Study 2 were to examine: (a) the efficacy of resilience training provided before witnessing a stressful event, in stress mitigation; and (b) the effect of resilience training upon memory for an emotionally laden event.
5.1.3 Hypotheses Based on a review of the previous research the following hypotheses were generated: Part 1) To examine the efficacy of resilience training provided before witnessing a stressful event, in stress mitigation
Hypothesis 1 : H0: That there will be no difference in the stress reactions of those
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who received resilience training, compared to those who did not receive resilience training Part 2) To examine the effect of resilience training upon memory for an emotionally laden event
Hypothesis 2: H1: That irrespective of condition, memory would be better for central rather than peripheral details of the video
Hypothesis 3: H1: That irrespective of condition, confidence would be greater for incorrect memories than for correct ones at follow-up
Hypothesis 4: H0: That there would be no difference between the two conditions over time for: a) central memory for the event; b) peripheral memory for the event; c) central memory confidence; d) peripheral memory confidence; e) confidence for correct memories; and f) confidence for incorrect memories.
Hypothesis 5: H0: That there will be no relationship between memory for the event and distress
5.2 Study 2: Method and Materials
5.2.1 Participants The sample for Study 2 comprised 80 individuals (35 male, 45 female) aged between 18 and 63 years ( M=28.3, SD =10.4) (see Results Section 5.3 for descriptive information; Table 7). Participants were recruited from the general population and were randomly allocated to one of two conditions: resilience training or control training. The sample comprised mainly of University administrators, rather than students, although ethical requirements for the study precluded the collection of student and occupation status within the University.
5.2.2 Approvals Approval was obtained from the Swinburne University Human Research Ethics Committee.
5.2.3 Consent Form and Information Sheet
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Brief advertisements requesting for volunteers to participate in the study were placed on university notice boards. All individuals who expressed interest in participating in the study were mailed or emailed an information sheet that described the study in more detail (see Appendix 8). Upon arrival at the testing location participants were once again given an information sheet, and had any queries answered (participants were required to be aged 18 years or over). At this time participants were advised that if they had experienced a road traffic accident recently, or had lost friends or family members from a traffic accident, that they may be best served by not taking part in the research. Participants then completed and signed an informed consent form (Appendix 9).
5.2.4 Recruitment and Group Allocation Twelve training groups were initially planned randomly across a one month period. It was decided that groups would be of a size that would be similar to those that would be used if a resilience programme were to be utilised in a ‘real world’ setting. The groups needed to be small enough that they were of a manageable size for the facilitator, yet large enough that were an resilience programme to be run by an organisation, the programme would be cost effective (and thus it would not be necessary to run an exorbitant number of groups). Therefore, it was decided that groups populated with six to eight participants would be aimed for. After the first week of the recruitment phase, groups were assessed for utility. Groups listing less than four participants were disbanded, and new group times were established. Groups with more than 13 participants had several members moved to a second group created for the same time the following week. This procedure continued during the second and third weeks of the recruitment phase, at the end of which, groups containing less than four participants were cancelled. In this way, participants were randomly allocated to one of the 14 final trial groups. Seven groups were designated as receiving resilience training and seven groups were designated as the non-treatment controls. The running of resilience and control groups alternated, with the decision of whether a control or a resilience group was run first, decided by the flip of a coin. Ultimately 38 individuals (19 male, 19 female) aged between 19 and 63 years (M=29.2, SD =11.5) were allocated to the control condition, with an average of 5.7 participants per group (range: 4-9). In the resilience condition there were 40 individuals
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(15 male, 25 female) aged between 18 and 54 years (M=27.6, SD = 9.5), with an average of 5.7 participants per group (range: 2-8). All participants were recompensed for their time. Originally there were 82 participants who attended the first session, but, 2 participants failed to attend the second session and were, therefore, excluded. As such, the attrition rate was very low at just 2.4%. Two participants also failed to complete the memory components of the follow-up assessment and were, therefore, excluded from the memory sections of the analyses. The self-report questionnaire battery (see Appendix IV) was the same questionnaire battery that was administered for Study 1. It consisted of a demographics survey, the Depression, Anxiety and Stress Scale-21 (DASS-21), the Interpersonal Support Evaluation List (ISEL-12), a word recall task, the PTSD Symptom Scale – Self- Report, a memory of the video questionnaire, items related to responses to stress and items assessing participant satisfaction. One additional questionnaire was added, which was the Ten-Item Personality Inventory (TIPI), which is a brief measure of personality (see Appendix 10).
5.2.5 Measures 5.2.5.1 Demographics General demographics were obtained using a questionnaire that asked questions related to age, sex, history of trauma and exposure to similar audio visual material.
5.2.5.2 The Depression, Anxiety and Stress Scale See Section 3.2.5.2
5.2.5.3 The Interpersonal Support Evaluation List-12 See Section 3.2.5.3
5.2.5.4 Word recall See Section 3.2.5.4
5.2.5.5 Memory of the video See Section 3.2.5.5
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5.2.5.6 Response to Stress See Section 3.2.5.6
5.2.5.7 The PTSD Symptom Scale – Self-Report See Section 3.2.5.7
5.2.5.8 Participant Satisfaction See Section 3.2.5.8
5.2.5.9 The Ten Item Personality Inventory Personality was measured using the Ten-Item Personality Inventory (TIPI; Gosling, Rentfrow, & Swann, 2003), a newly developed 10-item version of the NEO Personality Inventory Revised (Costa & McCrae, 1995). The questionnaire provides a brief measure of the Big Five personality dimensions (i.e., extroversion, openness to experience, agreeableness, conscientiousness and emotional stability). Responses to items are measured on a 7-point scale ranging from ( Disagree Strongly ) through to 7 (Agree Strongly ). The measure has been shown to reach adequate levels of convergent (mean r = .77) and discriminant validity (mean r = .20), and test-retest reliability ( r = .72) (Gosling et al., 2003).
5.2.6 Setting All trials were conducted in a single meeting room containing a central conference table and non-fixed seating for 10. Both the Powerpoint presentation which accompanied the training sessions, and the audiovisual stimulus, were projected onto a wall that was in close proximity, allowing the participants to feel as though they were immersed in the accident scene. The room also contained an area to facilitate provision of refreshments. This setting was maintained for all groups.
5.2.7 Procedure and Questionnaires After informed consent was obtained, the session 1 components of the questionnaires were then distributed, which included demographics, questions related to anticipatory anxiety, the TIPI, the DASS-21, and the ISEL-12. Once these were
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completed, participants were told that they would be read a list of words and that they were to try and remember as many of the words as possible. They were instructed that once the word list had been completely read out, they were to write down as many words, in any order, from the list as they could remember. They were instructed that they were not allowed to begin writing until the word list had been completely read out. Upon completion of the immediate recall task, both the resilience groups and the control groups were informed that they would now be receiving some training in preparation for watching the video. Participants were then provided with either resilience training, or accident management training. The training was accompanied by both a PowerPoint presentation, and handouts of the PowerPoint presentation. Once the training was completed, participants in the resilience group were directed to read through the handouts, and to practice the breathing, tension and thought stopping exercises three times in between the training session and the second session the following week. Those in the accident management group were told to read over their handouts and to think about the tips and strategies of accident management that they had been taught, three times in the week between the training session and the second session the following week. One week after the first training session, participants attended session 2. They returned to the testing site to view the video of paramedics attending the scene of a car accident. At the beginning of session 2 participants were informed that they would now be viewing a video of emergency workers attending the scene of a car accident. They were again reminded that some may find the video distressing and that they were free to leave with no obligation to complete the experiment. The lights were then turned off and the video was played. The same video as that used in Study 1 (detailed in Section 3.2.7.) was used in order to maintain consistency between the two studies and to allow for comparisons between the studies. The video stimulus is approximately 10 minutes of live footage following US emergency workers attending the scene of a single car accident. At completion of the video, the lights were turned back on and the post-video components of the questionnaires were filled in. As in Study 1, these questions assessed behavioural and emotional reactions to the video (e.g., mental avoidance), memory for aspects of the video, distress caused by the video, and satisfaction with treatment. There were also questions which assessed how useful participants felt that the training and the
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handouts provided in session 1 were in relation to their emotional reaction. At completion of the questionnaire, participants in both the resilience groups and the control groups were also provided with contact details of the local psychologist and of the facilitator in case any further issues, concerns or general questions should arise following the session. All groups were then informed that one month later they would be sent a follow-up questionnaire together with a reply-paid envelope. One month after their participation in the study, participants completed and returned the follow-up questionnaire. Participants who did not return the questionnaire within 10 days of it being sent to them were given a reminder phone call. The follow-up questionnaire contained questions which assessed behavioural and emotional reactions to watching the video; memory for aspects of the video; whether viewing the video changed participants’ driving behaviour and treatment satisfaction. They also filled in the PSS-SR, DASS-21 and were asked whether they thought that such a video would be appropriate to be shown on commercial television.
5.2.8 Interventions
5.2.8.1 Resilience Training Resilience training groups were provided with a 30 to 40 minute session of resilience training, based on the current research regarding the nature and aetiology of PTSD, and the maintenance of PTSD (reviewed in Chapter 2). A set of resilience training guidelines was developed, to ensure that the training would be standardised across groups (Appendix 11). Following an initial introduction (stage 1), participants received education about physical responses to trauma (stage 2), were taught breathing and relaxation techniques (stage 3), were taught thought stopping techniques (stage 4), were exposed to serial approximation/desensitisation using projected still images (stage 5), were taught about the importance of social support (stage 6) and received education about drug and alcohol use (stage 7). Participants were also given a handout to take home, of the information that was provided to them during the resilience training session (Appendix 12). Twenty-four projected still images used were presented in order, starting with those images that were least confronting (e.g., a car that had been in a minor accident) and progressing to those that were very confronting (e.g., a person with a bleeding head
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wound being attended to by a paramedic). The photos were rated by six independent judges on a 10-point Likert style scale ( 1 = not distressing , 10 = very distressing ).
5.2.8.2 Control Training The control training groups received accident management training, which gave participants practical tips and strategies on what to do if they are involved in, or witness a traffic accident. Following an initial introduction about the frequency of accidents, and an overview of the dangers posed by traffic accidents, participants received practical training on what to do if: (1) they are involved in a traffic accident; (2) they witness a traffic accident; (3) there are hazards such as spilt fuel, damaged powerlines or emotionally distraught/potentially violent victims; and (4) someone is injured in the accident. Participants were also taught about what the role of the police is when they are called to attend a traffic accident. A set of accident management training guidelines was developed, to ensure that the training would be standardised across groups (Appendix 13). Participants in the control group were also given a handout to take home, of the information that was given to them in the accident management training (Appendix 14).
5.3 Study 2: Results The results section will begin with a summary of the descriptive statistics of the sample. The analyses will be broken down into parts, according to each of the aims of the study. The two aims of this study are: (1) to determine the efficacy of resilience training provided before witnessing a stressful event, in stress mitigation; and (2) to examine the effect of resilience training upon memory for an emotionally laden event. Hypotheses will be presented in turn under each of the aims, with the appropriate analyses following.
5.3.1 Data Screening, Randomisation and Descriptive Statistics All data entry and analyses were conducted using Statistica Version 6.1 for Windows (2004) and ClinTools Version 4.1 (Devilly, 2007b). Prior to analysis all independent variables were examined for accuracy of data entry, missing values, presence of univariate and multivariate outliers and the distribution of data. Cases with a small number of missing values (3 or less) were
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retained, and the missing values replaced with the individuals’ mean score for the corresponding measure subscale (where possible), or with the mean score for the measure. Of the original 82 participants, two participants failed to attend the second session and were therefore removed. All participants completed the follow-up questionnaire however two participants failed to complete the memory and memory confidence components of the follow-up questionnaire. As such, these two participants were removed from the memory and memory confidence sections of the analyses. To ascertain whether the data was normally distributed both graphic and statistical methods were used. Box plots and frequency histograms for each variable were generated to examine the distribution of the data and to facilitate comparison of the shape of the data with the normal curve. Descriptive statistics were then generated for each variable and were examined for outliers using methods recommended by Tabachnik and Fidell (2001), whereby univariate outliers are characterised as cases with a z score over 3.29 ( p< .001). No univariate outliers were identified. Using Mahalanobis distance no multivariate outliers were detected. Two participants missed the History of Trauma question, however due to the small amount of missing data it was not considered necessary to remove these cases from the analyses. Statistica was used to assess the data for nonlinearity and heteroscedasticity, and bivariate scatterplots for each combination of variables were examined. The data appeared linear and homoscedastic. The variables were examined for multicollinearity by looking at their bivariate correlation coefficients. Correlations of r >.70 were considered too large (Tabachnik & Fidell, 2001). None of the variables included in the analyses exceeded this limit. To ensure that the randomisation process had not created any condition bias, the three groups were compared across various background, presentation and demographics variables. Analytical assumptions were met, and the data was parametrically distributed with approximate homogeneity of variance. There were no significant differences between the two groups in the distribution of: gender; history of trauma; previous exposure to similar styles of video; history of consultation for emotional problems; the extent to which they physically and mentally distracted themselves while viewing the video; blood phobia; anticipatory anxiety regarding what they were about to be shown; the seriousness with which they rated the accident; levels of participant empathy with either the accident victims or the emergency workers; word memory recall ability ( F(1,
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78) = 1.6, ns ); perceived social support; and group allocation sizes (see Table 7). Overall, these results suggest that no significant differences existed within the group compositions (Resilience vs Control) before the experimental phase.
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Table 7 Demographic Characteristics of the Sample (Study 2)* Resilience Control Total n=41 (%) n=39 (%) N=80 (%) Gender Male 15 (36.6) 20 (51.3) 35 (43.8) Female 26 (63.4) 19 (48.7) 45 (56.3) History of trauma a Yes 3 (7.7) 9 (23.1) 12 (15.4) No 36 (92.3) 30 (76.9) 66 (84.6) Exposure to similar video Never seen similar 25 (61.0) 19 (48.7) 44 (55.0) Seen similar / same 16 (39.0) 20 (51.3) 36 (45.0) History of emotional problems- M(SD) 2.22 (1.0) 1.92 (1.1) 2.08 (1.0) Blood phobia- M (SD) 1.85 (.9) 2.56 (1.3) 2.05 (1.1) Physical distraction- M (SD) 1.98 (1.0) 1.90 (1.0) 1.94 (1.0) Mental distraction- M(SD) 2.12 (1.1) 2.03 (.9) 2.08 (1.0) Anticipatory anxiety- M (SD) 2.20 (1.0) 2.46 (1.1) 2.33 (1.0) Accident seriousness- M (SD) 4.54 (.6) 2.56 (.9) 4.40 (.8) empathy for accident victims- M(SD) 3.95 (.8) 3.90 (1.1) 3.93 (1.0) Empathy for emergency workers- M(SD) 3.49 (.9) 3.51 (1.0) 3.50 (.9) Group size, number of participants- M (range) 5.9 (2-8) 5.6 (4-9) 5.7 (2-9) Age, years – M (SD) 27.8 (9.5) 29.1 (11.4) 28.4 (10.4) ISEL-12 Total (interpersonal support)- M(SD) 37.49 (5.89) 38.54 (6.87) 38 (6.37) ISEL- Tangible- M (SD) 12.80 (2.08) 12.92 (2.21) 12.86 (2.13) ISEL- Belonging- M (SD) 12.00 (2.20) 12.87 (2.71 12.43 (2.48) ISEL- Appraisal-M (SD) 12.68 (2.95) 12.74 (3.19) 12.71 (3.05) TIPI- Emotional Stability- M(SD) 4.65 (1.36) 4.79 (1.47) 4.72 (1.41) TIPI- Extroversion- M (SD) 4.29 (1.49) 4.35 (1.10) 4.32 (1.31) TIPI- Conscientiousness- M (SD) 4.98 (1.37) 5.24 (1.20) 5.11 (1.29) TIPI- Agreeableness- M (SD) 4.66 (1.07) 5.21 (.98) 4.93 (1.06) TIPI- Openness to Experience-M(SD) 5.11 (1.00) 5.50 (.90) 5.30 (.97) *Unless otherwise indicated, data are given as number (percentage) of subjects. Percentages have been rounded; a N= 78
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The internal reliability of each of the measures used in Study 2, using the present sample, was calculated using Cronbach’s Alpha (see Table 8). Each of the co-efficents are within acceptable parameters.
Table 8. Internal Reliability Coefficients of all Measures at Time 1 and Time 2 (Study 2; N= 80) Time 1 Time 2 Measure Cronbach’s α Cronbach’s α DASS-21 Depression .82 .88 Anxiety .80 .78 Stress .85 .87 ISEL-12 Appraisal .83 n/a Belonging .76 n/a Tangible Support .61 n/a TIPI a - - PSS-SR n/a .88 aIt was not possible to calculate Cronbach’s alpha because there were insufficient variables for each of the subscales.
5.3.2 Hypothesis 1
Part (a) To examine the efficacy of resilience training provided before witnessing a stressful event, in stress mitigation
Hypothesis 1: H0: That there will be no difference in the stress reactions of those who received resilience training, compared to those who did not receive the training A 2(Condition) by 2(Time) repeated measures ANOVA was conducted on participants’ Affective Distress (as measured by indices of depression, anxiety and stress), in order to address hypothesis (1). As can be seen in Table 9, passage of time
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was found to have a significant effect upon Affective Distress with distress significantly greater in session 1 (pre-video) than at follow-up. Looking at a post-hoc univariate test for Time, a significant main effect was found for Stress using Tukey’s HSD ( p< .01), but not for Anxiety or Depression. Generally participants reported less stress in the follow-up phase ( M =8.38, SD =8.60) than in session 1 ( M=13.05, SD =9.23), with a moderate effect size found for stress (Hedges’ g = -.52, 95%CI: -.84, .21). Further repeated measures analyses were conducted to investigate the effect of resilience training upon two other types of behavioural and emotional response. Specifically, the effect of resilience training upon people’s perceptions of their own anxiety, and participants’ distress were each examined (Table 9). A 2(Condition) by 2(Time) repeated measures ANOVA was conducted upon people’s perceptions for how anxious they were to participate in the study. In session 1, one week before being shown the video, people were asked to rate how anxious they were about watching the video. At follow-up participants were asked to estimate how anxious they had been (during session 1), about watching the video. As can be seen in Table 9, no significant effects were found. Participants were asked to rate ‘how distressing’ they found the video on a 5- point Likert type scale (1-5), both directly after watching the video and at follow-up. As can be seen in Table 9, there were no significant differences between the conditions, nor was there a significant effect for the passage of time. Means and standard deviations for emotional responses are presented below in Table 10.
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Table 9 3 (Condition) x 2 (Time) Repeated Measures ANOVA for Emotional Responses to the Video (Study 2)
Time Analysis Pre-video Follow-up (df) F p Hedges’ ĝ or Directly (95% CI) After Video M M (SD) (SD) (1)* Affective 27.45 21.30 T3 (1, 78) 8.22 <.006 .30 distress 1 (.01, .61) (19.48) (21.26) C4 (1, 78) 2.15 ns T x C (1, 78) 2.28 ns Anxiety for 2.33 2.43 T (1, 78) .79 ns participation 1 (1.04) (1.04) C (1, 78) 1.75 ns T x C (1, 78) 0.0 ns Distress caused 3.14 3.01 T (1, 78) 2.04 ns by video 2 (1.04) (1.04) C (1, 78) .05 ns T x C (1, 78) .70 ns Note: *Number denotes hypothesis being tested; 1 Pre-video; 2 Directly After Video; 3Time; 4Condition
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Table 10 Means and Standard Deviations for Emotional Responses to the Video, by Condition (Study 2) Resilience Control Total n=41 (%) n=39 (%) N=80 (%) Session 1 Follow-up Session 1 Follow-up Session 1 Follow-up M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) Affective 26.70 17.10 29.58 24.84 28.10 20.87 distress (17.03) (16.03) (21.55) (24.48) (19.29) (20.81) Anxiety for 2.23 2.58 2.50 2.33 2.36 2.45 participation (0.95) (1.18) (1.11) (0.89) (1.03) (1.04) Distress 3.23 3.03 3.08 3.03 3.15 3.03 caused by video (1.05) (1.07) (1.05) (1.03) (1.05) (1.04)
Additionally, the following elements of the resilience training were assessed: people’s perceptions of how much the training prepared them for the video; how helpful people found the training; and how helpful people found the handouts provided (Table 11). As can be seen from Table 11, passage of time was found to have a significant effect upon people’s reports of how prepared the training made them feel, with people reporting that they felt more prepared at follow-up than in session 2. Similarly, passage of time was found to have a significant effect upon people’s perception of how helpful the training was, with people reporting that they found the training more helpful at follow-up than in session 2. There were no significant differences between the conditions for the helpfulness of the training, nor was there a significant effect for passage of time.
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Table 11 One way ANOVAs for Training Elements (Study 2) Time Analysis Directly Follow- Hedges’ ĝ after up (df) F p (95% CI) Video M M (SD) (SD) Preparedness from 2.78 3.10 T (1, 78) 10.04 <.003 -.35 training (.95) (.89) (-.65,-.03) C (1, 78) .91 ns T x C (1, 78) 1.32 ns Helpfulness of 2.71 2.90 T (1, 78) 2.86 ns training (1.07) (1.06) C (1, 78) 1.16 ns T x C (1, 78) .09 ns Helpfulness of 2.76 2.99 T (1, 78) 4.74 <.04 -.21 handouts (1.11) (1.06) (-.52,.10) C (1, 78) 2.53 ns T x C (1, 78) 1.55 ns Note: 1Time; 2Condition
Trauma symptomatology scores were not found to differ significantly between the two groups ( F(3,76) =.53, ns ). The PSS-SR data within the three symptom clusters for each condition are displayed in Figure 5.1. In addition, chi-square analysis did not reveal any significant differences between the groups in the level of trauma symptomatology when symptom categories were applied (i.e., mild, moderate, moderate to severe and severe), however one participant in the Resilience group met criteria for PTSD whilst three participants in the Control group met criteria for PTSD. Overall, the level of trauma symptomatology was low in both the Resilience group ( M= 5.70, SD = 4.85) and the Control group ( M = 6.00, SD = 7.37).
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6
5
4
3 SymptomRating 2
1 Intrusions Avoidance 0 Arousal Control (No Treatment) Resilience
Note: Vertical bars denote 0.95 confidence intervals
Figure 5.1 Post-traumatic Stress Symptomatology Cluster Severity by Condition at Follow-up (Study 2)
5.3.3 Hypothesis 2 Part (b) To examine the effect of resilience training upon memory for an emotionally laden event
Hypothesis 2 : H1: That irrespective of condition, memory would be better for central rather than peripheral details of the video Paired samples t-tests revealed that, overall, participants recalled significantly more correct central details of the video than peripheral details in both session 2 (t(77)=7.93, p < .001; ĝ = 1.21; 95% CI : .87, 1.55), and at follow-up ( t(77)=7.96 p < .001; ĝ = 1.88; 95% CI : .75, 1.42).
5.3.4 Hypothesis 3
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Hypothesis 3 : H1: That irrespective of condition, confidence would be greater for incorrect memories than for correct ones Paired samples t-tests were also conducted for hypothesis (3), with confidence greater, at follow-up, for those details of the video that were recalled incorrectly than those details of the video that were recalled correctly ( t(77) = -5.26, p < .001; ĝ = .91; 95% CI : .58, 1.24). However, when looking at session 2 (directly after having watched the video) a two-tailed dependent t-test did not reveal a significant difference ( t(77) = 1.56, ns ). Interestingly, this trend at session 2 was in the reverse direction, with more confidence in correct memories.
5.3.5 Hypothesis 4
Hypothesis 4 : H0: That there would be no difference between the two conditions over time for: (a) central memory for the event; (b) peripheral memory for the event; (c) central memory confidence; (d) peripheral memory confidence; (e) confidence for correct memories; and (f) confidence for incorrect memories. A series of 2(Condition) x 2(Time) repeated measure ANOVAs were conducted on participants’ video memory scores and confidences for these memories in order to assess hypothesis (4). The results of these tests are shown below in Table 12. As can be seen from Table 12, passage of time was found to have a significant effect upon both central and peripheral memory, with recall significantly better in session 1 than at follow-up. Similarly, passage of time had a significant effect upon central and peripheral memory confidence, and correct and incorrect response confidence, with confidence greater in session 2 than at follow-up. Testing hypothesis (4b), Condition was found to have a significant effect ( F(1, 76)=8.47, p< .005). Post Hoc analysis using an unequal N HSD revealed a significant difference ( p < .03) between the Resilience and the Control conditions, with the Resilience group recalling fewer correct peripheral details overall. Condition also interacted with Time, with those in the Control condition reporting a greater decline in peripheral memory confidence between session 1 and follow-up, than those in the resilience group ( F(1, 76)=7.18, p < .01). In addition, for confidence for incorrect memories there was a significant interaction between passage of Time and Condition (F(1, 76)=5.22, p < .03), with those in the control condition reporting a greater decline in confidence for incorrectly recalled memories than those in the resilience group. Means and standard deviations are
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presented in Table 13.
Table 12 2 (Condition) x 2 (Time) Repeated Measures ANOVAs for Video Memory and Confidence Scores (Study 2)
Time Analysis Directly Follow- After Video up (df) F p Hedges’ ĝ M M (95% CI) (SD) (SD) (4a)* Central memory for 7.01 5.50 T (1, 76) 41.85 <.001 1.21 the event (.87, 1.56) (1.92) (2.13) C (1, 76) .05 ns T x C (1, 76) 1.60 ns (4b) Peripheral memory 4.73 3.31 T (1, 76) 35.01 <.001 1.06 for the event (.73,1.40) (1.84) (1.88) C (1, 76) 1.75 ns T x C (1, 76) 4.01 ns (4c) Central memory 46.28 35.46 T (1, 76) 142.40 <.001 1.46 confidence (1.11,1.82) (8.33) (8.50) C (1, 76) .51 ns T x C (1, 76) .30 ns (4d) Peripheral memory 30.27 25.94 T (1, 76) 35.97 <.001 1.18 confidence (.85,1.53) (7.59) (7.00) C (1, 76) 8.47 <.006 T x C (1, 76) 7.18 <.010 (4e) Confidence for 42.26 26.68 T (1, 76) 134.20 <.001 1.43 correct memories (1.08,1.79) (12.71) (11.38) C (1, 76) 1.40 ns T x C (1, 76) .30 ns (4f) Confidence for 39.10 36.95 T (1, 76) 4.22 <.044 1.03 incorrect memories (-.70,1.37) (10.75) (10.99) C (1, 76) 1.79 ns T x C (1, 76) 5.22 <.026
Note: * Numbers and letter denote hypothesis being tested; N = 78
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Table 13 Means and Standard Deviations for Video Memory Scores, Directly After Watching the Video and at Follow-up (Study 2)
Resilience a Control b Directly Follow-up Directly Follow-up After Video After Video
X (SD) X (SD) X (SD) X (SD)
(4a)* Central memory for the 7.20 (1.90) 5.40 (2.18) 6.82 (1.94) 5.61 (2.10) event (4b) Peripheral memory for the 4.28 (1.75) 3.33 (1.76) 5.21 (1.83) 3.29 (2.03) event (4c) Central memory confidence 45.28 (9.18) 35.38 (7.77) 47.34 (7.29) 35.55 (9.30) (4d) Peripheral memory 27.33 (7.23) 24.90 (6.16) 33.37 (6.75) 27.03 (7.73) confidence (4e) Memories correctly recalled 11.48 (2.65) 8.73 (2.97) 12.03 (2.90) 8.89 (3.46) (4f) Memories incorrectly 13.53 (2.65) 16.28 (2.97) 12.97 (2.90) 16.11 (3.46) recalled (4g) Confidence for correct 40.53 (13.20) 25.70 (10.26) 44.08 (12.09) 27.71 (12.50) memories (4h) Confidence for incorrect 36.48 (9.88) 36.73 (9.80) 41.87 (11.05) 37.18 (12.25) memories
Note: a n = 40, b n = 38; * Numbers and letter denote hypothesis being tested
5.3.6 Hypothesis 5
Hypothesis 5: H0: That there will be no relationship between memory for the event and distress Examination of the relationship between the measures of Affective Distress (i.e., the DASS) and Trauma Symptomatology (i.e., the PSS-SR), and memory for the video revealed no significant correlations between distress and memory at follow-up. There was, however, a significant weak to moderate correlation at follow-up between Trauma
Symptomatology and Memory for the Video ( r s (78)=.22, p <.05), with those who reported more trauma symptomatology at follow-up reporting greater confidence for
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incorrect answers. There were no significant correlations at follow-up, between either Affective Distress or Trauma Symptomatology and (a) the number of correct central or peripheral details recalled, and (b) participants’ confidence for correct and incorrect responses. There were two significant weak to moderate correlations between Trauma Symptomatology and Memory for the Video, with those who reported more trauma symptomatology at follow-up recalling less correct memories ( r s (78) = -.24, p < .05), and a greater number of incorrect memories ( r s (78)=.24, p < .05) in session 2. There were no significant correlations between affective distress and memory for the video in session 2.
5.4 Study 2: Discussion
5.4.1 Introduction The prevention of stress reactions is an area that is very early in its development. A small number of studies have aimed to prevent depression and anxiety symptomatology (e.g., Bearman et al., 2003; Clarke et al., 1995; Clarke et al., 2001; Peden et al., 2001) but there has never been a RCT for the prevention of stress reactions. Additionally, there has never before been an examination of the effect of preventative training upon an individual’s memory for a stressful event. In order to address these deficits in the literature, the effect of receiving resilience training before viewing an emotionally stressful video, upon individuals’ stress reactions and memory, was assessed in this analogue experiment.
5.4.2 Evaluation of Study 2 Descriptive Statistics There were no significant differences between the 2 groups for any of the demographic variables, and for group allocation sizes. Thus, these results suggest that the randomisation process did not lead to any systematic bias on core criteria within the group compositions (Resilience Training vs Control) before the experimental phase.
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Part (a) To examine the efficacy of resilience training provided before witnessing a stressful event, in stress mitigation There were no differential reactions noted between the two groups for affective distress, and both groups reported less affective distress and were less anxious about participating in the study at follow-up, than in session 1. Trauma symptomatology was not found to differ between the two groups. The ratings of participants in both groups for: (a) the degree to which they felt the training prepared them for the video; and (b) the helpfulness of the handouts; increased over time. These results suggest that resilience training has no obvious effect on distress following the viewing of a stressful video. People in both conditions reported very few trauma symptoms (i.e., intrusions, avoidance and arousal) in relation to the video and trauma symptomatology did not differ between the two groups. Overall, these results suggest that resilience training has no beneficial impact upon individuals’ stress reactions for a stressful event. This is in contrast to debriefing, which has been shown in some studies to have a deleterious effect (e.g., Devilly & Cotton, 2003; McNally et al., 2003). It is important that any type of training or intervention that is provided to individuals does not cause them a reaction that is worse than if the individual had no intervention or training.
Part (b) To examine the effect of resilience training upon memory for an emotionally laden event The effects of resilience training upon memory for an event, following viewing of an emotionally stressful event were assessed in this experiment. It was found that memory for both central and peripheral details was better in session 1 than at follow-up, with no apparent effect from resilience training. Participants in both groups recalled more central details correctly than peripheral details in both session 1 and at follow-up, although again there were no differences between the groups. At follow-up participants in both groups were found to be more confident of memories for incorrect details of the video than for memories of correct details. Participants in the control group reported more confidence in peripheral memories than those in the resilience group however those in the control group also reported a greater decline, over time, in peripheral memory than those in the resilience group. In addition, those in the control group reported a greater decline in confidence for incorrect memories over time, than those in
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the resilience group. Overall, these results are consistent with the findings of Study 1, suggesting that there are certain trends for memory of stressful events, which are consistent, despite the type of intervention that is delivered to an individual. Specifically, in both Study 1 and Study 2 it was found that: (a) memory for both central and peripheral details was better in session 1 than at follow-up; (b) participants recalled more central details correctly than peripheral details in both session 1 and at follow-up; (c) participants were found to be more confident of memories for incorrect details of the video than for correct details. The finding that there were no differences between the control group and the resilience group in the number of central or peripheral memories correctly recalled has important implications in terms of eyewitness testimony. People that experience stressful or traumatic incidents are often required to make a statement to police or to give evidence about what they have witnessed. If an individual is provided with a type of training that later impedes their ability to accurately recall the event, then this could have serious consequences for authorities trying to apprehend offenders or piece together what occurred in the incident.
5.4.3 Limitations of Study 2 It is acknowledged that the study has some limitations. In its present form, the resilience training failed to result in a reduction of the level of stress reaction experienced by those in the resilience group as compared to those in the control group. However, this may be due to several factors. Firstly, the length of time that participants received the resilience training may have been insufficient to adequately prepare them for video that they went on to view. Secondly, the participants may not have been provided with enough coping techniques to help them deal effectively with the graphic video. Thirdly, it may be that one-week is an insufficient time for the participants to practice the techniques that they have been taught. Perhaps if participants had attended an initial training session, followed by a “booster” training session one week later, followed by viewing the video one week later again (which would be two weeks after the initial training session), participants may have had a greater chance to master the coping strategies, and may have been more likely to utilise them whilst watching the video. In order to address all of the potential problems, it is necessary for further research to be conducted in this newly developing area. Finally, this study is an
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analogue study, and as such the generalisability of the findings to other populations will not be known until further field based research is undertaken.
5.4.4 Areas for Future Research As discussed above, field based research must be conducted in the future, using populations which are at risk for exposure to traumatic situations. Rather than relying on anecdotal evidence (as researchers have done in the past), scientifically robust, RCTs of this new type of intervention must be performed, and newly developed resilience training programmes must be manualised so that studies can be replicated by other researchers. Instead of solely trialling single session interventions, it may also be beneficial to trial interventions which are administered over a period of weeks or even months, so that practice effects may also be examined.
5.4.5 Summary The results suggest that participation in resilience training does not beneficially effect people’s stress reactions, nor does it impact negatively upon their memory for the event. Further research is required to determine if it is possible for resilience training to mitigate stress reactions in real world at-risk populations.
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Chapter Six: Resilience Training in the Real World
6.1 Introduction Although a great deal of research has examined the nature and aetiology of PTSD (e.g., Kessler et al., 1995; Kulka et al., 1990), the pre-trauma, peri-trauma and post-trauma risks associated with the development of the disorder (e.g., Breslau et al., 1995; Bromet et al., 1998; Green et al., 1990; Lauterbach & Vrana, 2001), and the most efficacious ways to treat PTSD (e.g., Bryant & Harvey, 2000; Cooper & Clum, 1989; Devilly & Spence, 1999; Foa et al., 1999; Foa et al., 1991), no-one has ever examined whether it is possible to prevent PTSD. One of the primary reasons for this is because in the general population, exposure to a traumatic event happens infrequently during a persons’ lifetime, and its occurrence is impossible to predict. There are, however, several occupations that have a predictable and foreseeable risk of being exposed to threat, horrific injury and death. Examples which have received notable attention in the literature include the emergency services, military, acute medical services, bank officers and train drivers (McFarlane & Bryant, 2007). For a group such as police officers, it is known that exposure to a traumatic event is highly likely to occur, and that such exposure is likely to occur early in an officer’s career. On any given day, police officers may be faced with a vast array of situations while performing their occupational duties. The majority of these situations are routine, involving tasks such as investigations, patrol and paperwork, yet a small number of these situations may be life threatening, violent, distressing or horrific (Adams & Stanwick, 2002). A recent Australian study found that for a group of 223 surveyed police officers, on average each officer experienced nearly 9 critical police incidents in a 12-month period (Hodgins, 2000). The most frequently experienced incidents were finding the corpse of someone who had died a natural death (54%), finding the corpse of a suicide victim (35%), attending traffic accidents where an adult was injured or killed (68% and 31% respectively), or an encounter with mentally disturbed individuals who were threatening (35%). A pilot study with Queensland police indicated that work- related traumatic events were ubiquitous - 95% of participants reported experiencing a work-related traumatic event some time in their career (Rallings, 2000). It has been estimated that at any given time 15-32% of all emergency responders will be dealing
152 Tracey Varker PhD Thesis 6. Resilience Training in the Real World with a reaction to Post Traumatic Stress, and there is a 30-64% chance that they will have a reaction to it during their lifetime (Everly & Mitchell, 1997). Due to the fact that it is known that emergency responders are at high risk of both being exposed to traumatic events and of developing a traumatic stress reaction, it is important that effective early interventions are developed. PD was originally developed as an early intervention for emergency services personnel, however, as discussed in Chapter 2 of this thesis, debriefing has not been proven to be effective as an early intervention designed to mitigate stress reactions. This was further supported by the results of Study 1 (presented in Chapter 3), where a RCT of group debriefing found debriefing to have no significant impact upon reducing stress reactions. In this chapter the literature relating to PTSD and policing is reviewed, as is the research related to stress and policing, and substance use and policing. In this review I then go on to consider, based on the current evidence the possibility of providing at-risk groups with resilience training to prevent them from developing traumatic stress reactions. By using the existing theories of PTSD development and maintenance, and PTSD treatment, a resilience programme designed specifically for police officers was developed. The development, implementation and efficacy of this programme are reported in Study 3 (see Chapter 9). A glossary of terms used in Study 3 is provided in Appendix 15.
6.2 Prevalence of PTSD in Police Police officers are exposed to traumatic events as part of their occupational role and, therefore, are at higher risk of developing PTSD than the general population. For example, Robinson, Sigman and Wilson (1997) found that 13% of their sample of police officers had diagnosable PTSD, whilst Carlier, Lamberts and Gersons (1997) found that 7% of the police officers in their sample met criteria for PTSD and 34% had partial or subthreshold PTSD. The pilot study with Queensland police officers found an 8% PTSD prevalence rate for work-related events (Rallings, 2000) and some studies have found PTSD prevalence to be as high as 26% among police officers (Martin, McKean, & Veltkamp, 1986). A study of early retirements from the New Zealand Police found that 16.8% of early retirees were diagnosed as having post-traumatic reactions, whilst the majority (69.2%) of early retirees cited psychological reasons for
153 Tracey Varker PhD Thesis 6. Resilience Training in the Real World leaving (Miller, 1996 cited in Stephens & Miller, 1998). A more recent study by Karlsson & Christianson (2003) revealed that for most police officers, the event that they considered most distressing and stressful occurred early on in their careers, with 32% of traumatic events experienced by the officers occurring during their first 5 years on the job. Recent figures released by the Victorian Police Association revealed that in the 2007-2008 financial year, 40 Victoria Police officers were treated internally for PTSD, as compared to 25 officers in 2006-2007 (McArthur, 2008). With approximately 11,000 sworn members currently working for Victoria Police, this represents 0.36% of members. However, given the fact that Workcover claims for PTSD are often rejected, and that many officers are reluctant to seek treatment, it is probable that this figure does not reflect the total number of Victorian police officers suffering from PTSD in 2007- 2008. Although there are some inconsistencies in the rates reported, these differences may be due to the nature of the traumas and the measurements used in the studies. Nonetheless, clinical observations strongly suggest that at least some emergency service workers do develop PTSD following work-related traumatic incidents (Tolin & Foa, 1999).
6.3 Occupational Stress and Police In the past policing has been an occupation that has been well recognised as being highly stressful and hazardous (Alkus & Padesky, 1983; Cooper, 1982; Davidson & Veno, 1980; Kroes, 1985), with policing ranked as among the top five most stressful occupations in the world (Dantzer, 1987). In the UK, policing is among the top three occupations most commonly reported by both occupational physicians and psychiatrists in the Occupational Disease Intelligence Network (ODIN) system for Surveillance of Occupational Stress and Mental Illness (SOSMI; Centre for Occupational & Environmental Health, 2000). In addition, a higher rate of suicide has been found for police officers. In Australia the national average for suicides is 13.25 deaths per 100,000 population (Victorian Suicide Prevention Task Force, 1997), while the average number of Australian police suicides is 21.6 deaths per 100,000 population (Cantor, Tyman, & Slater, 1995). However, it is important to note that suicide rates for males and females differ, with the male suicide rate being 21 deaths per 100,000 population and the female
154 Tracey Varker PhD Thesis 6. Resilience Training in the Real World rate being 5.5 deaths per 100,000 population (Victorian Suicide Prevention Task Force, 1997). The discrepancy between police suicide figures and general Australian population averages may be due to the fact that in the past males have been overrepresented within the Australian police service. Occupational stressors specific to policing have been found to include: unnecessary paperwork and competitiveness generated by a strict promotion system (Coman & Evans, 1991); inadequate supervisory and management practices (Davey, Obst, & Sheehan, 2001); having too much work to do, staff shortages, lack of communication, difficulties keeping up with new techniques, misuse of time by others, insufficient resources, and having to attend meetings (Brown & Campbell 1992, cited in Brown & Campbell, 1994). There is also a perception by police that there is public negativity directed towards police and less support for the police than for other emergency services. This perception reinforces an “us / them” mentality which encourages police to socialise and drink with colleagues. Drinking with workmates helps set social drinking norms, which have been shown to be well above the general community norms (Mann, 2006). There have been many attempts to categorise the various stressors experienced by police. Some researchers arranged the specific factors that led to stress into four categories: organisational practices, the criminal justice system, the public, and the police work itself (Reese, 1986; Swanson, Territo, & Taylor, 1998; Territo & Vetter, 1981). Other studies collapsed the specific factors into two categories: organisational and inherent police stressors (Martelli, Waters, & Martelli, 1989; Swanson et al., 1998; Violanti & Aron, 1995). For the studies which categorised police stressors as being either organisational stressors or inherent stressors, organisational stressors were defined as events that were bothersome or which were precipitated by the administration. Inherent stressors were defined as events that generally occurred in police work, which could be harmful to the officer (i.e., danger, violence and crime; Violanti & Aron, 1994). The influence of organisational factors on officer well-being has generally been perceived as peripheral and has not been deemed as salient to officers’ psychological functioning compared to the operational content of policing (see Abdollahi, 2002). Evidence, however, has also been presented to suggest the occupational stressors specific to policing may cause more stress than critical incidents. Hart, Headey and
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Wearing (1994) found that police officers considered organisational experiences (e.g., management practices, career opportunities, decision-making, clarity of role, performance feed-back, etc.) to be more stressful than the operational pressures of the occupation (including exposure to danger, threats and attending the aftermath of incidents with fatalities). More recently Hart and Cotton (2003) replicated this finding with another sample of police officers. They also found that a low level of positive affect (which they termed ‘morale’) was a much stronger determinant of police withdrawal behaviours (e.g., stress-related absenteeism and intention to submit a stress- related workers compensation claim) than levels of overt psychological distress. Since the evidence suggests that occupational stress can have a significant impact upon police officers’ physical and mental well-being, it would be prudent for any study to also measure occupational stress – particularly in the form of burnout.
6.4 Operational Stress and Police There are a number of police-specific operational stressors that can affect a police officer both during the course of his or her career, and after their career finishes. Brown and Campbell (1994) refer to three types of stressful and / or traumatic events: criminal injury or violence, accidents, and public disorder. Alternately, Carlier and Gersons (1992) divide police events into two categories: violent events (for example, shootings or escalating riot situations), and sad or depressing (for example, finding a corpse or being confronted with severely mutilated victims). Each individual officer will deal with a particular event in a different way. The individual’s characteristics and own pathology will play a role in their coping ability, as will their degree of preparedness. If an individual already has a high consumption rate of alcohol, or uses alcohol as a coping mechanism, then this will also have an impact. Recently released figures show that in the 12 month period between July 2006 and July 2007, police in Victoria were awarded $7.3 million in stress and injury compensation claims. During the same period of time, Victorian officers also accumulated 26,004 days of stress and injury leave. It was revealed that of the 11,000 officers in the Victorian police service, 239 officers took more than 16,550 days off for stress leave alone. The average stress claim was 69 days off work and $17,465.50 in compensation (Rolfe, 2008). As these figures indicate, police stress is a serious and costly problem, which affects not only the individual but also the organisation as a
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whole.
6.5 Police, Drugs and Alcohol It is not uncommon for those employed in a high stress occupation, where there is little opportunity to manage stress effectively, to resort to using self-defeating coping tactics. Such maladaptive tactics include self-medication through alcohol or drug use, anger, violence, or social withdrawal (Amaranto, Steinberg, Castellano, & Mitchell, 2003). It is well established that there is a frequent co-occurrence of substance use disorders and PTSD (Davidson, Hughes, Blazer, & George, 1991). For example the (American) National Comorbidity Survey found that men with an alcohol, or other drug use disorder were 2.06 and 2.97 times more likely, respectively, than those without an alcohol or another drug use disorder to have co-occurring PTSD. Among women, the odds of having co-occurring PTSD in the presence of an alcohol or other drug use disorder were 2.48 and 4.46, respectively (Kessler et al., 1995). Among the Australian population, the likelihood of co-morbidity has been found to be even higher with analysis of the National Survey of Mental Health and Well-Being revealing that men with an alcohol use disorder were 6.6 times more likely to have co-occurring PTSD than men without an alcohol use disorder. Men with a drug use disorder were 7.2 times more likely than men without a drug use disorder to have co-occurring PTSD. For women the odds were 4.5 and 12.4, respectively (Creamer et al., 2001). Among those with PTSD, the most common substance use disorder was an alcohol use disorder (24.1%), whereas among those with a substance use disorder, PTSD was most common among individuals with an opioid use disorder (33.2%) (Mills et al., 2006). In a recent large longitudinal study, 988 young adults were first assessed while in primary school and were followed through primary and middle school and on into adulthood (Reed, Anthony, & Breslau, 2007). It was found that overall drug abuse or dependence was more than 4 times more likely in young adults with PTSD than those with no trauma exposure, however, exposure to a traumatic event in the absence of PTSD was not associated with an increase in risk of drug abuse or dependence. This finding was robust even once early life experiences were adjusted for. As such, PTSD, but not trauma only, is clearly associated with subsequent drug use disorders. Many people try to alleviate the symptoms of their PTSD by self-medicating
157 Tracey Varker PhD Thesis 6. Resilience Training in the Real World with drugs (such as anti-depressants) and alcohol. Even in small quantities alcohol causes dysfunction in an individual, due to its depressive effect on the central nervous system, which in turn causes reaction times to become slow and thinking and co- ordination to become sluggish (McNeill & Wilson, 1993). Alcohol may also cause aggressive behaviour, particularly in the presence of a threat (Zeichner, Allen, Giancola, & Lating, 1994). Employee substance use has been found to be associated with excessive absenteeism (Crouch, Webb, Peterson, Buller, & Rollins, 1989; Normand, Salyards, & Mahoney, 1990; Zwerling, Ryan, & Orav, 1990), accidents at work (Holcom, Lehman, & Simpson, 1993; Taggart, 1989), poor job performance (Blum, Roman, & Martin, 1993; Lehman & Simpson, 1992) and turnover (Kandel & Yamaguchi, 1987; Zwerling et al., 1990). Given the fact that alcohol causes reaction times to slow, thinking and co-ordination to become sluggish, and increases aggression, the presence of alcohol in an officers’ system can greatly impact upon police work, placing both police officers and members of the public at unnecessary risk (Davey et al., 2001). Excessive use of alcohol can also be a sign of self-medication, and can result in marital problems and family dysfunction. Worryingly, research has shown that there is a strong normalisation of alcohol consumption within the police service, with this acceptance strongly predictive of both risk of alcohol dependency and negative consequences (Davey, Obst, & Sheehan, 2000). In a study of Queensland police officers by Davey, Obst and Sheehan (2001), it was found that 23% of the sample reported being affected by co-workers’ drinking in some way during the previous year, whilst 14% reported that drinking outside work hours had affected their performance at least once in the past year. However, research concerning alcohol consumption by Australian police personnel is somewhat limited. A survey by McNeill and Wilson (1993) found that although police officers reported drinking less frequently during a typical week than the general Australian population, on those occasions when they did drink the quantities consumed were far greater than the Australian norms. “Binge drinking” is defined by the World Health Organisation as imbibing more than 10 standard drinks for men, or more than 6 standard drinks for women on more than 2 occasions per month. McNeill and Wilson (1993) found that 32% of female and 16% of male were classified as binge drinkers according to this criterion. A study of Northern Territory police officers found that 28% consumed 5 to 8
158 Tracey Varker PhD Thesis 6. Resilience Training in the Real World standard drinks a day, which places them at moderate risk of alcohol dependence according to the National Health and Medical Research Council, whilst a further 12% consumed more than 9 standard drinks per day placing them at high risk of alcohol dependence (Daulby, 1991). In comparison, for the Northern Territory general population, 24% of males were classified as being at high risk, and 16% were classified as being at moderate risk. Anecdotal evidence also suggested that some of the officers surveyed regularly used benzodiazepines. One study of New South Wales police officers found that 37% of male officers consumed alcohol at levels which placed them at risk of harmful consequences (O'Brien & Reznik, 1988), whilst a study of New South Wales officers found that 48% of policemen and 40% of policewomen consumed alcohol excessively (Richmond, Wodak, Kehoe, & Heather, 1998). These figures are considerably higher than those for the general Australian population at the time, with a 1998 National Drug Strategy survey of households finding that approximately 11% of males and 3.8% of females drank excessively. In his study of Queensland police, Rallings (2000) found that hazardous drinking rates increased from 13% to 22% after commencement of police work and subsequent exposure to traumatic incidents, and that smoking rates increased from 8% to 15%. In a replication of this study, Rallings, Martin and Davey (2005) examined alcohol consumption in new recruit Queensland police officers. They found that there was a significant increase in the quantity and frequency of alcohol consumption from the time when the officers were undertaking initial training until they had completed 12 months of operational duties. The percentage of officers who drank more frequently than once a month increased from 47% to 60%, and the percentage of officers who reported consuming 6 or more drinks once a month increased from 25% to 32%. The number of females officers, but not male officers, who reported drinking at harmful levels increased over the 12 month period. There was also a significant increase in the number of officers who reported smoking. The findings of these two studies suggest that working as a police officer has a direct impact upon an individual’s alcohol consumption and smoking rate. Therefore, it is important that alcohol and drug use intervention and education occur when new recruits are still at the academy and before they get out into the field. It is not possible to review the literature relating to drug use (both licit and illicit) by police officers, because there are no published studies which have examined
159 Tracey Varker PhD Thesis 6. Resilience Training in the Real World police drug use. However, anecdotal evidence and officer testimonies suggest that there are a number of police officers that use both licit and illicit drugs. Very little has been written about the use of licit drugs by police officers, yet research in other industries suggests that there is a correlation between shift-work and the use of “uppers” (stimulants to keep you awake) and “downers” (sleeping tablets to put you to sleep). Even small amounts of medications such as anti-depressants, antihistamines, benzodiazepines, and analgesics, can impair cognitive and behavioural functioning. The multiple-use of these drugs, particularly in combination with alcohol or illicit drugs, can significantly impair performance (Fenlon, Davey, & Mann, 1997). It is generally accepted that any substance which interferes with the body’s’ normal functioning in a negative way, such as slowing reflexes or impairing judgment, should not be condoned in any way (Mann, 2006). Due to the limited amount of research involving alcohol consumption by police, and the complete lack of research examining drug use by police, key aims of Study 3 included: (a) to assess the use of licit and illicit drugs by police officers; (b) to assess the use of alcohol by police officers; and (c) to assess the efficacy of resilience training (detailed in Section 9.6) in reducing the use of drugs and alcohol by police officers.
6.6 Resilience Training and Police As previously noted, police officers are at increased risk, compared to the general population, of being exposed to traumatic incidents and going on to develop PTSD compared to the general population. It has been established that the severity of PTSD experienced by an individual is associated with uncontrollability and unpredictability (Foa et al., 1989). Although the many risks faced by police officers have been acknowledged and accepted, no evidence-based programme exists which is designed to prepare police officers for the psychological reactions that they may experience upon encountering a traumatic situation. Currently, the only assistance available to officers is in the form of psychological debriefing, counseling and peer support, each of which are offered after a traumatic event has occurred. One important aspect of pre-incident preparation is the provision of information. Sir Francis Bacon (1561-1626) once famously noted “ Knowledge itself is power ”. Many traumatic experiences result from a violation of expectancy, thus setting realistic expectations serves to protect against violated assumptions.
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It has been suggested that training programmes should be based on an all- hazards approach and designed to facilitate both technical and psychological preparedness and the development of a flexible and adaptable response capability (Driskell & Salas, 1996; Paton, 1994). Training to promote stress resilience should address the need to enhance the capability of workers to render atypical operational events coherent and to understand and manage the psychological impact of emotionally distressing events on themselves and others (Pollock et al., 2003). Being involved in a previous traumatic incident does not necessarily prepare a person for how to deal with a similar incident in the future, and if the initial incident is not emotionally and cognitively processed a person may in fact be more susceptible to future traumatic incidents (Williams, 1987). This suggests that experience alone, left to chance, is insufficient in preparing officers to deal with the future effects of a critical incident, and may allow officers to pick up inappropriate strategies that will leave them ill-prepared to act or recover and without the requisite variety of appropriate behavioural responses (Garrison, 1991). In Chapter 6 of this thesis, the literature relating to prevention of stress reactions was reviewed, and in particular, the evidence relating to resilience training was presented. As the review in Section 4.7 revealed, there is only a small number of the studies which have assessed the utility of resilience training using emergency worker populations. In the study conducted by Sarason, Johnson, Berberich and Siegel (1979), the efficacy a stress management programme was evaluated in relation to simulated police activities. Preparedness training was also found to have a positive impact upon the rescue workers for the Piper Alpha oil rig disaster. However, due to the fact that this study did not plan to assess this outcome from the outset, it was not possible to isolate the effects of preparation from other managerial and support interventions, and the specific contribution of training can only be inferred (Bartone, 2003). In another study Paton (1994) delivered training designed to increase the ability to impose coherence and meaning on disaster experiences to volunteer disaster workers and then compared their ability to cope against professional fire-fighters. He found that the volunteers were better equipped; however, these results must be treated with a great deal of caution since two different populations were compared. Finally, Backman, Arnetz, Levin and Lublin (1997) provided police academy trainees with mental imagery training, and found that those who received the training reported better physical health than those who did not
161 Tracey Varker PhD Thesis 6. Resilience Training in the Real World receive the training. Psychological factors were not reported. In Chapter 5 of this thesis a RCT of resilience training was presented. This training was designed to mitigate stress reactions for members of the general community who were shown a stressful video. The results of this study indicated that the resilience training did not have a harmful effect on the participants in the realms of either emotional coping or memory accuracy. The next logical step is to trial resilience training with a field based research study involving an at-risk population. There has never been a scientifically robust, RCT of resilience training with an at-risk population. To address this deficit in the literature, the two primary aims of Study 3 were: (a) to design a resilience training programme for use with an at-risk population; and (b) to evaluate the ability of this resilience programme to increase personal resilience.
6.7 The Police Resilience Training Programme A lack of research in the area of resilience development means that other evidence must be examined in order to gauge the potential efficacy of a resilience training programme. The programme that has been developed for the current trial is largely based upon the existing PTSD literature, which has been reviewed in Chapter 2 of this thesis. The theories and evidence that are presented here provide a justification for the use of each of the training modules for the resilience training programme.
6.7.1 Module 1: Introduction Foa and Kozak (1986) suggest that adaptive recovery from trauma depends on two conditions. First, emotional engagement must occur. The fear structure must be activated by fear-relevant information and accessed, so that the cognitive schema can be modified. According to information processing theory, if this activation is sufficiently repetitive and prolonged, and conducted in a safe environment, the stimulus-response associations will be weakened and reduce the magnitude and intensity of the fear network. Second, there needs to be an introduction of corrective information that challenges the fear-related schema. This new information facilitates the formation of new cognitive schemas (Foa & Kozak, 1986). The resilience training that will be given to the recruits is based upon the theory
162 Tracey Varker PhD Thesis 6. Resilience Training in the Real World proposed by Foa and Kozak (1986). It is thought that by providing the recruits with fear-relevant information in a repetitive and prolonged manner, and in a safe environment, fears that are associated with events such as seeing a dead body will be weakened and reduced in intensity. Corrective information will be introduced to the recruits that will give them realistic expectations of what to expect on the job, and this information will challenge the fear-related schema. This information will facilitate the formation of new cognitive schemas by the recruits. As noted in the previous section (Section 6.6), being involved in a previous traumatic incident does not necessarily prepare a person on how to deal with a similar incident in the future. The evidence indicates that there is an association between previous exposure to traumatic experiences and post-traumatic symptomatology resulting from subsequent trauma (Breslau et al., 1999; Brewin et al., 2000; Ozer et al., 2003). Janis (1982) argues that the most promising approach to intervening and countering the disruptive consequences of the stress from a critical incident is to prepare the officers by providing them with vivid information as to what they are likely to experience during and after a critical incident while developing skills and strategies for coping. Resilience training may be looked at as a way of activating new pathways for processing traumatic information and increasing the officer’s ability to respond to a variety of situations with greater flexibility (Garrison, 1991). The objective of pre- trauma training is to lessen the impact of stressful or traumatic incidents on police officers by increasing an officers’ ability to cope with a traumatic incident and their feelings after such an incident (Byatt, 1997). By providing recruits with skills and techniques to deal with emotionally stressful situations, they are able to have greater sense of control over the situation. This in turn reduces the deleterious effects of stress (Mandler, 1982). Exposing the recruits to vivid information about the types of emotionally stressful events that they will face as part of the job (in addition to the information and training that they receive related to operational factors), will enable them to develop realistic expectations and appropriate coping strategies. Anecdotal evidence suggests that many new recruit officers believe that they will not have to touch a deceased person, and that the majority of incidents that they attend will be simple assaults, car accidents, or drug related matters. They fail to take into account the fact that they will inevitably be faced with sad or depressing incidents (for example, finding a corpse or being confronted with severely mutilated
163 Tracey Varker PhD Thesis 6. Resilience Training in the Real World victims). In Module 1 of the resilience training, the recruits will be introduced to the concept of resilience training, the purpose of this training will be explained, and an overview of the sessions will be provided. Full details of Module (1) are provided in the training manual (Appendix 16).
6.7.2 Module 2: Policing Expectations In a study of new recruit Queensland police officers, Hodgins, Creamer and Bell (2001) found that in their first year on the job, the officers attended an average of seven critical incidents. The majority of those incidents could be described as depressing or sad, as opposed to violent. The most frequently experienced incidents included traffic accidents where an adult was injured or killed (55% and 28% of participants respectively), finding the corpse of someone who had died a natural death (49%), finding the corpse of a suicide victim (34%), and encounters with mentally disturbed individuals who were threatening (25%). A more recent study by Karlsson and Christianson (2003) revealed that for most police officers, the event that they considered most distressing and stressful occurred early on in their careers, with 32% of traumatic events experienced by the officers occurring during their first 5 years on the job. By providing the recruits with testimonials, photographs and videos of real life incidents, it is proposed that they will be able to gain a better appreciation of the types of situations that they will have to face as part of their job. As discussed previously in Section 4.2.3, serial approximation and desensitisation are exposure based approaches that originate from conditioning theory of fear and anxiety. They involve helping an individual confront fears and are based on the premise that direct therapeutic exposure to feared, but relatively harmless, stimuli will result in a reduction of PTSD symptoms (Solomon & Johnson, 2002). When serial approximation and desensitisation are applied before a traumatic exposure has occurred, it is an opportunity for an individual to emotionally process stressful or traumatic stimuli (i.e., photographs, videos) in an environment that is safe and supportive. Using the principles of classical conditioning, for the current study individuals will be shown a stimulus that elicits base level of fear or anxiety response repeatedly, until habituation occurs (i.e., there is a decline in the strength of the anxiety response that is elicited). In keeping with the protocol typically used to deliver exposure therapy to patients, and
164 Tracey Varker PhD Thesis 6. Resilience Training in the Real World with the protocol which was used in Study 2 of this thesis, recruits will be shown a hierarchical series of stimuli (i.e., photographs, videos). The first stimulus that is shown will be the least anxiety provoking, and the stimuli will sequentially become more severe, and the final stimulus shown is the most anxiety provoking stimulus (Hembree & Foa, 2003). These stimuli will be presented in conjunction with a talk by an experienced officer from either the homicide or major collisions unit, who will talk to the recruits about his or personal experiences of going to potentially traumatic scenes. Full details of the training procedure used for Module (2) are provided in the training manual (Appendix 16).
6.7.3 Module 3: Physical Responses to Trauma 6.7.3.1 Psycho-education In Module (3) of the resilience training programme, the officers will receive psycho-education, as well as breathing and relaxation techniques. The aim of psycho- education about the physical responses to trauma is to teach the recruits about the nature of the physical reactions that they may experience when exposed to a stressful situation. Whilst it is emphasised that physical reactions will not occur for every person in every case, the aim of the psycho-education is to inform the recruits that if a physical reaction does occur, it is not something that is abnormal or cause for alarm. Psycho-education also aims to describe management methods for the physical reactions that occur. During this process it was deemed prudent to not maximise expectations of negative reactions by delivering psycho-education in passing rather than as the focus of an intervention. It has been found in studies of patients with anxiety disorders such as panic disorder, social anxiety, and generalised anxiety disorder, that psycho-education can be very beneficial (Chavira & Stein, 2002; Dannon, Iancu, & Grunhaus, 2002; Sorby, Reavley, & Huber, 1991). It is proposed that psycho-education is successful because it gives the individual a sense of control, and increases their knowledge and understanding about the disorder (or their own personal reaction; Dannon et al., 2002). Psycho- education serves as an excellent tool which can assist in the development of coping mechanisms. Once an individual is informed about the types of physical reactions that they may experience, they can then go on to learn effective ways to deal with these reactions. During Module (3) the recruits will be taught the anxiety cycle and they will be
165 Tracey Varker PhD Thesis 6. Resilience Training in the Real World taught about common physical reactions (such as sweating, nausea, and shakiness) that a person can experience when they are feeling highly anxious. They will also be taught techniques for coping with the physical reactions which sometimes accompany a stressful situation.
6.7.3.2 Muscle Relaxation The Jacobsonian (1938) deep muscle relaxation technique will also be taught, whereby the individual is taught to differentiate between when muscles are tense and relaxed. This technique centres on gradually gaining the voluntary control of certain muscle groups through targeted contraction and relaxation of individual muscle groups. Muscle tension can be substantially reduced through alternated contraction and relaxation. Such tension release has been shown to be effective in reducing the amount of anxiety that is experienced by an individual (Luebbert, Dahme, & Hasenbring, 2001). The muscle relaxation/tension exercise can also be used to compete with vasovagal syncope which can occur sometimes when people are exposed to blood, injury or death.
6.7.3.3 Calm Breathing Exercise Controlled breathing (also known as diaphragmatic breathing Clark, Salkovskis, & Chalkley, 1985) has been shown to be an effective way of reducing anxiety (Bonn, Readhead, & Timmons, 1984; Clark et al., 1985; Rapee, 1985; Salkovskis, Jones, & Clark, 1986). Sometimes when a person witnesses something that is stressful or upsetting, they experience a physical reaction (i.e., the fight-or-flight response). One of the effects of this response is hyper-ventilation. This is when an individual begins gasping for air, leading to an increase in the amount of carbon dioxide released by the body. An increase in carbon dioxide increases blood acidity, increasing the amount of adrenalin being released, which increases the amount of stress that an individual experiences. This perpetuates the stress cycle. In order to gain control of breathing and interrupt the stress cycle, it is necessary to slow breathing down. This is achieved using the controlled breathing exercise that is described in the training manual for Study 3. Full details of the training procedure used for Module (3) are provided in the training manual (Appendix 16).
6.7.4 Module 4: Coping Skills
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Anxiety management programmes are therapies that have been developed to provide patients with skills and strategies to deal with anxiety. They are based on the assumption that conditioned emotional reactions to trauma related stimuli always occurs to some extent, therefore people who have experienced trauma need to learn how to manage their responses (Solomon & Johnson, 2002). Strategies include relaxation- training, biofeedback, breathing training, social-skills training, stress-inoculation training, guided self-dialogue, and distraction techniques (e.g., thought challenging). Relaxation and breathing training were discussed for Module (3). In Module (4), the focus is on guided self-dialogue and the distraction technique of thought challenging.
6.7.4.1 Thought-Challenging and Cognitive Restructuring Cognitive restructuring is the process of learning to refute cognitive distortions or fundamental "faulty thinking," with the goal of replacing one's irrational, counter- factual beliefs with more accurate and beneficial ones. Self-defeating or negative self- statements can cause emotional distress and interfere with performance, causing more negative self-statements and thus the cycle repeats again. Cognitive restructuring theory holds that one’s own unrealistic beliefs are directly responsible for generating dysfunctional emotions and their resultant behaviors, such as stress and anxiety, and that we can rid ourselves of such emotions and their effects by dismantling the beliefs that give them life. For example, because one may set unachievable goals — "Everyone must love me; I have to be thoroughly competent; I have to be the best in everything" — a fear of failure results. Cognitive restructuring then advises to change such irrational beliefs and substitute more rational ones such as "I can fail. Although it would be nice, I don't have to be the best in everything" (Ellis & Harper, 1975). To achieve rational thoughts and beliefs, an individual must gain an awareness of detrimental thought habits. They must then learn to challenge them, before finally substituting these faulty thoughts for life-enhancing, beneficial thoughts. Thought- challenging (Wolpe, 1973) involves identifying distorted thoughts, challenging them, and replacing them with more adaptive thoughts. In the medical field, researchers have consistently found that cognitive strategies such as putting negative thoughts aside and comparing oneself with less fortunate others, are key factors in successful adaptation to chronic illness (Beckham, Keefe, Caldwell, & Roodman, 1991; Dakof & Mendelsohn,
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1989). To enable participants to engage in thought challenging and cognitive re- structuring, they will be taught thought challenging questions. These questions are based upon the questions developed by Foa and Rothbaum (p. 188, 1998) for their PTSD treatment protocol. In addition, a commonly used CBT exercise is to teach people Beck’s (1964) model (i.e., the connection between events, thoughts, moods and behaviours), and to teach them to identify these connections through the use of ABC sheets (Beck & Emery, 1985; Resick & Schnicke, 1993). The conceptualisation phase of SIT training involves teaching a person to consider threats as problems-to-be-solved and to identify those aspects of both the situation and the clients’ reaction, which are amenable to change. By teaching the police officers Beck’s model and showing them how to use the ABC sheet, they in turn can be taught how to identify and change their own emotional reactions. Therefore, participants were provided with ABC sheets and taught how to use them. Additional ABC sheets were also included in the resilience handbook, which was given to the recruits both in their final training session, and 3 months after completing the training.
6.7.4.2 Guided Self-Dialogue Guided self-dialogue involves teaching an individual statements that a stressed or anxious person can say to themselves while preparing for a stressful event, when confronting or handling a stressful event, when feeling overwhelmed by stress, and when reflecting on coping efforts (Keyes, 1995). It is the process whereby faulty, defeating and negative self-talk is replaced with more rational, facilitative and task- enhancing dialogue. Guided self-dialogue is based on the premise that a person's internal dialogue is a significant factor in anxiety reactions and that the modification of cognitions is important. People are able to become self-directed by learning how to purposefully control their own thoughts (Neck, Steward, & Manz, 1995). Using positive talk, combined with realistic beliefs and assumptions, people can form constructive, habitual thought patterns. Guided self-dialogue involves telling oneself that one is performing well, and that one can improve performance by trying harder. Such positive thinking is enhanced by becoming aware of self-defeating internal statements (e.g., “I am of no use to anyone” or “I messed up on this last time”). Positive self-dialogue can lead to higher
168 Tracey Varker PhD Thesis 6. Resilience Training in the Real World levels of reflection, confrontation control and empathy in dealing with others (Richardson & Stone, 1981). There are four phases to self-dialogue. The first phase is preparation . In other words – the self-talk an individual engages in before they are in the situation. The second phase is confrontation and management . This is the self-talk an individual engages in during the situation. The third phase is coping with their feelings and the fourth phase is reviewing and reinforcing their progress. Building on Ellis’s (1977) concept of rational-emotive processes, rational thoughts result in positive emotional states whilst irrational or maladaptive thoughts result in emotional distress. Thus, changing internalised thoughts (self-dialogue) should affect emotions. It is known that emotional states can influence behavior, learning, perceptions, memory and judgment (Zajonc, 1980). Positive and negative thought patterns can become habitual and thereby influence emotional and behavioural reactions. Positive patterns, such as concentrating on opportunities, worthwhile challenges, and constructive ways of dealing with challenging situations, are more productive than are negative patterns such as concentrating on reasons why a goal can’t be achieved. Optimistic patterns of thought support positive behaviors and drive people to be successful, while pessimistic thoughts presumably have the opposite effect (Seligman, 1991). Optimism plays an important role in a diverse range of behavioural and psychological outcomes, when people are faced with adversity, with optimists displaying better physical and mental well-being than pessimists (Ebert et al., 2002; Peterson & Bossio, 1991; Schweizer et al., 1999). Participants in the current study will be educated about each of the four phases of guided self-dialogue and will be taught how to engage in it. They will be provided with a sheet which gives a number of exemplar statements for each of the phases, and will also receive another copy of this sheet in the resilience handbook (which is given to them both in their final session, and 3 months after training completion. Full details of the training procedures used for Module 4 are provided in the training manual (Appendix 16).
6.7.5 Module 5: Social Support After a traumatic event, those involved are typically in great need of support of all types. They are often very sensitive to how others react to them, and how others
169 Tracey Varker PhD Thesis 6. Resilience Training in the Real World describe or make attributions about both the event, and the role the victim played (Johnson et al., 1997). The extent to which a person’s social network validates or invalidates their experience can have an important effect on the victim’s psychological adaptation following a traumatic event. This type of validation, known as social support, is commonly defined as “the degree of emotional and instrumental support received by a person from the people in his or her environment” (Maercker & Müller, 2004, p. 346). A key element of social support is that it provides one with an opportunity to discuss a traumatic event with peers (Buchanan, Stephens, & Long, 2000). Social support can be gained from a variety of sources, including family, friends, work colleagues, supervisors and the organisation (in the form of management support). Those victims’ who receive poor or few social supports following a traumatic event are more likely to have higher levels of post-trauma symptomatology (Cordova et al., 2001; Marmar et al., 1999; Southwick et al., 2000). The literature related to social support is reviewed in greater detail in Section 2.2.4 (Post-trauma Vulnerabilities). In Study 3, participants will be educated about the importance of both received and perceived social support from family, friends and colleagues. With police officers in particular, they are often reluctant to discuss work stressors with friends and family, due to the belief that these people will either not understand the situations, or that they will become upset by the information discussed. For this reason, new recruits will be advised to use their own judgment about how little or how much to discuss with loved ones, but they will be told that it is of the utmost importance that they discuss difficult events with someone – particularly respected or trusted colleagues. Full details of the training procedures used for Module (5) are provided in the training manual (Appendix 16).
6.7.6 Module 6: Drugs and Alcohol It is not uncommon for those employed in a high stress occupation, where there is little opportunity to manage stress effectively, to resort to using self-defeating coping tactics. Such maladaptive tactics include self-medication through alcohol or drug use (Amaranto et al., 2003). It is well established that there is a high rate of comorbidity for substance abuse among individuals who suffer from PTSD (Davidson et al., 1991). Many people try to alleviate the symptoms of their PTSD by self-medicating with drugs
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(such as anti-depressants) and alcohol. Even in small quantities alcohol causes dysfunction in an individual, due to its depressive effect on the central nervous system, which in turn causes reaction times to become slow and thinking and co-ordination to become sluggish (McNeill & Wilson, 1993). Alcohol may also cause aggressive behaviour, particularly in the presence of a threat (Zeichner et al., 1994). Employee substance use has been found to be associated with excessive absenteeism (Crouch et al., 1989; Normand & Salyards, 1989; Normand et al., 1990; Zwerling et al., 1990), accidents at work (Holcom et al., 1993; Taggart, 1989), poor job performance (Blum et al., 1993; Lehman & Simpson, 1992) and turnover (Kandel & Yamaguchi, 1987; Zwerling et al., 1990). Given the fact that alcohol causes reaction times to slow, thinking and co- ordination to become sluggish, and increases aggression, the presence of alcohol in an officers’ system can greatly impact upon police work, placing both police officers and members of the public at un-necessary risk (Davey et al., 2001). For Module (6) of the resilience training programme, the recruits will receive education about the dangers of substance use, the impact that substance use can have upon the individual both physically and behaviourally, and they will be educated about how to recognise problem drinking. The information regarding safe levels of alcohol consumption is based upon the Australian Alcohol Guidelines (National Health and Medical Research Council, 2001), and the guidelines on how to recognise problem drinking are based upon guidelines developed by the American Academy of Family Physicians (Enoch & Goldman, 2002). Contact information for substance use support agencies will also be provided. Full details of the training procedures used for Module (6) are provided in the training manual (Appendix 16).
6.7.7 Module 7: Help Services Available In addition to educating the recruits about the dangers of substance use the recruits will also be provided with information for professional help services that they can contact if they feel that either themself, or a colleague require help. The recruits will also be provided with contact information for professional help if they feel that their usual coping mechanisms and support systems are not being useful, when dealing with the aftermath of a traumatic incident.
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Full details of the training procedure used for Module (7) are provided in the training manual (Appendix 16).
6.7.8 Module 8: Conclusion As means of a conclusion to the resilience training programme, the recruits will be given a re-cap of each of the eight core Modules. The recruits will be reminded of the topics that have been covered as part of the training programme, and the skills and tools that they have been taught which can be utilised to help each recruit cope with a stressful situation. Full details of the training procedure used for Module (8) are provided in the training manual (Appendix 16).
6.8 Conclusion In Chapter 8 studies assessing the prevalence of PTSD for police officers were reviewed, and the policing occupational and operational stress literature was examined. The prevalence of drug and alcohol use by police officers was considered and literature relating to the creation of a resilience training for police officers was presented. Based upon these findings, the rationale for a police resilience training programme was given, and the background literature for each of the eight resilience training modules was provided. The police resilience training programme (for both the intervention group and the control group) is detailed in Section 7.2.1 (and in the training manual, Appendix 16).
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Chapter Seven: Study 3- A Controlled Trial of Resilience Training for Police
7.1 Study 3: Overview This chapter presents a stratified longitudinal trial of a resilience training programme which was delivered to new recruit police officers, before they began operational policing. The aim was to assess the efficacy of resilience training upon: (a) resilience; (b) stress reactions; and (c) drug and alcohol consumption. This study utilised a longitudinal design, with entire squads of new recruit police officers ( n = 89) allocated to either: resilience training; or control training. In groups, participants received training at a number of different intervals over the twenty weeks during which they were stationed at the Academy. All participants completed pre-training and post- training assessments, and were again reviewed after six months. Resilience was conceptualised to consist of three domains: Health and Well-being, Reactivity to Trauma, and Workplace Functioning. Overall, there was no significant difference between the groups for resilience across all three domains. There was, however, a significant difference for Workplace Functioning, with those who received the resilience training showing greater resilience for this domain. All recruits except one showed resilience for the Reactivity to Trauma domain, indicating that resilience in this domain is the norm. No significant differences were found between the groups for drug and alcohol usage. Importantly, resilience training was not found to have any beneficial effects, but it was also not found to produce harmful effects. These findings are discussed in relation to resilience, distress mitigation, and drug and alcohol mitigation, and future directions for research are suggested.
7.1.1 Introduction In Chapter 4 of this thesis, literature related to the prevention of stress reactions was reviewed, with particular emphasis placed upon stress, burnout, appraisal, coping, hardiness and resilience. From this review, it was hypothesised that it may be possible to provide people with resilience training, aimed at mitigating stress reactions. Several key aspects of SIT were utilised and combined with education, in order to create a
173 Tracey Varker PhD Thesis 7. Study 3 resilience training programme designed specifically to reduce the level of stress experienced by individuals who watch a distressing video. In a proof of concept study, a RCT of resilience training aimed at mitigating stress reactions was conducted and reported in Chapter 5 of this thesis (Study 2). The resilience training was not found to significantly reduce the levels of stress experienced by those in the resilience group, as compared to the control group. However, the resilience training was also not found to increase stress levels. In Chapter 6, the literature related to whether it is possible to apply resilience training to ‘real-world’ at-risk populations was reviewed. Police officers were selected as a group at particularly high risk of being exposed to traumatic events, and as such, an emphasis was placed upon the literature related to police officers. The vulnerabilities to the development of pathology following trauma were also detailed in Chapter 6, and these factors were taken into consideration for the current study, Study 3. In the current stratified longitudinal trial of resilience training, a programme designed specifically for police officers was created (detailed in Section 6.7) and trialled with a group of new recruit police officers. Participants received either resilience training or control training whilst they were at the Police Academy. They were assessed pre-programme, immediately post-programme, and again six months later. A glossary of the terms used in Study 3 is provided in Appendix 15.
7.1.2 Project Aims The overall aims of Study 3 were to examine the efficacy of resilience training provided before beginning work as a police officer in: (a) enhancing resilience; (b) mitigating stress reactions; and (c) reducing drug and alcohol consumption.
7.1.3 Hypotheses Based upon a review of the previous literature, the following hypotheses were generated:
Part (a) To conduct an exploration of the primary outcome variables (the
174 Tracey Varker PhD Thesis 7. Study 3 three domains of resilience: Health and Well-being; Reactivity to Trauma; and Workplace Functioning) and intake attributes Hypothesis 1 :
H0: That the major variables of Study 3 (the three domains of resilience: Health and Well-being; Reactivity to Trauma; and Workplace Functioning) will not be related to: (a) age; (b) gender; (c) relationship status; and (d) station location (metropolitan vs rural) Hypothesis 2:
H1: (i) That those who score highly on the CD-RISC resilience measure will be more likely to display resilience
H1: (ii) That there will be a relationship between personality and resilience, with those high in neuroticism more likely to report low levels of resilience
H1: (iii) That those with higher levels of perceived social support will be more likely to display resilience
Part (b) To evaluate the efficacy of the resilience training programme Hypothesis 3: Resilience
H0: That there will be no difference in the levels of resilience (i.e., the domains of Health and Well-being; Reactivity to Trauma; and Workplace Functioning) for those who received the resilience training compared to those who received the control training Hypothesis 4 : Intervention Satisfaction
H0: That there will be no difference in participation satisfaction for those who took part in the resilience training as compared to those who received the control training
Part (c) To conduct a general exploration of the outcome variables Hypothesis 5 : Trauma Symptomatology and Alcohol and Drug Use
H1: That those who score highly on the trauma symptomatology measure will be more likely to use drugs and alcohol Hypothesis 6: Credibility/Expectancy and Resilience
H1: That those who give the resilience training greater credibility/expectancy ratings will demonstrate greater resilience Hypothesis 7: Attitudes Towards Victims of Crime
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H1: That there will be a difference in attitudes towards victims of crime between those who received the Victims of Crime training module (control group) and those who did not (intervention group) Hypothesis 8: Attitudes Towards Sexual Offenders
H1: That there will be a difference in attitudes towards sexual offenders between those who received the Sexual Offenders training module (control group) and those who did not (intervention group)
7.2 Study 3: Method and Materials
7.2.1 Method A: Development of the Resilience Training Programme Study 3 involved the development of a resilience training programme as well as the formulation of trainer manuals and participant handbooks. This process involved a number of systematic steps which are outlined below.
7.2.1.1 Review of the Literature Given the relative absence of resilience training programmes, the resilience programme which was developed was based upon the theories and the types of skills and techniques reported in the literature, which were suggested to be possibly useful in preparing an individual for a stressful situation. A link was then made as to how these theories, skills and techniques could be extrapolated to the development of personal resilience training modules (refer to Table 14 below). For instance, CBT is one of the most successful treatment methods for people diagnosed with PTSD. A commonly used CBT exercise is to teach people Beck’s (1964) model (i.e., the connection between events, thoughts, moods and behaviours), and to teach them to identify these connections through the use of ABC sheets (Beck & Emery, 1985; Resick & Schnicke, 1993). Exercises of this type were then selected to be included in the current programme with the hypothesis that they would develop resilience (Table 14 presented below outlines the exercises incorporated in the resilience training programme). Linking these types of theories, skills and techniques is a significant part of the theoretical contribution of this thesis (refer to Section 7.7 for detail on the link between these training programmes and the development of the resilience training programme). Finally, it was identified that no programme existed that incorporated traditional aspects
176 Tracey Varker PhD Thesis 7. Study 3 of trauma theory, and which aimed to increase personal resilience before the occurrence of a traumatic event. Further design elements that were specific to this programme were as follows: a psycho-educational training approach to resilience and stress; face-to-face training groups rather than individual sessions; skills training in the form of group interaction and shared experiences; and provision of handbooks containing all the course materials to enable practice of learnt skills.
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Table 14 Exercises Included in the Resilience Training Programme (Study 3) Exercise to be included in Method of development References training programme a) Viewing graphic Serial approximation / Barlow (1988); Heimberg photographs and videos of desensitisation & Barlow (1988); Kozak et murder scenes or car al., (1988); Rabavilas accident scenes (1976); Steketee, at al., b) Being talked through each (1989) of these scenes in terms of the emotional impact they may have, by an experienced well-respected officer Thought challenging Enables negative thoughts to Foa & Rothbaum, (1998) questions be challenged and replaced with rational ones The ABC worksheet. Teaches individuals to make Beck (1964); Beck & Participants are taught to connections between events, Emery (1985); Resick & identify: the Activating thoughts, moods and Schnicke (1993) event; the negative thought behaviours. Teaches them to or Belief; consider threats as problems- to-be-solved and to identify those aspects of both the situation and the individuals’ reaction, which are amenable to change. Guided self-dialogue Involves teaching an Keyes (1995); Neck, individual statements that a Steward, & Manz, (1995) stressed or anxious person can say to themselves when preparing for, confronting or handling a stressful event
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Calm breathing exercise Involves teaching participants Bonn, Readhead & a controlled breathing exercise Timmons, (1984); Clark, (also known as diaphragmatic Salkovskis & Chalkley breathing) which has been (1985); Rapee, (1985); shown to be an effective way Salkovskis, Jones & Clark, of reducing anxiety (1986) Muscle Relaxation The Jacobsonian (1938) deep Jacobs (1938); Luebbert, muscle relaxation technique Dahme, Hasenbring (2001) has been shown to be effective in reducing the amount of anxiety that is experienced by an individual How to recognise problem Educates participants about the National Health and drinking worksheet dangers of alcohol, and Medical Research Council increases self-awareness (2001)
7.2.1.2 Identification of How to Structure the Resilience Training Programme Sessions
Resilience Training Programme The next stage in the development of the resilience training programme was the identification of how to structure and present the programme to the police officers. It was decided that the first session should present an overview of the resilience training programme, and also introduce the officers to the types of unpleasant situations and experiences that they may have to encounter as part of their job. These images and videos were presented by a well-respected member of either the Homicide unit or the Major Collisions unit, who also discussed the types of feelings and emotions that are associated with such scenes. It was important that these images be shown in a supportive environment, and that the officers also be told at this time about the types of coping strategies that can be used in difficult times, as well as the different types of professional help services available to them. Therefore, in Session 1 (Session title: Policing Expectations ) of the resilience training, the following training Modules were included: (1) Introduction; (2) Policing Expectations and Serial Approximation / Desensitisation; (3) Physical Responses to Trauma; (5) Social Support; and (7) Help Services Available.
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In Session 2 (Session title: Coping Skills ) of the resilience training, the recruits were taught coping skills that they could use when faced with stressful, traumatic or upsetting events. During this session, the material of Module (4); Thought Challenging, Cognitive Re-structuring and Guided Self-dialogue, was taught. For the third session (Session title: Coroner’s Court ) of the resilience training, the researcher accompanied the recruits on a field trip to the Coroner’s Court and the Morgue. Here the recruits are shown two bodies- one pre-autopsy and one post-autopsy. Historically, at this session there is usually one or two people in every group of 20 who either faint or leave the room because they are overcome with physical symptoms. Therefore, it was decided that this would be a most opportune occasion for the recruits to be taught methods for dealing with the physical symptoms of anxiety. At the trip to the Morgue, the recruits were taught the controlled breathing and the muscle relaxation/tensing exercises upon arrival at the location. The muscle relaxation/tension exercise was also used to compete with vasovagal syncope which can occur sometimes when people are exposed to blood, injury or death. Just before entering the viewing area at the Morgue, the recruits were once again reminded to use the exercises that they had been taught less than an hour earlier. These exercises were drawn from Module (3) Physical Responses to Trauma. The fourth session (Session Title: Drugs and Alcohol ) of the resilience training involved the recruits being taught about the dangers of excessive alcohol use and the dangers of drug use. The recruits were provided with information and statistics specific to policing. They were also taught how to recognise if they, or someone else (such as colleague) has a drinking problem, and they were provided with contact numbers of professional help organisations. The content of Module (6) Drugs and Alcohol was covered. The fifth and final session of the programme provided a re-cap of all of the information that had been taught in the previous four sessions. The information was all tied together to form a cohesive programme, and the recruits were given another opportunity to ask questions about any elements which they were unsure of. The material in Module (8) Conclusion was covered in this session. The training program formed part of the Academy syllabus and all of the content was potentially examinable material. The recruits were informed that they would be examined on the training content.
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Control Training Programme The non-treatment control programme was designed in order to account for the concern that any observable effects in the resilience group may simply be due to the fact that this group had a number of sessions with a trainer, and spent time together as a group. These sessions were designed to be interesting and of some relevance to police officers, but they were not intended to improve the officers’ resilience in any way. Full details of the content of the control training programme may be found in the Trainers Manual (Appendix 16) In Session 1 (Session title: Critical Incidents ) the recruits were shown the same photographs of the type of critical incidents that they may be attending, as those used in resilience training Session 1. The control groups were taught about such scenes from an operational perspective, learning how to preserve evidence and the crime scene, and also how to deal with the victim’s family and friends. They did not receive any information, however, on the type of emotional impact that these events may have and they were not given education or information about coping strategies for such incidents. The content on control of the following training Modules was included in this session: (1) Introduction; (2) Critical Incidents; (3) Preserving Evidence and the Crime Scene; 4) The Role of Clinical Services; and (5) Dealing with the Victim’s Family and Friends. The fact that the control group was shown crime scene photographs is a significant limitation of the current study. Unfortunately, this situation was unavoidable, due to the fact that the course administrators at the Academy felt that it would not be possible for half of the groups to receive a talk by a well-respected guest lecturer showing crime scene photographs whilst half would not. It was felt that cross- contamination would occur, with those who received the talk giving those who did not receive the talk detailed accounts of what was discussed, and it was also considered that a number of complaints would be filed by officers who did not receive the guest lecturers’ talk. Therefore, it was decided that the best solution was to have the guest- lecturer attend talks for both groups, but that an alternate session would be presented to the control group. For Session 2 (Session title: Sexual Offenders ) of the control training, a talk on sexual offenders was delivered. The focus of this talk was to dispel some of the myths surrounding sexual offending, and topics such as different types of offenders (male vs
181 Tracey Varker PhD Thesis 7. Study 3 female; adult vs adolescent; preferential vs situational), offending rates, and rehabilitation potential and recidivism rates were discussed. The content of Module (6) Sexual Offenders, was covered in this session. In Session 3 (Session title: Victims of Crime ), the recruits received a presentation on Victims of Crime. This talk was designed to provide the recruits with an understanding of the experience a person goes through when they become a victim of crime, and also informed them about the types of thought and feelings that a victim may have. The recruits were taught about the importance of being empathetic and understanding of victims, and they were also taught that subjective it the number one predictor of who will do well after being victimised and who will not do well. The recruits were also given a copy of ‘The Victims’ Charter’ ( Victims’ Charter Act, 2006 ), which they were taken through point-by-point, in order to ensure that they were made aware of the principles which criminal justice agencies must follow when dealing with victims. The content of Module (7) was covered in this session Session 4 (Session title: Conclusion ) provided the recruits with a re-cap of the material which had been presented in the previous three sessions. Recruits were given a final opportunity to ask any questions that they may have had. The content of Module (8) was covered in this session. The training program formed part of the Academy syllabus and all of the content was potentially examinable material. The recruits were informed that they would be examined on the training content. The training modules were delivered via a total of 5 sessions for the resilience group and 4 sessions for the control group. Table 15 shows the sessions and the corresponding modules which were covered during each particular session.
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Table 15 Training Sessions and Corresponding Modules (Study 3)
Resilience Group Control Group Name of Module Name of Module Session Session (duration) (duration) Session 1 Policing 1) Introduction Critical 1) Introduction Expectations 2) Policing Incidents 2) Types of Critical (3hrs) Expectation and (3hrs) Incidents that may be Serial Attended Approximation/ 3) Preserving Evidence Desensitisation and the Crime Scene 3) Physical 4) The Role of Clinical Responses to Services Trauma 5) Dealing with the 5) Social Support; Victims Family and 7) Help Services Friends Available Session 2 Coping 4) Thought Sexual 6) Sexual Offenders Skills challenging, Offenders (30 mins) cognitive re- (30 mins) structuring and guided self- dialogue Session 3 Coroners 3) Physical No Session No Session Court Responses to (10 mins) Trauma Session 4 Drugs and 6) Drugs and Victims of 7) Victims of Crime Alcohol Alcohol Crime (30 mins) (30 mins) Session 5 Summary 8) Conclusion Summary 8) Conclusion (40 mins) (40 mins)
For each session of the programme the recruits were given a worksheet to fill-in, using the content of the session. This served two purposes: a) to assist the recruits in retaining the information presented through the process of them hearing
183 Tracey Varker PhD Thesis 7. Study 3 information and also writing it down; and b) the worksheet could then be used at a later date by the recruits as a reference for the information that was provided, and to study for the upcoming exam. In the final training session, recruits in the resilience training group were given the “Police Resilience” handbook, which contained all of the information that was presented for the duration of the resilience training programme. Those in the control group were given the “Strengthening Police Resilience” handbook, which contained all of the information that was presented for the duration of the control training programme. This handbook was given out in the final session, to prevent the recruits from reading ahead and using the examples provided, rather than their own examples, during the group discussions. Three months after the recruits finished their training and graduated from the academy, they were sent another (2 nd ) copy of the “Police Resilience” handbook if they were in the resilience group, and another copy of the “Strengthening Police Resilience Handbook” if they were in the control group. This second copy of the handbooks acted as a “booster”, designed to refresh the recruits memory of the information that they were taught as part of the resilience training programme and to remind them of the programme once they had left the Academy.
7.2.1.3 Write-up of the Manuals and Handbooks The final stage of the development of the resilience training programme was the write-up of the trainer and new recruit manuals (Appendix 16), to ensure that the programme would be standardised across groups. The trainer manuals included copies of all presentations, exercises and worksheets, as well as the theoretical justifications for the use of each of the training components. The manuals were divided into two sections: Part (1) the resilience training programme; and Part (2) the control training programme. Each of the two sections in the manual encompassed eight modules. For Part (1) (the resilience training programme) the modules were as follows: Module (1) Introduction; Module (2) Policing Expectations and Serial Approximation / Desensitisation; Module (3) Physical Responses to Trauma; Module (4) Thought Challenging, Cognitive Re-structuring and Guided Self-dialogue; Module (5) Social Support; Module (6) Drugs and Alcohol; Module (7) Help Services Available; and Module (8) Conclusion.
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For Part (2) (the control training programme) the following modules were included: Module (1) Introduction; Module (2) Critical Incidents; Module (3) Preserving Evidence and the Crime Scene; Module (4) The Role of Clinical Services; Module (5) Dealing with the Victim’s Family and Friends; Module (6) Sexual Offenders; Module (7) Victims of Crime; and Module (8) Conclusion.
7.2.2 Method B: Implementation and Evaluation of the Resilience Training Programme 7.2.2.1 Participants The sample for Study 3 comprised 89 new recruit Victorian police officers (39 male, 50 female) aged between 19 and 49 years of age ( M = 28.3, SD = 6.6). Participants were required to have the potential, by virtue of their work, to be exposed to a critical incident of sufficient seriousness to meet DSM-IV criterion A1 for PTSD. Study 3 utilised a stratified longitudinal design with a convenience sample. The sample was considered convenient due to the fact that only police officers were selected to take part (refer to Chapter 6 for reasoning).
7.2.2.2 Approvals Approval was obtained from the Swinburne University Human Research Ethics Committee and the Victoria Police Research Coordinating Committee.
7.2.2.3 Consent Forms and Information Sheet New recruit Victoria Police officers were informed about the research study, in a separate session which was conducted the week before the recruits were due to begin the resilience or control training programme. At this time the recruits were verbally informed about the research project, were given an information sheet (Appendix 17) to read and to keep for future reference, and were given an opportunity to ask questions about the research project. Due to the nature of the training that police receive, recruits were unable to ‘opt- out’ of receiving either the resilience or control training. Logistically, it was not possible for a few members to be removed from the class. However, participants were informed that they had three options that they could choose from, in regards to the psychological questionnaires that they would be asked to fill in. Participants could elect
185 Tracey Varker PhD Thesis 7. Study 3 to: (a) participate in the study and fill in the questionnaires; (b) fill in the questionnaires, but have these questionnaires destroyed later on by the researchers; or (c) not fill in any questionnaires. Option (b) aimed to negate the possible effects of peer group pressure, with recruits able to anonymously elect to not have their information included in the study. Following this information, participants completed and signed the consent form (Appendix 18).
7.2.2.4 Recruitment and Group Allocation Before joining the police service, all participants underwent a medical examination to screen out chronic diseases and current mental disorders (including PTSD), use of medication and drug or alcohol abuse as well as a psychological assessment to screen for psychopathology. All participants had undertaken this screen just a few months before entering the study. As such, people with any major pre- existing medical or psychological disorders were screened out by Victoria Police, prior to the commencement of the research project. Six police academy squads participated in the study. Three squads received the resilience training programme, and three squads received the control training programme. Using a stratified randomisation process, squads were assigned to receive one of the two types of training. Recruits therefore received the resilience training or the control training by virtue of which squad they were in. Upon applying to enter the police Academy, recruits completed a series of tests and then received an overall ranking score. Individuals were admitted to the Academy based upon vacancy rates, recruitment intake schedules, and their overall ranking score. In this way recruits were randomly allocated to a squad. Squads were then stratified using proportional stratified sampling, with 3 squads (each squad with 20 members) allocated to each strata. Stratified sampling was used to avoid cross-pollination between the two conditions. The aim was for participants in each of the two groups to remain blind to which condition they were in. By reducing the opportunities for those in the different conditions to communicate with one another, the chance of discovering which condition they had been allocated to was limited. This was a likely possibility due to the fact that at any one time there were only approximately four different squads receiving training at the Academy. As such, as far as most recruits were aware, they were
186 Tracey Varker PhD Thesis 7. Study 3 receiving the same training as everyone else at the Academy (since most people at the Academy at any one time, were receiving the same training). One-hundred and eleven people were deemed eligible for the study. Of these, 8 people wished to have their questionnaire destroyed and withdrew their intake data, 2 people did not agree to participate in the study, and 2 people agreed to participate, but once they began filling in the questionnaire they changed their mind and decided to no longer participate (withdrawing their data). This meant that 12 people were excluded because they refused to participate. Ninety-nine people were then allocated to one of the two conditions. Of these, 4 people left the police academy and failed to complete the training, 5 people refused to continue participating in the study, and 1 person finished his training at the Academy, and began work as a police officer, but then later quit the police force (and therefore follow-up data was not collected). This left a final sample of 89 participants. Ultimately 47 individuals (25 male, 22 female) aged between 19 and 50 years (M = 28.7, SD = 7.4) were allocated to the control condition, with an average of 17 participants per squad (range: 16-18). In the resilience condition there were 52 individuals (19 male, 33 female) aged between 19 and 49 years ( M = 29.0, SD = 6.9), with an average of 17.3 participants per squad (range: 14-20). Those who dropped out after the intake assessment were compared to the final sample, for a number of key variables. This was to check that those who dropped out were representative of the final sample, and had not dropped out due to pre-existing factors such as high levels of depression, for example. No significant differences were found between those who dropped out after intake and the final sample for any of the key variables (i.e. depression, stress, anxiety, alcohol use, drug use, social support, relationship satisfaction, or general health). A flow diagram of participant numbers for each of the assessment times is shown in Figure 7.1.
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111 New recruit officers were assessed for eligibility 12 recruits were excluded
Enrollment Reason: Refused to participate (n=12)
99 people allocated to condition using stratified randomisation
52 allocated to Resilience Training 47 Allocated to Control Training
49 received allocated intervention Allocation 46 received allocated training
3 did not receive allocated 1 did not receive allocated intervention intervention
Reason: Failed to complete the Reason: Failed to complete the police academy training police academy training.
Follow- up at Follow- Up at
Week 20: n = 47 Week 20: n = 45 Missing data: n = 2 Missing data: n = 1 Reason: 2 were absent on day of Follow -up Reason: Absent on day of assessment assessment
6-Months: n = 46 6-Months: n = 43 Lost to follow-up (n=3) Lost to follow-up (n=3) Reason: 2 refused to participate. Reason: 3 refused to participate. 1 left the police force
Analysis Analysed (n = 46) Analysed (n= 43)
Figure 7.1 Diagram Showing the Flow of Participants Through Each Stage (Study 3)
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7.2.2.5 Design The training component of the study was conducted over a 7-month period. This was due to the fact that new squads of recruits are admitted into the academy at 1-month intervals, and six squads were included in the study (thus accounting for the first 6 months). A period of 4 months elapsed from the time that the sixth squad received its first training session until it received its last training session (which accounted for the remaining 1 month). Questionnaires were administered and collected at the following three stages (for a diagrammatic representation see Figure 7.2 below): 1. Time 1: one week prior to either the resilience or control training programme (intake assessment) 2. Time 2: immediately post-programme (training satisfaction) 3. Time 3: 6 months after completion of resilience or control training (6-month follow-up)
Time 1 Intake Assessment
1 week
Training programme begins
15 weeks
Time 2 Training Satisfaction Assessment / Training programme concludes
6 months
Time 3
6-Month Follow-up Assessment
Figure 7.2 Design of Questionnaire Administration (Study 3)
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The questionnaire was administered during a normal teaching period at the Police Academy, without training or commanding officers being present. The researcher was present during all sessions and was available to all recruits before, during and after survey completion to answer any questions the recruits may have had.
7.2.2.6 The Training Programmes In total six groups were run to evaluate the resilience training programme. The structure and content was identical across the different groups, and the candidate co- ordinated and attended all of the sessions. The candidate delivered all sessions except for Session 1 (for both the resilience and control groups), which was delivered by the Clinical Services unit of Victoria Police and a member of either the Victoria Police Homicide unit or the Victoria Police Major Collisions unit. In addition, the first 20 minutes of Session 5 (for both the resilience and the control groups) was presented by the Clinical Services Unit and the Employee and Support Unit. The resilience training programme consisted of 5 sessions, which were held over a 15 week period whilst the recruits were training at the police academy. The candidate and the presenters from the Clinical Services unit, the Homicide unit and the Major Collisions unit used the trainer manual developed as part of this thesis in each of the sessions. The training sessions were consistently held at the same time points, during the recruit’s 20 week stay at the police academy. The time points were the same for both the resilience training groups and the control training group. A large number of the sessions were also rated by an independent assessor, who rated the trainer’s adherence to the training manual.
7.2.2.7 Measures Three different questionnaire packages were administered at each of the three assessment time points (see Figure 7.1). The measures that were administered at each assessment time point are detailed below in Table 16. At each assessment (Time 1, Time 2 and Time 3) the recruits were administered the questionnaire package in a classroom setting. They filled in the questionnaire and handed it back to the researcher upon completion. The complete questionnaire packages that were administered at each time point are attached in the Appendices (for Time 1 questionnaire package see Appendix 19; for Time 2 questionnaire packages see Appendix 20 and Appendix 21; for
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Time 3 questionnaire packages see Appendix 22 and Appendix 23).
Table 16 Questionnaires that were Administered at Time 1, Time 2, and Time 3 (Study 3) Time 1 (Pre-programme) Time 2 (Post-programme) Time 3 (6 month follow-up) DASS-21 DASS-21 DASS-21 ASSIST DEVS3 ASSIST ISEL-SF CEQ ISEL-SF ADAS Training Satisfaction ADAS STAXI (Trait Anger Training Importance PLES Subscale Only) LOT-R PSS-SR History of Traumatic MBI-HSS Events Scale TIPI SF-36 SF-36 Victims of Crime CD-RISC Sexual Offenders Training Satisfaction Training Importance Support Services Access
Note: ASSIST = Alcohol, Smoking and Substance Involvement Screening Test; CD-RISC = Connor Davidson Resilience Scale; CEQ = Credibility / Expectancy Questionnaire; DASS-21 = Depression, Stress and Anxiety Scale- 21 item short form; DEVS3 = Distress Endorsement Validation Scale; ISEL-SF = Interpersonal Support Evaluation List-Short Form; MBI-HSS = Maslach Burnout Inventory – Human Services Survey; PLES = The Police Life Events Schedule; PSS-SR = The Posttraumatic Stress Diagnostic Scale- Self report; History of Traumatic Events Scale = Degree of trauma from the traumatic incident per DSM-IV criteria A.1 and A.2; Sexual Offenders = Attitudes towards sexual offenders; STAXI = State Trait Anger Expression Inventory; TIPI = Ten Item Personality Inventory; Training Importance = Importance of the training that the participant received Victims of Crime = Attitudes towards victims of crime.
At Time 1 demographic information was also collected, while at Time 2 two non-standardised instruments were utilised. These instruments were used to collect information regarding: (a) participant satisfaction with each of the training modules; and (b) participant’s ratings of the importance of each of the training modules. At Time 3, participant satisfaction, and participant importance rating measures
191 Tracey Varker PhD Thesis 7. Study 3 which were used at Time 2 were administered once again. In addition, non-standardised measures of support services accessed (see Section 7.2.2.7.18), attitudes towards victims of crime (see Section 7.2.2.7.16), and attitudes towards sexual offenders (see Section 7.2.2.7.17) were also used.
7.2.2.7.1 Demographics General demographics were obtained using a questionnaire that asked questions related to age, sex, relationship status, religion, ethnicity, education, personal history of psychiatric illness and family history of psychiatric illness.
7.2.2.7.2 The Depression, Anxiety and Stress Scale Refer to Section 3.2.5.2.
7.2.2.7.3 The Interpersonal Support Evaluation List-12 Refer to Section 3.2.5.3
7.2.2.7.4 The Alcohol, Smoking and Substance Involvement Screening Test The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST; WHO ASSIST Working Group, 2002), is an 8-item self-report screening measure used to detect both alcohol and psychoactive substance use, and related problems. It is also able to detect risky, but non-dependent illicit drug use (Dennington, Humeniuk, Newcombe, Ali, & Vial, 2007). Several different domains can be derived for each respondent, such as a “specific substance involvement score” and a “global continuum of risk score”. The average test-retest reliability coefficients range from α = .90 (consistency of reporting ‘ever’ use of substance) to a low of α = .58 (regretted what was done under the influence of substance), whilst the average coefficients for substance classes ranged from α = .61 for sedatives to α = .78 for opiods (WHO ASSIST Working Group, 2002). The measure has been found to have good reliability and validity for an Australian population (Newcombe, Humeniuk, & Ali, 2005).
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7.2.2.7.5 The Abbreviated Dyadic Adjustment Scale Sharpley and Rogers’ (1984) Abbreviated Dyadic Adjustment Scale (ADAS) is a measure of relationship satisfaction. This 7-item self-report measure is derived from the 32-item Spanier Dyadic Adjustment Scale (Spanier, 1976). Alpha reliability for the ADAS is α = .76, there are item-total correlations of α = .57 or greater, and the inter- item correlations range from α = .34 to α = .71 (Sharpley & Rogers, 1984). The ADAS correlated highly with, r > .85, with the full Dyadic Adjustment Scale (Sharpley & Rogers, 1984), and has good test-retest reliability (Hunsley, Best, Lefebvre, & Vito, 2001).
7.2.2.7.6 The Spielberger Trait Anger Scale The 10-item Spielberger Trait Anger Scale is a self-report questionnaire measuring an individual’s disposition to experience anger over time, and is a subscale of the 44-item State-Trait Anger Expression Inventory (STAXI; Spielberger, 1988). For the purposes of this study, only the Trait Anger subscale was utilised. On this scale respondents rate their typical experience with anger on a 4-point scale ranging from 1 (almost never ) to 4 ( almost always ). An overall trait anger score is obtained by summing each of the individual items, and two further subscales are yielded- Angry Temperament (T – Anger/T) and Angry Reaction (T – Anger/R). The trait anger subscale has reliability coeffients of .82 for both male and female adults (Spielberger, 1991). The angry temperament subscale has reliability coefficients of .89 and .88 for adult men and women respectively, which the angry reaction subscale has reliability coefficients of .69 for both male and female adults (Spielberger, 1991). The STAXI has good convergent and divergent validity (Spielberger, 1991) and a good level or reliability over a two week period for trait anger (test-retest reliability r = .74, Bishop & Quah, 1998).
7.2.2.7.7 The Life Orientation Test – Revised Dispositional optimism was measured using the 10-item self-report measure known as the Life Orientation Test – Revised (LOT-R; Scheier, Carver, & Bridges, 1994). Six core items are measured on a 5-point Likert scale, which ranges from 0
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(strongly disagree ) to 4 ( strongly agree ). The remaining four items are included to obscure the intent of the scale. Core items are evenly divided between negatively- and positively-worded items. Total scores range from 0 to 24 with higher totals suggestive of greater optimism. Cronbach’s α = .78 for the 6 items used to calculate the optimism score, indicating that the measure has an acceptable level of internal consistency (Scheier et al., 1994). The LOT-R also appears stable over time as test-retest reliability has been measured as r = .79 over a 28 month interval (Scheier et al., 1994). Only modest correlations emerge between the LOT-R and measures of neuroticism, self- esteem and trait anxiety (range α = -.35 to α = .54) (Scheier et al., 1994), suggesting that responses to the LOT-R tap a construct distinct from established personality traits.
7.2.2.7.8 The History of Traumatic Events Scale The History of Traumatic Events Scale is a 14-item self-report measure of whether an individual has experienced a traumatic event in the past (directly or observed), the number of times it was experienced and the degree of distress that was experienced both at the time, and currently. The inventory offers a range of events that would be broadly experienced as traumatic for the respondent to choose from, and also allows for them to name a traumatic experience not mentioned, or to indicate that a traumatic experience occurred without further specification. Respondents indicate their distress regarding the experience using a 5 point Likert-Type scale ranging from 1 ( no distress ) to 5 ( extreme distress ). The variable history of personal trauma was calculated from responses on this measure, by adding the number of traumatic experiences endorsed by the participant, where they rated the experience on the Likert-Type scale as being 3 or greater at the time. This was to avoid including experiences which the participant endorsed, but which was not experienced as traumatic. This inventory is an adaptation of the trauma screen which forms part of the Posttraumatic Stress Scale (PSS-SR; Foa et al., 1993), and was first used in a study conducted by Wright (2005)
7.2.2.7.9 The Ten Item Personality Inventory Refer to Section 5.2.5.9.
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7.2.2.7.10 The Connor-Davidson Resilience Scale The Connor-Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003) is a recently developed 25-item measure of resilience. The CD-RISC comprises items reflecting several aspects of resilience including: a sense of personal competence; tolerance of negative affect; positive acceptance of change; trust in one’s instincts; sense of social support; spiritual faith, and an action-oriented approach to problem solving. Items are rated on a 5-point scale ranging from 0 (strongly disagree ) to 4 ( strongly agree ). The total score ranges from 0-100, with higher scores reflecting greater resilience. A study of the psychometric properties in general population and patient samples found the internal consistency for the full scale to be Cronbach’s α = .89 and acceptable convergent and discriminant validity (Connor & Davidson, 2003). Test-retest reliability has only been conducted with a group of patients with Generalised Anxiety Disorder (GAD) and PTSD, and has been found to be r = .87.
7.2.2.7.11 SF-36 A multi-purpose short-form survey, the SF-36 (Ware, 1992) yields an 8-scale profile of functional health and well-being, as well as physical and mental health summary measures and a preference-based health utility index. Cronbach’s α coefficients for each of the 8 subscales exceed .80, except for social functioning, where α = .76 (Jenkinson, Coulter, & Wright, 1993). The scale has been found to have good convergent and discriminant validity (McHorney, Ware, & Raczek, 1993). Using the Bland and Altmann technique for calculating test-retest reliability, Brazier, Harper and Jones (1992) found that for all dimensions, 91-98% of cases lay within the 95% confidence interval. The maximum mean difference in dimension scores was 0.80 (Brazier et al., 1992).
7.2.2.7.12 The Police Life Events Schedule The Police Life Events Schedule (PLES; Carlier & Gersons, 1992) is a 42-item measure of the type and number of traumatic incidents experienced by police officers, and the degree to which they felt threatened, anxious and helpless at each of the incidents. The incidents can be divided into two categories: violent (e.g., taking part in a raid/arrest accompanied by violence) and sad or depressing (e.g., finding a corpse).
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Participants indicate for each item, whether they have experienced it or not (yes or no) at any time in their career, and then to rate the level of threat, anxiety and helplessness that they experienced at the time. The reliability co-efficient for the total score has been found to be Cronbach’s alpha .87 (Carlier & Gersons, 1992). For the purposes of the current study, the PLES was modified. For those events that participants indicated that they had experienced, they were also required to indicate the number of times that they had experienced that particular event. Participants did not rate the level of fear anxiety and helplessness that they experienced for each event. Instead, participants were required to rate on 5-point Likert type scale, the degree of distress that they experienced both at the time ( 1 = None, 5 = Extreme ), and currently ( 1 = None, 5 = Extreme ). This alternate rating system was used so that comparisons with the History of Traumatic Events Scale could be made.
7.2.2.7.13 The Maslach Burnout Inventory – Human Services Survey Maslach and Jackson’s (1996) Maslach Burnout Inventory – Human Services Survey (MBI-HSS) is a 22-item self-report measure, designed to measure the following three aspects of burnout in health services employees: (a) emotional exhaustion; (b) depersonalisation; and (c) lack of personal accomplishment. The emotional exhaustion subscale assesses feelings of being emotionally overextended and exhausted by one’s work. The depersonalisation subscale assesses an unfeeling and impersonal response to the recipients of one’s care. The personal accomplishment subscale describes feelings of competence and successful achievement in one’s work with people. The items are written in the form of statements about personal feelings or attitudes, and are answered in terms of frequency with which the respondent experiences feelings on a 7-point scale, ranging from 0 ( never ) through to 6 ( every day ). Leiter and Schaufeli (1996) have shown that the internal consistency for each of the three subscales is acceptable for each of Emotional Exhaustion ( α = .74), Depersonalisation ( α = .89) and Personal Accomplishment ( α = .69) subscales. High levels of Emotional Exhaustion and Depersonalisation and low levels of Personal Accomplishment are indicative of burnout (Bakker, Killmer, Siegrist, & Schaufeli, 2000). The test-retest reliability of the three subscales has been found to be stable over time, with correlations ranging from .50 to .82 found for time spans of three months to one year (Leiter & Durup, 1996).
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7.2.2.7.14 The Post-traumatic Stress Diagnostic Scale Refer to Section 3.2.5.7.
7.2.2.7.15 Coping Style Two non-standardised items were used to assess coping style. Participants were asked to rate two statements on a 7-point scale, ranging from 1 ( strongly agree ) to 7 (strongly disagree ). The first statement sought to measure emotion-focused coping, and consisted of “ When I am worried about something I talk to friends”. The second statement sought to measure problem-focused coping and consisted of “ When I am worried about something I try to do something to fix the situation ”.
7.2.2.7.16 Attitudes Towards Victims of Crime Seven non-standardised items were used to assess participants’ attitudes towards victims of crime. Participants were asked to rate their degree of agreement with the seven statements on a 6-point scale, ranging from 0 (not at all) to 5 (a very great degree). Two examples of these statements were: (a) “Victims of crime are usually implicated in their own victimhood to some extent” ; and (b) “I try to provide support for victims of crime at a personal level” .
7.2.2.7.17 Attitudes Towards Sexual Offenders Five non-standardised items were used to assess participants’ degree of contact with, and attitudes towards sexual offenders. Participants were asked to indicate “yes” or “no” to; (a) “Have you had any interaction with sexual offenders while working as a police officer?” , and (b) “Have you had any interaction with SOCAU (Sexual Offence and Child Abuse Unit)?” Participants were also asked to rate three items relating to attitudes towards sexual offenders on a 6-point scale, ranging from 0 (not at all) to 5 (a very great degree). An example of these items is: “To what degree do you believe that child sexual offenders (adults who offend sexually against children) can be rehabilitated?”
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7.2.2.7.18 Access of Support Services Ten non-standardised items were used to assess the degree to which the officers accessed a number of support services over the preceding 6-month period. Participants were asked to indicate whether or not they accessed 10 different support services, and for those services which they did access they were also asked to rate their degree of satisfaction with the service on a 5-point scale ranging from 1 (very dissatisfied) through to 5 (very satisfied). Four Victoria Police services were assessed: Clinical Services; Employee / Welfare Support; Chaplain; and Peer Support; whilst six external services were assessed: Psychologist; Psychiatrist; Social Worker; Priest / Spiritual Advisor; G.P.; and Counsellor / Other.
7.2.2.7.17 The Distress / Endorsement Validation Scale (III) The Distress/Endorsement Validation Scale III (Devilly, 2004) is a 10-item measure of course / intervention satisfaction. Items are measured on a 9-point anchored Likert scale. The scale demonstrates high internal consistency (Cronbach’s α = .84), and inter-item correlations of between .67 and .74 (Devilly, 2004).
7.2.2.7.18 The Credibility / Expectancy Questionnaire The Crediblity / Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000) is self-report questionnaire which was developed for use by Borkovec and Costello (1993) and derives two factors: expectancy for change and treatment credibility (Devilly & Borkovec, 2000) . For the current study, the wording of the items was modified slightly, so that participants rated their expectancies of, and the credibility for, the training programme. Items for both the credibility and expectancy subscales are rated on a 9- point scale ranging from 1 ( not at all ) to 9 ( very much ). The scale has demonstrated factors that are stable across multiple populations, high internal consistency (standardised α of between .84 and .85 for the whole scale), and good test-retest reliability ( α of .82 for expectancy and .75 for credibility) (Devilly & Borkovec, 2000). The CEQ was administered on the final day of the training programme, after the training rationale had been given to the participants of the course. The wording was
198 Tracey Varker PhD Thesis 7. Study 3 modified slightly so that the questions related to a training programme rather than a treatment programme. For analyses, all items were standardised and composites were derived for the expectancy and credibility factors.
7.2.2.7.21 Training Adherence Trainer’s adherence to the prescribed content of each of the training sessions was assessed by an independent assessor. For each of the sessions (in both conditions), a training adherence integrity summary was created. For each of these integrity summaries, the independent assessor was required to check a list of key concepts that should have been covered in the session. The independent assessor was also required to provide an overall rating of the integrity of the training provided in session. The overall training integrity rating was scored on a 6 point scale, ranging from 0 ( unacceptable ) to 6 ( high ). The training adherence integrity summary for each of the sessions is provided in Appendix 24.
7.3 Study 3: Results All data entry and analyses were conducted using Statistica (version 6.1) and ClinTools Version 4.1 (Devilly, 2007). The results section will begin with a summary of the data management strategies used, and transformations made to the data to satisfy the assumption of normality. This will be followed by a summary of the descriptive statistics for the sample. The analyses will be broken down into parts according to each of the aims of the study. The overall aims of Study 3 were to assess the effect of resilience training upon: (a) resilience (as measured by the three domains of Health and Well-being; Reactivity to Trauma; and Workplace Functioning); (b) drug and alcohol usage; and (c) to conduct a general exploration of the outcome variables.
7.3.1 Data Screening Prior to analysis all independent variables were examined for accuracy for data entry, missing values, presence of univariate and multivariate outliers and the distribution of data. All data screening and analyses were conducted using
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Statistica (version 6.1). Cases with a small number of missing values (3 or less) were retained, and missing values were replaced with the individuals mean score for the subscale of the measure where the missing value was located (when the measure contained subscales), or with the individuals mean score for the corresponding measure. Where cases were missing a significant number of values on any one measure (>3), the case was deleted from analyses involving this measure. Both graphic and statistical methods were used to determine whether the data was normally distributed. Frequency histograms and box plots were produced so that the distribution of the data could be considered and so that the shape of the data could be compared to the normal curve. Skewness and kurtosis values (and their significance levels) were calculated for those variables with a distribution which did not appear to be normal, as were Shapiro-Wilkes values. Transformations were applied if the skewness and kurtsosis statistics differed significantly from zero. The same tests were conducted after the data had been transformed to determine whether the transformation improved the distribution, including whether skewness and kurtosis statistics were closer to zero. Although there is much controversy surrounding the transformation of data, the use of data transformation in this study can be justified due to the relatively large sample size (Osborne, 2002) and because there was no specific reason not to transform the data to satisfy tests of normality (as emphasised in Tabachnick and Fidell, 2000). All analyses hereon in will use the transformed variables. The data was assessed for nonlinearity and heteroscedasticity using the Statistica ‘plot’ function to examine bivariate scatterplots for each combination of variables. The data appeared linear and homoscedastic. The variables were examined for multicollinearity by looking at their bivariate correlation coefficients using the Statistica ‘correlate’ function. Correlations of r >0.70 were considered to be too large (as recommended by Tabachnik & Fidell, 2001). None of the variables included in the analyses exceeded this limit. Univariate outliers were identified by standardising the scores for each variable and examining the range of scores using the Statistica ‘frequencies’ function. Those cases with a z score over 3.29 (Tabachnik & Fidell, 2001) were considered potential outliers. Box plots and frequency histograms for each variable were generated and skewness and kurtosis values were also examined, using Statistica ‘frequencies’ to check the distribution of the data. All except one of the identified outliers were deemed
200 Tracey Varker PhD Thesis 7. Study 3 to be sampled from the target population and were retained in the analyses, however their influence was reduced and the quality of the analyses enhanced by transforming variables so that the distribution was more normal (see Table 17 for a summary of variable transformations and Appendix 25 for skewness and kurtosis statistics). A single outlier was identified for ‘PDS Part2 total score’ (z-score = 7.31). This case was therefore removed from significance tests involving the PDS, but retained for the clinical classification analyses. Multivariate outliers were identified by calculating Mahalanobis distance using the Statistica ‘Regression’ function. Mahalanobis distance was calculated as χ2 with 18 degrees of freedom (as there are 18 independent variables), which meant that at a probability of p<0.001, as recommended by Tabachnik & Fidell (2001), a distance greater than χ2 (18)=42.31 was considered a multivariate outlier (refer to Tabachnik & Fidell, 1996, Appendix C, Table C4 – critical values of chi square). No multivariate outliers were identified. Further information regarding analytic specific assumptions that have not been discussed here is presented under each hypothesis. The homogeneity of variance-covariance matrices was calculated once normality violations were remedied (as recommended by Tabachnik & Fidell, 2001), and was found to be satisfactory (Box’s M=65.57, p >0.05).
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Table 17 Transformations Made to Variables Prior to Analyses to Meet the Assumption of Normality Variables Transformation ASSIST total score Square Root Emotion focused coping Square Root Problem focused coping Log10 T1a DASS total score Square Root T1 DASS depression Log10 T1 DASS anxiety Square Root T1 DASS stress Log10 T1 ISEL total score Reflect, Log10 T1 ISEL appraisal Reflect, Inverse T1 ISEL belonging Reflect, Square Root T1 ISEL tangible Reflect, Square Root T1 SF-36 total score Reflect, Log10 T1 ADAS total score Reflect, Square Root CD-RISC total score Reflect, Log10 TIPI- Extraversion Reflect, Square Root TIPI- Emotional Stability Reflect, Square Root TIPI- Conscientiousness Reflect, Square Root TIPI- Openness to Experience Reflect, Square Root DEVS Distress Log10 T2b DASS total score Square Root T2 DASS depression Square Root T2 DASS anxiety Square Root T2 DASS stress Square Root T3c ASSIST total score Square Root T3 DASS total score Log10 T3 DASS depression Log10 T3 DASS anxiety Log10 T3 DASS stress Log10 T3 ISEL total score Reflect, Log10
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T3 ISEL appraisal Reflect, Square Root T3 ISEL belonging Reflect, Square Root T3 ISEL tangible Reflect, Log10 T3 SF-36 total score Reflect, Log10 MBI Emotional Exhaustion Square Root MBI Personal Accomplishment Reflect, Square Root PDS Part2 total score Log10 PDS Intrusions Log10 PDS Avoidance Log10 PDS Arousal Log10 Note. To determine whether the distribution for each variable was normal (pre and post transformation), the skewness and kurtosis statistics were examined, along with graphical representations such as histograms and boxplots. a Time 1; b Time 2
7.3.2 Attrition, Session Attendance, Questionnaire Completion and Training Integrity Adherence Sample retention was high over the course of the training programme, with the majority of recruits attending all five training sessions. Originally there were 99 participants who completed the pre-programme assessment at Time 1. However, 4 participants failed to complete their operational training at the academy and as a result failed to complete the resilience / control training, and were therefore excluded from the study. This represented 4% of the initial sample. Of the 95 recruits who completed the training programme, 89 (94%) recruits completed all five sessions. Five recruits (5%) missed one of the five sessions. Recruits who missed a session did so for reasons unrelated to the study (e.g., physical illness). The completion rate of the Time 2 (training satisfaction) assessment was high, with 92 out of the 95 recruits who completed the training programme also completing the Time 2 assessment (97%). The completion rate of the Time 3 (6-month follow-up) assessment was relatively high, with 89 of the 95 recruits who completed the training programme also completing the Time 3 assessment (94%). The attrition rate from Time 1 to Time 3 was relatively low, at 10%.
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Overall, for the 6 different squads that participated in the two different training programmes, 24 separate training sessions were run. Of these 7 (29%) were attended by an independent assessor who rated the trainer’s adherence to the training manual. The mean training adherence rating was high, at 5.43 ( SD =.53).
7.3.3 Descriptive Statistics Of the 89 participants, over half were aged under 29 years (see Table 18). With respect to relationship status, 55% of the sample were single, while another 45% were in a relationship. Participants identified with several religions, 30% were Catholic, 13% were generally Christian, 1% were Muslim, 10% described themselves as Other. Overall 55% of participants had some type of religious belief compared to 45% who had no religious belief. The majority of the sample identified themselves as feeling that they were Australian (79%), while 4% reported feeling that they were Northern or Western European, 2% reported feeling Southern or Eastern European, and 3% described themselves as ‘Other’. The majority of participants reported having completed Year 12 or its equivalent (87%), with 22% completing an undergraduate degree, and 7% having completed a postgraduate degree. Twenty-four percent of people reported having seen somebody for emotional problems, before joining the police service. All descriptive statistics are detailed below (see Table 19).
As this study incorporates people who come from a wide range of backgrounds a series of factorial, between subjects multivariate analyses of variance were conducted (after the data were screened and transformed) to determine whether these differences within the sample had any impact on the measures of interest throughout the analyses. MANOVAs were used, with Health and Well-being (i.e., General Health, Affective Distress, Substance Involvement, and Relationship Satisfaction), Reactivity to Trauma (i.e., Trauma Symptomatology), and Workplace Functioning (i.e., Burnout, Police Services Accessed and External Services Accessed) as dependent variables. Independent variable in each analyses were: (a) gender; (b) relationship status (single vs in relationship); (c) station location; (d) religious belief; and (e) ethnicity (Australian (n= 79) vs Other (n=9) due to small sample sizes of specific ethnic groups).
In each case Pillai’s criterion was used to determine the significance of the main effect of group as it is considered more robust than other commonly used statistics, and
204 Tracey Varker PhD Thesis 7. Study 3 is recommended when unequal group sizes among the independent variable are being used (Tabachnick & Fidell, 1996, p.401). The combined dependent variables were found to not be significantly influenced by: (a) gender ( F(8,17)=0.69, ns ; (b) relationship status (single vs in relationship) ( F(8,17)=0.64, ns ; (c) station location (F(8,17)=0.64, ns ); (d) religious belief ( F(8,17)=1.41, ns ); or (e) ethnicity (Australian vs Other ( F(8,17)=1.66, ns ). Subsequently it was considered valid to use a sample with mixed backgrounds. See Appendix 26 for Tables summarising the mean and standard deviation scores for these analyses.
Table 18 Age Ranges of Participants (Study 3)
n % Age Range (years)
18-28 58 65.2% 29-38 21 23.6% 39-48 9 10.1% 49-58 1 1.1% 59+ 0 0
Table 19 Baseline Characteristics of the Sample (N = 89; Study 3)
Resilience Control All Conditions (n=46) (n= 43) (n=89) Mean S.D Mean S.D Mean S.D Sex (m : f) 16:30 23:20 39:50 Relationship status 24:22 25:18 49:40 (single: in a relationship) Religious belief (yes:no) 19:27 13:30 32:57** Ethnicity (Australian: Other) 43:2 36:7 79:9 Highest education attained Postgraduate: 3 Postgraduate: 3 Postgraduate: 6 Undergraduate: Undergraduate: 8 Undergraduate: 12 20 TAFE: 12 TAFE: 5 TAFE: 17 Year 12: 13 Year 12: 21 Year 12: 34 Did not complete Did not complete Did not complete Year 12: 5 Year 12: 6 Year 12: 11
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Number who have seen someone 12(26%) 9(21%) 21(24%) for emotional problems prior to joining the police Number of times that a 2.28 2.9 3.26 4.77 2.75 3.91 professional was seen for emotional problems Location of participants’ police 41:5 34:9 75:14 station (metropolitan: rural) Emotion focused coping 2.22 1.0 2.51 .86 2.36 1.20 Problem focused coping 1.67 .50 1.91 .89 1.79 0.73 History of Traumatic Events- .93 1.6 .65 1.04 0.80 1.37 Number of personal trauma events where distress was ‘3’ or greater, at the time of the event ISEL-12 Total (‘interpersonal 39.04 3.15 38.49 4.33 38.78 3.76 support’) ISEL-12- Belonging 12.04 1.19 11.86 1.64 11.96 1.42 ISEL-12- Tangible Support 14.89 1.58 14.56 2.02 14.73 1.80 ISEL-12- Appraisal 12.11 1.68 12.07 1.62 12.09 1.64 ADAS (relationship satisfaction) 26.11 4.14 24.79 6.05 25.47 5.16 STAXI (Trait Anger) Total 15.87 3.06 17.09 3.92 16.46 3.54 LOT-R (optimism) 17.20 3.22 16.42 3.17 16.82 3.20 CD-RISC (resilience) 78.35 10.18 77.30 9.86 77.84 9.98 TIPI- Extraversion 10.74 2.22 10.00 2.74 10.38 2.50 TIPI- Emotional Stability 11.63 2.20 10.86 2.13 11.26 2.19 TIPI- Conscientiousness 11.78 2.24 11.53 2.38 11.66 2.30 TIPI- Agreeableness 10.76 1.74 10.37 2.05 10.57 1.89 TIPI- Openness to Experience 11.02 1.93 10.86 2.20 10.94 2.05 DASS total score 12.26 11.53 14.05 14.37 13.12 12.94 ASSIST total score 19.89 16.03 18.91 17.58 19.42 16.71 SF-36 total score 83.02 12.47 86.57 7.27 84.74 10.39 Group size, number of 15.33 14.83(12-18) participants- M (range) (13-18) 14.33(12-17) * p< .05; **p<.01
Due to the fact that there was a significant difference between the groups for religious belief, further analyses were conducted for this variable. A series of one-way ANOVAs found that there was no significant difference between those with religious
206 Tracey Varker PhD Thesis 7. Study 3 belief compared to those without religious belief for any of the major variables. Thus the two groups were considered to be equal at intake.
The internal reliability of each of the measures used in Study 3 across each time of collection, was calculated using Cronbach’s Alpha (see Table 20). The majority of the co-efficients are within acceptable parameters, although 3 of the scales were found to have reliabilities far below the accepted level of 0.70 (Tabachnik & Fidell, 2001). However, it should be noted that low reliability does not call results obtained using a scale into question, it simply decreases the chances of finding significant results. It cannot cause false findings of significance, but rather serves as an indication of particularly strong effects, since it was able to overcome the hindrances of an unreliable scale. In this way using a scale with low reliability is analogous to conducting an experiment with a low number of participants (DeCoster, 2005).
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Table 20 Internal Reliability Coefficients for all Measures Used at Time 1, Time 2 and Time 3 (Study 3) Measure Time 1 Time 2 Time 3 α N α N α N ASSIST total score .79 99 n/a n/a .94 89 ADAS .78 99 n/a n/a .95 84 DASS total score .89 99 .89 88 .93 89 Depression .84 99 .78 90 .89 89 Anxiety .74 99 .63 89 .85 89 Stress .80 99 .86 92 .79 89 ISEL total .72 99 n/a n/a .77 89 Tangible .53 99 n/a n/a .48 89 Belonging .72 99 n/a n/a .41 89 Appraisal .37 99 n/a n/a .49 89 Trait Anger .75 99 n/a n/a n/a n/a LOT-R .12 99 n/a n/a n/a n/a CD-RISC .88 99 n/a n/a n/a n/a SF-36 total .03 99 n/a n/a .29 89 TIPI Extraversion .62 99 n/a n/a n/a n/a Emotional Stability .57 99 n/a n/a n/a n/a Conscientiousness .55 99 n/a n/a n/a n/a Agreeableness .08 99 n/a n/a n/a n/a Openness to Experience .24 99 n/a n/a n/a n/a DEVS3 Distress n/a n/a .83 92 n/a n/a Endorsement n/a n/a .87 92 n/a n/a CEQ Credibility n/a n/a .86 92 n/a n/a Expectancy n/a n/a .95 90 n/a n/a MBI-HSS Emotional Exhaustion n/a n/a n/a n/a .90 88
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Depersonalisation n/a n/a n/a n/a .74 88 Personal Accomplishment n/a n/a n/a n/a .84 88 PSS-SR Avoidance n/a n/a n/a n/a .88 71 Arousal n/a n/a n/a n/a .86 71 Re-Experiencing n/a n/a n/a n/a .83 71
7.3.4 Hypotheses Part (a) To conduct an exploration of the primary outcome variables (the three domains of resilience: Health and Well-being; Reactivity to Trauma; and Workplace Functioning) and intake attributes Hypothesis 1:
H0: That the major variables of Study 3 (the three domains of resilience: Health and Well-being; Reactivity to Trauma; and Workplace Functioning) will not be related to: (a) age; (b) gender; (c) relationship status; and (d) station location (metropolitan vs rural) • No previous research has conceptualised resilience in the manner that it is conceptualised for the current study. Therefore, there is no basis for making differential hypotheses in relation to age, gender, relationship status, and station location. To test for relationships between the demographics variables age, gender, relationship status, and station location and the main variables (Health and Well-being, as measured by General Health, Affective Distress, Substance Involvement, and Relationship Satisfaction; Reactivity to Trauma, as measured by Trauma Symptomatology; and Workplace Functioning, as measured by Burnout, and Use of Support Services), a number of statistical techniques were used. Pearson correlation coefficients (two-tailed) were performed to determine whether a relationship existed between the major variables of Study 3 and the age of the recruits. The results of these analyses are presented in Table 21.
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Table 21 Correlations between Major Variables and Age (Study 3; N = 89) Age General Health .30 Affective Distress .13 Substance Involvement -.05 Relationship Satisfaction .01 Trauma Symptomatology -.13 Burnout- Emotional .18 Exhaustion Burnout- Depersonalisation -.25 Burnout- Personal .28 Accomplishment Police Services Access .04 External Services Access .11 *p<.05
Table 21 shows that there were no significant correlations between age and any of the major variables. A number of one-way analyses of variance (ANOVAs) were conducted to investigate the relationships between gender, relationship status, and station location, and the major variables. Effect sizes were calculated using Hedges ĝ and power (P) is reported so as to contribute to the meaningfulness of the findings. As previously discussed, Tables of the means and standard deviations for these variables are shown in Appendix 24. The results of the ANOVAs are shown below in Table 22.
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Table 22 F-Statistics for Gender, Relationship Status, Station Location and the Major Variables Relationship Gender Station Location Status (df)F, p (df)F, p (df)F, p Affective Distress (1,67) .67, p=.41 (1,67) .38, p=.54 (1,67) .01, p=.92 Substance Involvement (1,84) .40, p=.53 (1,84) .12, p=.73 (1,84) .35, p=.56 General Health (1,87) .01, p=.92 (1,87) 2.39, p=.13 (1,87) .44, p=.51 T3 Relationship (1,79) .00, p=.95 (1,79) 2.60, p=.11 (1,79) .02, p=.90 Satisfaction Trauma Symptomatology (1,27) .44, p=.51 (1,27) .02, p=.90 (1,27) .03, p=.87 MBI Emotional (1,86) .99, p=.32 (1,86) 2.62, p=.11 (1,86) 2.82, p=.10 Exhaustion MBI Depersonalisation (1,86) 2.91, p=.09 (1,86) 1.40, p=.24 (1,86) 2.42, p=.12 MBI Personal (1,86) 1.98, p=.16 (1,86) 1.74, p=.19 (1,86) .08, p=.78 Accomplishment Police Services Access (1,87) .08, p=.78 (1,87) 1.01, p=.32 (1,87) .59, p=.45 External Services Access (1,87) .77, p=.38 (1,86) 1.71, p=.19 (1,86) .96, p =.33 *p< 0.05
As can be seen from Table 22, as hypothesised, there were no significant relationships between gender, relationship status, and station location, and any of the major variables.
Hypothesis 2:
H1: (i) That those who score highly on the CD-RISC resilience measure will be more likely to display resilience • Given the fact that the CD-RISC resilience measure is purported to measure resilience, it would be expected that this measure will be related to the major variables of this study A Pearson correlation analysis (two-tailed) was used to assess the degree to which the CD-RISC scores were associated with the major variables. CD-RISC scores were found to correlate moderately-highly with MBI Depersonalisation (r=0.47, p<0.05), and highly with General Health (r=0.52, p<0.01), MBI Emotional Exhaustion
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(r=0.60, p<0.01), and very highly with MBI Personal Accomplishment (r=0.67, p<0.01). Contrary to expectation, significant correlations were not found between CD- RISC scores and any of the other major variables (i.e., affective distress, substance involvement, relationship satisfaction, trauma symptomatology, police services access or external services access).
H1: (ii) That there will be a relationship between personality and resilience, with those high in neuroticism more likely to report low levels of resilience • Numerous studies have found a relationship between neuroticism and trauma symptomatology, and links between neuroticism and coping ability have also been made. Therefore it was predicted that those high in neuroticism would be more likely to report low levels of resilience A Pearson correlation analysis (two-tailed) was used to assess the degree to which intake neuroticism (known as emotional stability for the TIPI) scores were associated with the major variables. Neuroticism was not found to significantly correlate with any of the major variables (p <.05) and, therefore this hypothesis was not supported.
H1: (iii) That those with higher levels of perceived social support will be more likely to display resilience • Social support is known to increase an individual’s ability to cope with adverse situations. Therefore, it is hypothesised that social support will be related to resilience. The degree to which perceived social support at the 6-month follow-up time- point was related to the major variables was assessed using a Pearson correlation analysis (two-tailed). Perceived Social Support was found to correlate moderately with MBI Depersonalisation (r= -0.44, p<0.05), with those with higher perceived social support reporting less depersonalisation. Similarly Perceived Social Support was found to correlate highly with MBI Emotional Exhaustion (r= -0.57, p<0.05), with those with higher perceived social support reporting less emotional exhaustion. Perceived Social Support was not found to significantly correlate with any of the other major variables.
Part (b) To evaluate the efficacy of the resilience training programme Hypothesis 3: Resilience
H0: That there will be no difference in the levels of resilience (i.e., the domains
212 Tracey Varker PhD Thesis 7. Study 3 of Health and Well-being; Reactivity to Trauma; and Workplace Functioning) for those who received the resilience training compared to those who received the control training • Since there has never before been a RCT of resilience training, it is not possible to make a directional hypothesis
Health and Well-being A number of 2 (Condition: Resilience, Control) x 2 (Time: pre-programme, follow-up) repeated measures ANCOVAs were performed to test the hypothesis that there would be no change in the level of Health and Well-being following participation in the resilience training programme. The covariate in these analyses was ‘CD-RISC score’, which was used due to the fact that it was found to be highly correlated with a number of the major dependant variables, and it was not correlated with the other independent variables. Removing the variance attributed to this variable enables a clearer comparison between the two groups. The results of the repeated measures ANCOVAs are presented in Table 23.
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Table 23 2 (Condition) x 2 (Time) Repeated Measures ANCOVA for the Pre-Programme Major Variables (Study 3)
Time Analysis Pre- Follow-up (df) F pHedges’ ĝ programme M (95% CI) M (SD) (SD) Affective 13.12 12.93 T1 (1, 66) 2.11 ns distress (12.94) (15.95) C2 (1, 66) .08 ns T x C (1, 66) .14 ns Substance 19.42 20.31 T (1, 83) .44 ns Involvement (16.71) (1, 83) .26 ns (16.52) C T x C (1, 83) 3.40 p = .07 General Health 84.74 85.85 T (1, 86) 5.36 p < .03 .44 (.15-.74) (10.39) (12.37) C (1, 86) .61 ns T x C (1, 86) 3.29 p = .07 Relationship 25.63 25.90 T (1,78) .48 ns Satisfaction (4.68) (5.12) C (1,78) .63 ns T x C (1,78) .29 ns 1Time; 2Condition
As shown in Table 23, there was a significant increase in General Health across Time (pre-programme and follow-up), irrespective of Condition ( F(1, 86)=5.36, p< .03), and this represented a moderate effect size ( Hedges’ ĝ = .44, 95% CI : .15, .74). Affective Distress and Relationship Satisfaction: Further analyses were conducted to investigate the reliability of change in some of the major variables from pre- programme- to follow-up. In order to determine how many recruits showed reliable change after participating in the resilience training programme, a reliable change (RC) index was calculated for Affective Distress and Relationship Satisfaction. As outlined by Maassen (2000) the difference between observed pre- and post-test scores are an obvious measure of change, however, only if the variables assessed perfectly measure the phenomenon they are supposed to measure is the observed difference really
214 Tracey Varker PhD Thesis 7. Study 3 dependable. Observed differences in pre- to post-test scores may be partially or even totally due to measurement error, practise effects, or sample fluctuations, and it has become increasingly important to assess the extent to which any observed changes in pre- to post-tests scores are statistically reliable (Maassen, 2000) All RC indices in this study were calculated using Devilly’s (2007b) reliable and clinical change generator which is based on the formulae of Jacobson and Truax (1991). The criterion used to interpret reliable change was taken from Jacobson and Truax. These authors suggested that a RC index larger than 1.96 (p<.05) is unlikely to occur without actual change in the individual. Reliability data for Affective Distress used in the RC calculations was obtained from the thesis of McGrail (2006), due to the fact that reliability for the total DASS score has not been previously reported by the authors of this measure. Reliability data for Relationship Satisfaction was obtained from Hunsley and colleagues (2001). Tables 24 and 25 show the number of recruits who showed a reliable change (for both no deterioration and improvement) for Affective Distress and Relationship Satisfaction at the follow-up assessment.
Table 24 Number and Percentage of Recruits who Reliably had No Deterioration/Improvement for Affective Distress (Study 3) Affective Distress Deterioration No Improvement Total (No N(%) Deterioration (RCI=15.73) Deterioration/ N(%) N(%) Improvement) N(%) Resilience 4 (8.7%) 37 (80.4%) 5 (10.9%) 42 (91.3%) (n=46) Control 3 (7.1%) 34 (81%) 5 (11.9%) 39 (92.9%) (n=42) Note: RCI = Reliable Change Index for a change of at least 68.26% *p<.05
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Table 25 Number and Percentage of Recruits who Reliably had No Deterioration/Improvement for Relationship Satisfaction (Study 3) Relationship Satisfaction Deterioration No Improvement Total (No N(%) Deterioration (RCI=2.85) Deterioration/ N(%) N(%) Improvement) N(%) Resilience 15 (34.1%) 16 (36.4%) 13 (29.5%) 29 (65.9%) (n=44) Control 10 (27.0%) 14 (37.8%) 13 (35.2%) 27 (73.0%) (n=37) Note: RCI = Reliable Change Index for a change of at least 68.26%; *p<.05
Chi-square tests revealed that there was no significant difference between the conditions in the numbers of people who had no deterioration/improvement for Affective Distress, compared to those who had deteriorated ( χ2 (2)=.09, ns ; see Table 24). There was also no significant difference between the conditions in the numbers of people who had no deterioration/improvement for Relationship Satisfaction, compared to those who had deteriorated ( χ2 (2)=.53, ns ; see Table 25). Substance Involvement: It was not possible to calculate RC scores for Total Substance Involvement and Alcohol Involvement, due to the fact that the test-retest reliability for the Total Substance Involvement Score has not been reported anywhere, and the means and standard deviations for the test-retest reliability coefficient for Alcohol Involvement has not been reported. However, ASSIST cut-off scores for the Australian population have been published (Newcombe et al., 2005). Therefore a chi- square analysis was performed to determine the number of recruits in both the Resilience and the Control group, who reported Substance Involvement at pre- programme and at follow-up, which was at: (a) below risk level; (b) use/abuse level; or (b) abuse/dependence level. The numbers of recruits with Total Substance Involvement and Alcohol Involvement scores above the risk cut-off scores, for the pre-programme and follow-up assessments, are shown below in Table 26.
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Table 26 Total Substance Involvement and Alcohol Involvement Cut-off Scores, Pre-Programme and at Follow-up (Study 3) Pre-Programme Follow-up Resilience Control Total Sample Resilience Control Total Sample (n=46) (n=43) (n=89) (n=45) (n=41) (n=86) N(%) N(%) N(%) N(%) N(%) N(%) Total Substance Involvement Below risk level 24 (52.2%) 28 (65.1%)* 52 (58.4%) 23 (51.1%) 22 (53.7%) 45 (52.3%) Met criteria for use/abuse (Cut-off score = 15.0) 18 (39.1%) 7 (16.3%)* 25 (28.1%) 16 (35.6%) 13 (31.7%) 29 (33.7%) Met criteria for abuse/dependence (Cut-off score = 4 (8.7%) 8 (18.6%)* 12 (13.5%) 6 (13.3%) 6 (13.0%) 12 (14.0%) 39.50) Alcohol Involvement Below risk level 31 (67.4%) 32 (74.4%) 63 (70.8%) 20 (44.4%) 26 (63.4%) 46 (53.5%) Met criteria for use/abuse (Cut-off score = 4.5) 7 (15.2%) 4 (9.3%) 11 (12.4%) 17 (37.8%) 7 (17.1%) 24 (27.9%) Met criteria for abuse/dependence (Cut-off score = 8 (17.4%) 7 (16.3%) 15 (16.9%) 8 (17.8%) 9 (22.0%) 17 (19.8%) 10.5) *For the difference between the resilience group and the control group p <.05
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As can be seen in Table 26, a significant difference was found between the Resilience and Control conditions for the number of recruits who had (a) below risk level, (b) use/abuse criteria and (c) abuse/dependence criteria Total Substance Involvement scores at the pre-programme assessment ( χ2(2)=6.39, p<. 05, Cramer’s Phi =.27). No significant difference was found between the Resilience and Control conditions for the number of recruits who had below risk level, use/abuse criteria or abuse/dependence criteria Alcohol Involvement scores at the follow-up assessment ( χ2 (2)=4.91, ns ), although the difference was approaching significance ( p=.09). Overall, at the pre-programme assessment, 41.2% of participants (both groups combined) met criteria for substance involvement use/abuse or abuse/dependence, and 29.2% of participants met criteria for alcohol use/abuse or abuse/dependence. At follow-up, 47.7% of all participants met criteria for substance involvement use/abuse or abuse/dependence, and 47.7% of participants met criteria for alcohol use/abuse or abuse/dependence. In order to evaluate whether or not individuals were resilient for Substance Involvement, comparisons were made between the groups for those who had no deterioration or improvement at follow-up, as compared to the pre-programme assessment. No deterioration/improvement was defined as being when an individual’s Total Substance Involvement Score was either in the same range (i.e., below risk level, use/abuse level, or abuse/dependence level) at both the pre-programme assessment and at follow-up, or when an individual’s score improved from being at risk level (use/abuse or abuse/dependence) to being in the below risk level category. Deterioration was defined as being when a person’s score moved from the below risk level category at the pre-programme assessment to being at risk level (use/abuse or abuse/dependence) at follow-up. These results are shown in Table 27.
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Table 27 Number of Participants in the Resilience and the Control Groups, who Demonstrated Resilience for Substance Involvement (Study 3) Substance Involvement (Total Substance Resilience Control Involvement Score) N(%) N(%) (n=45) (n=41) No deterioration/improvement 39 (86.7%) 32 (78.0%) Deterioration 6 (13.3%) 9 (22%) *p <.05
As can be seen from Table 27, there was no significant difference between the groups for the number of people who demonstrated no deterioration/improvement, or who demonstrated deterioration ( χ2 (1)=1.11, ns ). Further analysis for Alcohol Involvement was conducted, in order to assess whether there were any significant differences between the two conditions. A repeated measures ANCOVA was performed with ‘CD-RISC score’ as the covariate. A significant effect was not found for Time ( F(1,84)=.44, ns ) or Condition ( F(1,84)=.07, ns ), and there was no significant interaction between Time and Condition ( F(1,84)=.52, ns ). General Health: As described earlier (and shown in Table 23), a 2(Condition) x 2(Time) repeated measures ANCOVA showed that there was a significant increase in General Health across Time (F(1,86)=5.36, p<. 05; Hedges’ ĝ = .44, 95%CI : .15 - .74). There was no significant effect for Condition ( F(1,86)=.61, ns ), and there was no significant interaction between Time and Condition ( F(1,86)=3.29, ns ), although this interaction was approaching significance ( p=.07). It was not possible to calculate RC scores, due to the fact that the General Health measure was only administered at follow-up. However, participants’ General Health scores were divided into two categories: those with General Health scores between 80-99; and those with scores between 1-79. Scores of between 80-99 were considered to be reflective of good General Health, while scores of 1-79 were considered reflective of poor General Health. The number of participants with scores in these categories, for each of the conditions, is shown below in Table 28. A Pearson chi- square analysis revealed that there were no significant differences between the numbers
219 Tracey Varker PhD Thesis 7. Study 3 of participants in each of the categories, for each of the groups at the pre-programme assessment ( χ2 (1)=.14, ns ), or at follow-up (χ2 (1)=.11, ns ).
Table 28 Number of Participants in the Resilience and the Control Groups, with Good General Health Scores and Poor General Health Scores (Study 3) General Health (SF- Pre-programme Follow-up 36 Total Score) Range Resilience Control Resilience Control N(%) N(%) N(%) N(%) (n=46) (n=43) (n=46) (n=43) Good: 80-99.99 36(78.3%) 35(81.4%) 35(76.1%) 34(79.1%) Poor: 1-79.99 10(21.7%) 8(18.6%) 11(23.9%) 9(20.9%) *p <.05
Further comparisons were made of those who had good General Health (i.e., a General Health score between 80-89 or between 90-99) at both the pre-programme assessment and at follow-up, compared to those who did not. For General Health, no deterioration/improvement was defined as being when an individual’s General Health score was either in the same range (i.e., 1-79.99 or 80-99) at both the pre-programme assessment and at follow-up, or when an individual’s score improved from being in the poor health range (1-79.99) to being in the good health range (80-99.99). Deterioration was defined as being when a person’s score moved from the good health range at the pre-programme assessment to the poor health range at follow-up. These results are shown in Table 29.
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Table 29 Number of Participants in the Resilience and the Control Groups, who Demonstrated Resilience for General Health (Study 3)
General Health (SF-36 Total Score) Resilience Control N(%) N(%) (n=46) (n=43) No deterioration/improvement 43(93.5%) 37(86.0%) Deterioration 3(6.5%) 6(14.0%) *p <.05
As can be seen from Table 29, there was no significant difference between the groups for the number of people who were demonstrated no deterioration/improvement, or who showed deterioration ( χ2 (1)=1.35, ns ).
Reactivity to Trauma In order to compare the two groups on the Reactivity to Trauma domain, two one-way ANOVAs were conducted in order to assess whether the groups had been exposed to trauma in a similar (or dissimilar) way. A one-way ANOVA of the Number of Different Types of Critical Policing Incidents (as measured by the PLES) that the recruits were exposed to, showed that there was no significant difference between the Resilience and the Control condition ( F(1,87)=.11, ns ). Similarly, a one-way ANOVA revealed that there was no significant difference between the two groups for the Number of Policing Incidents that the recruits rated as causing “ distress at the time ” of the event (events for which distress at the time was rated 3 or greater), ( F(1, 87) = 0.00, ns ). Trauma Symptomatology: A one-way ANCOVA was performed to determine whether there were any differences between the Resilience and the Control condition for Trauma Symptomatology. Once again the covariate ‘CD-RISC score’ was used. No significant difference in Trauma Symptomatology was found between the two conditions ( F(1,26)=.68, ns ), with participants in the Resilience group showing very low levels of Trauma Symptomatology ( M=1.65, SD =3.49), as did those in the Control group ( M = 2.32, SD = 7.78). Overall, 86.5% of participants were exposed to a traumatic policing event. Of those that were exposed to a traumatic policing event, half
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(n=35; 45.5%) rated the event as causing significant distress at the time. Only one person was found to meet criteria for PTSD (a member of the control group). It was not possible to calculate RC scores, due to the fact that the Trauma Symptomatology measure was only administered at follow-up (after the recruits had been working 6 months, and had the chance to be exposed to traumatic policing events). Therefore, the number of recruits who fell within certain clinical classifications were calculated instead. Clinical classification scores enable an assessment to be made about whether an individual’s score that they obtain for a given measure is within the normal distribution of scores (as opposed to the abnormal distribution). For the current study, the compromise clinical cut-off C, as proposed by Jacobson and Truax (1991), was used. Clinical cut-off C is the score where the normal and clinical distributions intersect, and this score can be used to determine whether an individual’s score falls within the normal distribution of the clinical population. All clinically RC indices were calculated using Devilly’s (2007b) reliable and clinical change generator which is based on the formulae of Jacobson and Truax (1991). The criterion used to interpret clinically RC was taken from Jacobson and Truax. These authors suggested that a clinically RC index larger than 1.96 (p<.05) is unlikely to occur without actual change in the individual. The reliability data for Trauma Symptomatology, which was used in the RC calculations was obtained from Foa, Cashman, Jaycox and Perry (1997). Table 30 shows the number of recruits with scores below “Cut-off C” for the Reactivity to Trauma domain at the follow-up assessment.
Table 30 Number and Percentage of Recruits who were Below “Cut-off C” in the Domain of Reactivity to Trauma Trauma Symptomatology N(%) (Cut-off C = 23.36) Resilience (n=37) 37 (100%) Control (n=38) 37 (97.68%)
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Table 30 shows all recruits from the Resilience group had Trauma Symptomatology scores which were below “Cut-off C”, meaning that all of this groups scores were towards the normative mean. One person from the Control group had a score which was greater than cut-off C, and which was towards the clinical mean. A Pearson chi-square analysis showed that this difference was non-significant ( χ2 (1)=.99, ns ).
Workplace Functioning Burnout: Three one-way ANCOVAs were performed to determine whether there were any differences between the Resilience and the Control condition for each of the three Burnout subscales (i.e., Emotional Exhaustion, Depersonalisation, Personal Accomplishment). For each of these analyses, ‘CD-RISC score’ was used as a covariate. The difference between the groups for Emotional Exhaustion was found to be approaching significance ( F(1,85)=3.61, p =.06), with those in the Control condition reporting higher levels of Emotional Exhaustion ( M=15.07, SD =9.80), compared to those in the Resilience condition ( M=11.36, SD =9.80). No significant difference was found between the groups for Depersonalisation ( F(1,85)=2.00, ns ), or for Personal Accomplishment ( F(1,85)=1.49, ns ). The means and standard deviations of the three types of burnout, for each of the two conditions are shown below in Table 31. In addition, the means and standard deviations for both a clinical sample and a normal sample are also shown.
Table 31 The Means and Standard Deviations for Each of the Three Types of Burnout, for the Resilience and Control Condition, and for a Clinical Sample and a Normal Sample (Study 3) Resilience Control Clinical Normal (n=46) (n=42) Sample Sample M(SD) M(SD) M(SD) a M(SD) b Emotional Exhaustion 11.37 (9.80) 15.07 (10.75) 22.0 (11.0) 14.24 (7.29) Depersonalisation 6.54 (5.29) 8.48 (6.52) 8.2 (6.1) 5.95 (4.07) Personal 37.57 (7.96) 34.90 (9.10) 40.1 (5.8) 29.47 (5.60) Accomplishment a Maslach, Jackson and Leiter (1996); b Schaufeli and Van Direndock (2000)
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Single sample two-tailed t-tests were used to assess whether the Resilience or the Control condition, differed significantly from the clinical sample (Maslach et al., 1996) or the normal sample (Schaufeli & Van Direndonck, 2000), for each of the three types of Burnout - Emotional Exhaustion, Depersonalisation, and Personal Accomplishment. These results are shown below in Table 32.
Table 32 Single Sample Two-Tailed T-Tests Comparing the Resilience and Control Group to a Clinical Sample and a Normal Sample, for Each of the Three Types of Burnout (Study 3) Normal Sample in Comparison Clinical Sample in Comparison to: to: Resilience Control Resilience Control (df)t, p (df)t, p (df)t, p (df)t, p Emotional (45) -7.36, (41) -4.18, (45) -1.97, (41) .50, p=.62 Exhaustion p=.00** p=.00** p=.05 Depersonalisation (45) -2.12, (41) .27, p=.78 (45) .76, p=.45 (41) 2.51, p=.00** p=.02* Personal (45) -2.16, p=.04* (41) -3.70, (45) 6.90, (41) 3.87, Accomplishment p=.00** p=.00** p=.00** *p< 0.05; ** p<.001
As can be seen from Table 32, single sample two-tailed t-tests revealed that for Emotional Exhaustion, the Resilience group scored significantly lower in comparison to the clinical sample ( t(45)=-7.36, p<.001) and that this represents a very large effect size (Hedges’ ĝ = .99, 95%CI : -1.24, -.74). The Control group also scored significantly lower in comparison to the clinical sample ( t(41)=-4.18, p<.001) and this represents a moderate effect size ( Hedges’ ĝ = .63, 95%CI : -.88, -.39). The Resilience group scored lower for Emotional Exhaustion ( M=11.37, SD =9.80) than the normal sample (M=14.24, SD =7.29), with this difference approaching significance ( t(45)=-1.97, p =.05). For Depersonalisation, the Resilience group was significantly lower in comparison to the clinical sample ( t(45)=-2.12, p<.05), representing a small effect size (Hedges’ ĝ = .28, 95%CI : -.52, -.04). There was also a difference between the
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Depersonalisation scores of the Control group and the normal sample, with the Control group reporting significantly greater Depersonalisation than the normal sample (t(41)=2.51, p<. 05). This difference represented a moderate effect size ( Hedges’ ĝ = .52, 95%CI : -.28, -.77). The Resilience group was found to be significantly lower in Personal Accomplishment compared to the clinical sample ( t(45)=-2.16, p<.05), and this represented a small effect size ( Hedges’ ĝ = .39, 95%CI : -.64, -.15). The Control group was found to be lower than the clinical sample to an even greater degree ( t(41)=-3.70, p< .001), with this difference representing a large effect size ( Hedges’ ĝ = .76, 95%CI : - 1.01, -.51). In comparison to the normal sample, the Resilience group reported significantly greater Personal Accomplishment ( t(45)=6.90, p<.001), and this represented a very large effect size ( Hedges’ ĝ = 1.28, 95%CI : 1.02, 1.54). The Control group also reported significantly greater Personal Accomplishment ( t(41)=3.87, p< .001), which was a large effect size ( Hedges’ ĝ = .81, 95%CI : .56, 1.06). Risk cut-off scores have been published for the MBI, which determine high, moderate and low risk levels for each of the three types of burnout (Maslach et al., 1996). Therefore, a chi-square analysis was performed to determine the number of recruits in both the Resilience group and the Control group, who reported high, moderate and low risk levels for each of the three types of burnout. Table 33 shows the number of recruits in each of the two conditions who had low, moderate and high risk levels for each of the three types of burnout.
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Table 33 Number and Percentage of Recruits who had Low, Moderate and High Risk Levels for each of the Three Types of Burnout (Study 3) Resilience Control (n=46) (n=42) N (%) N (%) Emotional Exhaustion Low Risk (score range 0-16) 35 (76.1%) 29 (69.0%) Moderate Risk (17-26) 7 (15.2%) 8 (19.1%) High Risk (27-54) 4 (8.7%) 5 (11.9%) Depersonalisation Low Risk (0-6) 26 (56.5%) 18 (42.9%) Moderate Risk (7-12) 16 (34.8%) 15 (35.7%) High Risk (13-30) 4 (8.7%) 9 (21.4%) Personal Accomplishment Low Risk (16-48) 44 (95.7%) 40 (95.2%) Moderate Risk (9-15) 2 (4.3%) 2 (4.8%) High Risk (0-8) 0 (0%) 0 (0%) *p<.05
Pearson chi-square analyses revealed that there were no significant differences between the groups, for the low, medium and high risk levels, for Exhaustion for Emotional Exhaustion ( χ2 (2)=.56, ns ), Depersonalisation (χ2 (1)=3.23, ns ), or Personal Accomplishment (χ2 (1)=.01, ns ). Police Services and External Services Access: There was a significant difference between the groups for the degree to which police services were accessed, with those in the Control group ( M=.51, SD =1.03) accessing a significantly larger number of police services compared to those in the Resilience group ( M=.07, SD =.33) ( F(1,87)=7.78, p< .05), with this difference representing a moderate effect size ( Hedges’ ĝ = .58, 95%CI : 0.15, 1.00). Resilience Across the Three Domains of Resilience Analyses were conducted to determine the number of recruits from each of the two conditions, who showed resilience across each of the three domains of resilience
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(i.e., Health and Well-being, Reactivity to Trauma and Workplace Functioning). For the Health and Well-being domain, resilience was defined as having no deterioration/improvement for Affective Distress, Relationship Satisfaction, Substance Involvement and General Health. For the Reactivity to Trauma domain, resilience was defined as having a trauma score which was below Cut-off C, and within the normative sample distribution. For the Workplace Functioning domain, resilience was defined as having burnout scores which were within the low risk range for at least two out of the three domains of burnout, and not having accessed police help services, or external help services. These results are shown below in Table 34.
Table 34 Number of People who Showed Resilience for Each of the Three Domains of Resilience (Study 3) Health and Reactivity to Workplace Resilience Well-being a Trauma b Functioning c across all 3 N(%) N(%) N(%) Domains N(%) Resilience 22 (47.8%) 37 (100%) 35 (76.1%)* 17 (37.0%) Control 24 (55.8%) 37 (97.4%) 23 (53.5%) 15 (34.8%)
*p<.05, a no deterioration/improvement for the four measures of Affective Distress, Relationship Satisfaction, Substance Involvement and General Health, b having a trauma score which was below Cut- off C, and within the normative sample distribution, c having burnout scores which were within the low risk range for at least two out of the three domains of burnout, and not having accessed police help services, or external help services
Chi-square analysis revealed that there was a significant difference between the groups on Workplace Functioning ( χ2 (1)=5.00, p< .05), with significantly more people in the Resilience group showing resilience in this domain (defined as having burnout scores which were within the low risk range for at least two out of the three domains of burnout, and not having accessed police help services, or external help services) as compared to those in the Control group.
Training Elements: The following elements of the training programmes (both resilience and control) were assessed at Follow-up: how helpful people found the
227 Tracey Varker PhD Thesis 7. Study 3 handouts provided; and how helpful people found the handbook which was given to them upon completion of the training programme (and mailed out again 3 months after training completion). Additionally, those in the Resilience group were asked how often they had practiced the breathing and muscle tension exercises that they were taught during the training programme. A one-way ANOVA revealed that there was no significant difference between the Resilience and Control group for how helpful they considered the handouts to be (F(1,87)=.82, ns ), and on average the recruits considered the handouts to be between “a little” and “somewhat” helpful ( M=2.47, SD =.87). Likewise, there was no significant difference between the groups for how helpful they considered the handbook to be (F(1,87)=.17, ns ), with the recruits on average considering the handbook to be “a little” helpful ( M=2.39, SD =.97). Overall, those in the Resilience group reported that they practiced the breathing and muscle tension exercises between “not at all” and “a little” (M=1.46, SD =.69).
Hypothesis 4 : Intervention Satisfaction
H0: That there will be no difference in participation satisfaction for those who took part in the resilience training as compared to those who received the control training • Participants were also asked to rate how important they felt that the content of the training programme was, and it was hypothesised that there would be no difference in how important participants who took part in the resilience training rated the content, as compared to those who received the control training. Participants were asked to rate their satisfaction with the content of the training programme, as well as how important they felt that the content was. Participants were asked to make ratings for each of the 7 training modules that they received (resilience or control). Participants were also given an option of selecting that they could “not remember” any given training module. Table 35 below, shows the number of people, at each time point (i.e., immediately after Programme, Follow-up), in each Condition who could remember: (a) All 7 training modules; (b) only 6 training modules (c) only 5 training modules; (d) only 4 training modules; and (e) only 3, 2 or 1 training modules.
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Table 35 Number and Percentage of Recruits who could Remember Training Modules Number of Modules Resilience Control Remembered N(%) N(%) Immediately after All 7 Training Modules 40(90.9%) 32(76.2%) Programme 6 Training Modules 4(9.1%) 4(9.5%) 5 Training Modules 0 4(9.5%) 4 Training Modules 0 2(4.8%) Follow-up* All 7 Training Modules 41(89.1%) 24(60%) 6 Training Modules 1(2.2%) 5(12.5%) 5 Training Modules 3(6.5%) 3(7.5%) 4 Training Modules 1(2.2%) 1(2.5%) 3, 2 or 1 Training Modules 0 7(17.5%) *p<.05
A Pearson chi-square analysis revealed that Immediately after the Programme, there was no significant difference between the two Conditions for the numbers of people who could remember all 7 training modules, 6 training modules, 5 training modules, and 4 training modules (χ2 (3)=6.85, ns ), although this analysis was approaching significance ( p=.08). A Pearson chi-square analysis was also used to assess whether there were any differences between the groups for the memory for training modules at Follow-up. Due to small group sizes, an analysis was conducted comparing those who could remember: all 7 training modules vs 6 modules vs 5 modules vs 0 - 4 training modules. The Pearson chi-square analysis showed that at Follow-up, there was a significant difference between the groups for memory of training modules (χ2 (3)=13.7, p<. 05), with those in the Resilience group displaying a better memory for the training content than those in the Control group. A number of 2(Condition: Resilience, Control) x 2(Time: Immediately after programme, follow-up) repeated measures ANOVAs were performed to test the hypotheses that: (a) there would be no difference the level of participant satisfaction following participation in the training programme (control or resilience); and (b) that there would be no difference between the groups for the degree of importance that the participants placed upon the training content. Results have been provided for those who
229 Tracey Varker PhD Thesis 7. Study 3 could remember all 7 training modules (resilience condition or control condition) in Table 36.
Table 36 2(Time) x 2(Condition) Repeated Measures ANOVAs for Training Satisfaction and Degree of Importance (Study 3) Time Analysis Immediately Follow-up (df) F p Hedges’ ĝ after M(SD) (95% CI) Programme M(SD) Satisfaction when 41.77 40.59 T1 (1, 54) 1.61 ns all 7 Training Modules could be Remembered (12.83) (12.83) C2 (1, 54) 1.71 ns T x C (1, 54) 4.85 <.04 -.60 (-.97,-.22) Importance when 43.19 43.53 T1 (1, 57) .34 ns all 7 Training Modules could be Remembered (11.32) (16.79) C2 (1, 57) .52 ns T x C (1, 57) 6.14 <.02 -.87 (-1.25,-.49) Note: 1‘T’ denotes Time; 2‘C’ denotes Condition.
As can be seen from Table 36, a significant interaction was found between Time and Condition for participant satisfaction ( F(1,54)=4.85, p<. 05). Satisfaction of those in the Control group decreased over Time, whilst satisfaction of those in the Resilience group increased over time. This interaction is shown below in Figure 7.3. There was no significant difference across Time for satisfaction, nor was there a significant effect for Condition.
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50
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36 Satisfaction with Training
34
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30 Resilience Control Post-Programme Follow-up
Note: Vertical bars denote 0.95 confidence intervals
Figure 7.3 Interaction between Time and Condition for Participant Satisfaction
A significant interaction was also found between Time and Condition, for the degree of importance the participants place upon the training content ( F(1,57)=6.14, p<. 05; see Figure 7.4 below). The training content importance rating of those in the Resilience group increased over time, whilst the importance rating of those in the Control group decreased over time. There was no significant difference across Time for importance, nor was there a significant effect for Condition (see Figure 7.4).
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55
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40 Importance of Training
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30 Intervention Control Post-Programme Follow-up
Note: Vertical bars denote 0.95 confidence intervals
Figure 7.4 Interaction between Time and Condition for Training Content Importance
Part (c) To conduct a general exploration of the outcome variables Hypothesis 5 : Trauma Symptomatology and Alcohol and Drug Use
H1: That those who score highly on the trauma symptomatology measure will be more likely to use drugs and alcohol Follow-up Substance Involvement was found to correlate moderately with Trauma Symptomatology (r=0.25, p<0.05). Those with higher Substance Involvement scores were more likely to have high Trauma Symptomatology scores. Pre-programme Substance Involvement was not found to correlate with Trauma Symptomatology (r=0.09, ns ).
Hypothesis 6: Credibility/Expectancy and Resilience
H1: That those who give the resilience training greater credibility/expectancy ratings will demonstrate greater resilience. Two one-way ANOVAs (two-tailed) were conducted to determine whether there were any differences between the two groups for credibility or expectancy. For
232 Tracey Varker PhD Thesis 7. Study 3 credibility, no significant difference was found between the Resilience group ( M=.65, SD =2.51) and the Control group ( M=.21, SD =2.60) ( F(1,86)=.64, ns ). Similarly, for expectancy, no significant difference was found between the Resilience group ( M=.33, SD =2.46) and the Control group ( M=.43, SD =2.83) ( F(1,87)=.04, ns ). A Pearson correlation analysis (two-tailed) was used to assess the degree to which credibility and expectancy were related to: Affective Distress, Relationship Satisfaction, Substance Involvement, General Health, Trauma Symptomatology, and the three types of Burnout (Emotional Exhaustion, Depersonalisation, Personal Accomplishment. Credibility was found to correlate moderately with Relationship Satisfaction (r= -0.29, p<0.05), with those who rated the intervention as more credible Immediately after the Programme reporting less Relationship Satisfaction at Follow-up. Credibility and expectancy were not found to significantly correlate with any of the other major variables.
Hypothesis 7 : Attitudes Towards Victims of Crime
H1: That there will be a difference in attitudes towards victims of crime between those who received the Victims of Crime training module (control group) and those who did not (resilience group) • Due to the fact that those in the Control group received specific educational training related to Victims of Crime, it was hypothesised that there would be a difference between the groups for attitudes towards Victims of Crime. In order to assess participants’ attitudes towards Victims of Crime, a series of one-way ANOVAs were conducted, for each of the seven Victims of Crime questions. The results of these tests are shown below in Table 37.
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Table 37 One-way ANOVAs for Attitudes Towards Victims of Crime Condition Analysis Resilience Control (df) F p Hedges’ ĝ (n=46) (n=42) (95% CI) M(SD) M(SD) (1) Victims of crime are usually implicated in their own victimhood to 1.83 (1.06) 2.24 (1.01) (1, 86) 3.48 ns some extent (2) I am aware of the practical needs of victims of crime 3.47 (.84) 3.36 (1.06) (1, 86) .29 ns (3) I am aware of the emotional needs of victims of crime 3.37 (.85) 3.48 (1.02) (1, 86) .29 ns (4) I am aware of the referral procedures and options for different types of 3.28 (.89) 3.00 (1.31) (1, 86) 1.43 ns victims of crime (5) I refer victims of crime to other professionals 3.02 (1.18) 2.60 (1.25) (1, 86) 2.70 ns (6) I try to provide support to victims of crime at a personal level 2.78 (1.41) 2.40 (1.36) (1, 86) 1.62 ns (7) I try to provide support to victims of crime at a professional level 3.67 (1.01) 3.60 (1.04) (1, 86) .13 ns Note: Values are the mean of reported scores on a 6-point scale (0= not at all , 5 = very great degree )
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As can be seen from Table 37, Hypothesis 7 was not supported as there were no significant differences between the groups for any of the seven victims of crimes questions. For Question (1), there was a trend for a paradoxical effect, with those in the Control group believing that victims are implicated in their own victimhood to a greater extent than those in the Resilience group, but this difference was not significant ( p=.07).
Hypothesis 8: Attitudes Towards Sexual Offenders
H1: That there will be a difference in attitudes towards sexual offenders between those who received the Sexual Offenders training module (control group) and those who did not (resilience group) • Due to the fact that those in the Control group received specific educational training related to Sexual Offenders, it was hypothesised that there would be a difference between the groups for attitudes towards Victims of Crime. Of the total sample, 44.3% reported that they had had interaction with sexual offenders while working as a police officer (47.8% of those in the resilience group, and 49% of those in the control group). Overall, 35.2% of the sample reported that they had had interaction with the Sexual Offence and Child Abuse Unit (41.9% of those in the resilience group, and 57.9% of those in the control group). In order to assess participants’ attitudes towards Sexual Offenders, a series of one-way ANOVAs were conducted, for each of the three Sexual Offenders questions. The results of these tests are shown below in Table 38.
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Table 38 One-way ANOVAs for Attitudes Towards Sexual Offenders Condition Analysis Resilience Control (df) F p Hedges’ (n=46) (n=42) ĝ (95% M(SD) M(SD) CI) (1) To what degree do you 1.11 (.88) .95 (.88) (1, 86) .72 ns believe child sexual offenders (adults who offend sexually against children) can be rehabilitated? (2) To what degree do you 1.57 (1.00) 1.21 (.90) (1, 86) 2.97 ns believe adult sexual offenders who offend against other adults can be rehabilitated? (3) To what degree do you 1.89 (1.16) 1.64 (1.06) (1, 86) 1.23 ns believe adolescent sexual offenders who offend against other children can be rehabilitated?
Hypothesis Eight was not supported as there were no significant differences between the groups for any of the sexual offenders questions (see Table 38). Antithetically, for Question (2), there was a trend for those in the Resilience group to believe that adult sexual offenders who offend against other adults can be rehabilitated to a greater degree than those in the Control group, but this difference was not significant ( p=.09).
7.4 Study 3: Discussion This study was the first ever RCT of resilience training for emergency services personnel. The goal was to assess the impact of this training in relation to the Health and Well-being; Reactivity to Trauma and Workplace Functioning domains of resilience, in the short-term. It was found that overall there was no significant difference between the two groups for resilience across all three domains. A significant difference
236 Tracey Varker PhD Thesis 7. Study 3 was found, however, between the groups for Workplace Functioning, with those who received resilience training more likely to show no deterioration or improvement in this domain at the 6-month follow-up as compared to those in the control group. Immediately following the training there were no significant differences between the groups for participant satisfaction. Over time however, the satisfaction of those in the resilience group increased while satisfaction of those in the control group decreased. This may be due to the fact that the efficacy of the resilience training was most salient to participants once they had a chance to consider the training in light of their working experiences. For the Reactivity to Trauma domain all recruits except one showed resilience, indicating that resilience in this domain is the norm. No significant differences were found between the groups for drug and alcohol usage at follow-up. Resilience training was not found to have any beneficial effects and it may be possible that further effects of this resilience training will be most evident at a time point further down the line. Although, it should be noted that for significant results to be evident after such a short follow-up is quite remarkable, given that others in the field have noted that short follow-ups can sometimes make it difficult to detect effects of any kind (e.g., Guthrie & Bryant, 2005). Breaking these global results down further, no relationship was found between age and any of the three domains of resilience. Similarly, no relationship was found between gender and the primary outcome variables. This finding is in line with studies by both Carlier and colleagues (1997), and Hodgins and colleagues (2001), which found no relationship between gender and post-traumatic stress symptoms for police officers. Relationship status was not found to be related to the three domains of resilience, nor was station location (i.e. rural vs metropolitan). The CD-RISC is a resilience measure which has previously been found to be related to trauma symptomatology. An examination of survivors of violent trauma found that those who scored more highly on the CD-RISC had less post-traumatic symptomatology and better general health than those with low scores (Connor et al., 2003). This finding was partially replicated for the current study. Resilience as measured by the CD-RISC was found to be highly correlated with general health, with higher resilience scores on the CD-RISC correlated to higher general health scores. However, CD-RISC score was not found to be related to be related to post-traumatic symptomatology.
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CD-RISC scores were found to correlate with all three types of burnout (depersonalisation, emotional exhaustion, and personal accomplishment), with high scores on the CD-RISC found to be related to high levels of personal accomplishment, low levels of emotional exhaustion, and low levels of depersonalisation. These results suggest that the CD-RISC may in fact, to some degree be measuring burnout. Currently, no study has been published which has examined the relationship between the CD-RISC and the MBI, and whether the CD-RISC has acceptable content validity. Future research should be directed in this area to ensure that the CD-RISC is in fact evaluating the domains that are claimed to be measured. Contrary to expectation, significant correlations were not found between CD-RISC scores and any of the other major variables (i.e., affective distress, substance involvement, relationship satisfaction, trauma symptomatology, police services access or external services access). Neuroticism was not found to be associated with any of the major variables, and more specifically, no relationship was found between neuroticism and post-traumatic distress. This finding is in contrast to the large number of studies which have found a link between these two factors (e.g., Breslau et al., 1991; Charlton & Thompson, 1996; Davidson et al., 1987). The finding for the current study may be explained by the fact that the vast majority of participants reported extremely low levels of PTSD symptomatology, and many participants reported no trauma symptoms at all. It is most likely that the link between neuroticism and trauma symptomatology is only evident when trauma symptoms are at a detectable level. Perceived social support was found to correlate with two types of burnout- depersonalisation and emotional exhaustion- with those who reported higher levels of social support reporting lower levels of depersonalisation and emotional exhaustion. This finding is consistent with a number of other studies which have found perceived social support to be negatively related to burnout (e.g., Brown, Prashantham, & Abbott, 2003; Greenglass, Fiksenbaum, & Burke, 1994; Koniarek & Dudek, 1996). Perceived social support was not found to correlate with any of the other major variables, including trauma symptomatology. This finding is contradictory to the emergency services personnel trauma literature which has found a robust relationship between poor, or few social supports and trauma symptoms (Carlier et al., 1997; Regehr et al., 2000; Stephens, 1996).
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The domain of Health and Well-being was assessed by the four factors of affective distress, substance involvement, relationship satisfaction and general health. Overall, there was no significant difference between the resilience and control groups for resilience for the Health and Well-being domain. Approximately half of the recruits demonstrated resilience for this domain (47.8% for the resilience group, 55.8% for the control group). Each of the four factors that comprised Health and Well-being are discussed in greater detail below. No significant difference was found between the groups for affective distress. The majority of recruits in both the resilience and control groups exhibited either no change, or improvement in their levels of affective distress at follow-up, as compared to the pre-programme assessment. Levels of affective distress were low at the pre- programme assessment, and remained low at follow-up. Likewise, no significant difference was found between the groups for relationship satisfaction. Participants reported high relationship satisfaction at the pre- programme assessment, and relationship satisfaction remained high across the two groups at the follow-up assessment. In terms of substance involvement, no significant difference was found between the resilience and the control group at follow-up. However, it should be noted that at the pre-programme assessment there was a significant difference between the resilience and the control group, with a higher percentage of the resilience group members meeting criteria for total substance involvement use/abuse as compared to the control group. At follow-up, the percentage of people in the resilience group who met criteria for total substance involvement use/abuse was reduced, whilst the percentage of people in the control group who met criteria increased from the percentage of people who met criteria at the pre-programme assessment. This resulted in approximately equal numbers of people in each group at follow-up, for people who met criteria for total substance involvement use/abuse. No significant differences were found between the resilience and the control groups for levels of alcohol involvement. There was however, a trend which was approaching significance, with a higher percentage of people in the resilience group meeting criteria for alcohol use/abuse as compared to the control group. At follow-up there were a higher percentage of people in the resilience training group who demonstrated no change/improvement in their substance involvement in comparison to the control group but this difference was not significant.
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At follow-up, 47.7% of all participants reported total substance involvement scores which were at risk level (for either substance use/abuse or abuse/dependence), and 47.7% of participants met criteria reported alcohol involvement scores which were at risk level (for either alcohol use/abuse or abuse/dependence). These findings support previous research which has shown that there is a strong normalisation of alcohol consumption within the police service, and that police officers are more likely to drink alcohol at risk levels than members of the general public (e.g., Davey et al., 2001; McNeill & Wilson, 1993). The rates of alcohol consumption for the current study are comparable to a study of New South Wales police officers, which found 48% of policemen and 40% of policewomen consumed alcohol excessively (Richmond et al., 1998). The figures reported in the current study are considerably higher than those for the general Australian population at, with a 2007 National Drug Strategy survey of households finding that approximately 10.3% of the population consume alcohol in a way that is considered risky in the long term (Australian Institute of Health and Welfare, 2008). Research of Queensland police by Rallings (2000) found that hazardous drinking rates increased from 13% to 22% after commencement of police work. In a later replication study with Queensland new recruits Rallings, Martin and Davey (2005) found a significant increase in the quantity and frequency of alcohol consumption from the time when officers undertook initial training until they had completed 12 months of operational duties. The percentage of officers who drank more frequently than once a month increased from 47% to 60%, and the percentage of officers who reported consuming 6 or more drinks once a month increased from 25% to 32%. These findings were replicated in the current study, with the percentage of recruits who drank alcohol at a risky level increasing from 29.2% of the pre-programme assessment, to 47.7% at the 6-month follow-up. These findings suggest that working as a police officer has a direct impact upon an individual’s substance involvement and alcohol consumption. General health was found to increase significantly over time, irrespective of condition, with this representing a moderate effect size. There was a trend for the general health of those in the resilience group to be lower at the pre-programme assessment than the general health of those in the control group. At the follow-up assessment the general health of the resilience group increased, and the general health of the control group decrease, to a point where both groups had approximately equal levels
240 Tracey Varker PhD Thesis 7. Study 3 of general health at the follow-up assessment. This interaction was not significant however, and nor was the difference between the two groups at the pre-programme assessment. As discussed previously, both the control group and the resilience groups reported very low levels of affective distress (as measured by indices of stress, anxiety and depression) at both the pre-programme assessment and at follow-up. Given that there are strong links between stress, and anxiety and depression (affective distress), and physical ill health (Martin et al., 1995; Rice, 1999) it is logical that those reporting low levels of affective distress would also report good levels of general health. The Reactivity to Trauma domain was only assessed at the follow-up time-point, due to the fact that it could only be assessed once the recruits had had the opportunity to be exposed to potentially traumatic policing events. Preliminary analyses showed that there were no significant differences between the groups for the number of different types of policing critical incidents that they were exposed to, nor was there a significant difference for the number of policing incidents which were rated as causing significant ‘distress at the time’, indicating that both groups were exposed to policing trauma in a similar way. Analyses revealed that there were no significant differences between the groups for the level of trauma symptomatology which was reported, and that both groups reported extremely low levels of trauma symptomatology with many recruits reporting no trauma symptoms at all. Clinical classification scores were calculated in order to assess the number of people above the clinical cut-off for trauma symptomatology, and the number of people below the cut-off. It was found that all recruits in the sample, except one (a person from the control group), obtained trauma symptomatology scores below the clinical cut-off. As such, all participants except one, demonstrated resilience for the Reactivity to Trauma domain. This finding adds support to recent research which suggests that resilience, when considered in terms of a lack of trauma symptoms following exposure to a traumatic event, may be the norm rather than the exception. For example, in a study of September 11 survivors by Bonanno and colleagues (2006), resilience was considered to be having 0 or 1 PTSD symptom following exposure to the events of September 11. Using this definition, 65.1% of participants (where n=2,752) were found to be resilient. In the current study, not all participants were exposed to a traumatic policing event, although the majority (86.5%) were. Of those that were exposed to a traumatic event, approximately half (45.5%) rated the event as causing significant
241 Tracey Varker PhD Thesis 7. Study 3 distress at the time. Yet of these people, only one person reported trauma symptoms at a level to meet criteria for PTSD. This finding supports the notion of resilience in terms of trauma symptoms being “ordinary magic” (Masten, 2001) and replicates findings by those such as Bonanno and colleagues (2007), who have found that the majority of people who are exposed to a traumatic incident do not go on to report trauma symptomatology. The domain of Workplace Functioning was measured in terms of burnout (i.e., emotional exhaustion, depersonalisation and personal accomplishment), and access to police and external help services. Burnout and access to services were only measured at follow-up, due to the fact that these factors were only relevant and meaningful after the recruits had been working as police officers for six months. Recruits were considered resilient in the domain of Workplace Functioning if they reported low-risk levels for at least two out of the three domains of burnout, and if they had not accessed police or external help services in the previous six months. A significant difference was found between the two groups for the domain of Workplace Functioning, with a significantly greater number of people in the resilience training group demonstrating resilience as compared to the control group. For burnout, a trend was found for the domain of emotional exhaustion, with those in the control group reporting higher levels of emotional exhaustion than the resilience group, however this difference was not significant ( p=.06). When the resilience and the control groups were compared to both a clinical and a normative sample, both the resilience and the control groups were found to have significantly lower levels of emotional exhaustion in comparison to the normative sample, with the resilience group having lower levels to a greater degree than the control group. For depersonalisation the resilience group scored significantly lower than the clinical sample, whilst there was no significant difference from the clinical sample for the control group. The control group was found to report significantly greater depersonalisation in comparison to the normative sample, while no significant difference was found between the resilience group and the normative sample for depersonalisation. These findings indicate that those in the resilience group demonstrated less emotional exhaustion than those in the control group. Both the resilience and control groups were found to be significantly lower in personal accomplishment in comparison to the clinical sample, with the control group
242 Tracey Varker PhD Thesis 7. Study 3 reporting scores which were lower than the clinical sample to a greater degree than the resilience group. For personal accomplishment, a higher score represents less burnout, and therefore the control group demonstrated a higher level of this type of burnout than the resilience group. Both the resilience and the control groups reported significantly greater personal accomplishment than the normal sample. Comparisons were made between the resilience group and the control group using previously published risk cut- off scores, for each of the three domains of burnout. No significant differences were found between the two groups for any of these domains. The degree to which police services and external services were accessed in the previous six months was assessed. Those in the control group were found to have accessed police services to a significantly greater degree than those in the resilience group. There was no significant difference between the groups for the degree to which external services were accessed. These results suggest that those recruits who were provided with the resilience training may have learnt important skills and strategies which have helped them to deal with workplace stress, which in turn has led to a significantly lower level of emotional exhaustion, and a significantly lower degree of access to police help services. These results may indicate that rather than needing to seek professional advice, the recruits in the resilience group were able to either deal with problems on their own using the coping strategies that they were taught, or they talked to friends, family and colleagues to receive help and advice in dealing with any stressors or problems that they may have faced. The Reactivity to Trauma results indicated that both groups were exposed to traumatic policing incidents to a similar degree, therefore the differences observed for Workplace Function cannot be simply explained by the fact that the resilience group was exposed to fewer stressors. In a study of resilience in physicians, Keeton, Fenner and Hayward (2007) reverse scored the emotional exhaustion domain of burnout, renamed it ‘emotional resilience’ and claimed that high levels of emotional exhaustion were representative of low levels of resilience. Although this approach has not been replicated by other researchers (and is not being advocated here), such an approach does raise the question of whether resilience as conceptualised by some researchers may not in fact be representative of low levels of burnout. In the current study, high correlations were found between the CD-RISC measure of resilience and burnout, adding support to this
243 Tracey Varker PhD Thesis 7. Study 3 argument. When resilience was measured across a number of domains, however, the picture changed, with the majority of recruits failing to display resilience for the domains of Health and Well-being and Workplace Functioning. Only approximately one third of recruits in the resilience group (37%) and one third of those in the control group (34.8%) showed resilience across all three domains of resilience. When factors such as affective distress, substance involvement, relationship satisfaction, general health, burnout and use of help services were taken into account, overall the majority of recruits were shown to have deteriorated in these areas when their responses were compared to the responses given six months earlier before they began working as police officers. This finding is consistent with the theory of Layne and colleagues (2007), who suggest that resilience is a multidimensional process, and that an individual can display resilience in one domain, but can be also be non-resilient in another. There were no significant differences between the groups for how helpful they considered the training handouts to be, for how helpful they considered the handbook to be, and those in the resilience group reported that the breathing and muscle exercises that they were taught were practiced to a very small degree. There was no significant difference between the groups for memory of the training modules immediately after the end of the training programme, although there was a trend for those in the resilience group to have greater memory for the training content. At follow-up there was a significant difference between the groups, with those in the resilience condition reporting greater memory for the training modules content than those in the control condition. These results indicate that the information that was provided to the resilience group was more salient than the information that was give to the control group. An assessment of participant satisfaction with the training content showed that both groups had equal satisfaction levels with the training content immediately after completing the training programme. There was, however, a significant interaction, with the satisfaction level of those in the resilience condition increasing over time, whilst the satisfaction of those in the control group decreased over time. This result indicates that although initially both groups thought that the training information would be useful, once they had been out of the Academy and working for six months, this attitude changed. For those in resilience group, their level of satisfaction with the training content increased at follow-up, suggesting that once they had a chance to consider the
244 Tracey Varker PhD Thesis 7. Study 3 content in relation to their working experience they could see the relevance and importance of the training content, which in turn increased their level of satisfaction. For those in the control condition, level of satisfaction decreased at follow-up, suggesting that when they considered the training that they had received, they did not find the control training to particularly useful or relevant. Similarly, and as would be expected given the findings for satisfaction, a significant interaction was also found for the importance of the training content. Immediately after completion of the training programme, those in both the resilience condition and resilience condition rated the importance of the training content approximately equally. However, at follow-up the resilience group increased their rating of importance of the training, whilst those in the control group decreased their importance rating. This result suggests that once the recruits has been working for six months, those in the resilience group realised the importance of the training that they had received, when it was considered in light of their working experience. For those in the control group, the training they received was not considered to be as important, once they were able to consider it in relation to their policing experience. As predicted, a significant relationship was found between trauma symptomatology and substance involvement (alcohol and drug use) at follow-up, with those with higher substance involvement scores more likely to have higher trauma symptomatology. No relationship was found between pre-programme substance involvement and follow-up trauma symptomatology. These findings add to the body of evidence which suggests that drugs and alcohol are used to self-medicate trauma symptoms (e.g., Davidson et al., 1991; Kessler et al., 1995). No significant differences were found between the two groups for credibility or expectancy. This means that both groups found the training programme that they received (either the resilience training or control training) to be of equal credibility, and that both groups had equal expectancies of training efficacy. Due to the fact that participant’s ratings of credibility/expectancy have been found to play an important role in treatment outcome studies (e.g., Borkovec & Costello, 1993; Borkovec & Mathews, 1988), it was important to establish that no differences existed between the groups for the current study. Credibility ratings which were provided immediately after the programme, were found to significantly correlate with relationship satisfaction, with those who rated the training as more credible immediately after the programme
245 Tracey Varker PhD Thesis 7. Study 3 reporting less relationship satisfaction at the six month follow-up. Credibility and expectancy were not found to correlate with any of the other major variables. Contrary to prediction, there was no significant difference in attitudes towards victims of crime between those who received the Victims of Crime training module (control group) and those who did not (resilience group). There was a paradoxical trend, with those in the control group believing that victims are implicated in their own victimhood to a greater extent than those in the resilience group, but this difference was not significant. A possible explanation for this finding is that those in the control group who received training designed to improve victim empathy may have felt that they had a comprehensive understanding of victims of crime before beginning work as a police officer. As such, they may not have made as much effort to gain an understanding of victims of crime in a real-life setting (i.e. while working as a police officer) as those in the resilience group who did not receive the victims of crime training while they were at the Academy. Significant differences were not found in attitudes towards sexual offenders between those who received the Sexual Offenders training module (control group) and those who did not (resilience group), contrary to prediction. There was a paradoxical trend, with those in the resilience group believing that adult sexual offenders who offend against other adults can be rehabilitated to a greater degree than those in the control group, but this difference was not significant. Both groups were found to have had equal levels of interaction with sexual offenders while working as a police officer, and both groups had approximately equal levels of interaction with the Sexual Offence and Child Abuse Unit.
7.5 Limitations of Study 3 This study contained several limitations which may have affected the results of the evaluation of the resilience training programme. The first limitation was that the follow-up was relatively short in duration (6 months) and may not be an accurate assessment of sustained change. Recently, Layne and colleagues (2007) called for an increase in sophisticated methods for measuring risk and adaptation across multiple domains of functioning, and recommended more longitudinal studies be undertaken (although these authors also noted the formidable logistical challenges associated with such an approach). They suggested that study designs which comprise at least four
246 Tracey Varker PhD Thesis 7. Study 3 waves of data collection over an extended period (often more than 2 years) may be needed to shed light on the mechanisms and processes that underpin positive adaptation. The timeline of a short follow-up was necessary due to the time constraints of this students’ candidature (and due to the fact that funding for this project was delayed by two and a half years). This presents an opportunity for future research to include assessment at a longer time period, such as at the 12 month or even 3 year time-point, to further investigate sustained change. A second limitation of this study was the sample size. Although the sample was relatively large (n=89), a larger sample would be needed to detect very small effects, such as those that may be expected to result from a training programme. If all squads from an entire year at the police Academy were included in a resilience training programme, it could have the effect of changing the culture of an entire generation of police officers, and presents an interesting opportunity for future research. Although it was originally planned that reliable change scores would be calculated for all of the major variables, this was not possible due to the fact that test- retest reliabilities had not been reported for some of the measures, or for some of the measures the means and standard deviations associated with test-retest reliabilities had not been reported. This represented the third limitation of this study. Due to the absence of these statistics, cut-offs had to be used for several analyses instead. This meant that although the numbers of people who had changed categories could be observed and counted, and the number of people who reliably changed could not be accounted for in several instances. Although limited in several ways, the results of Study 3 are valuable and provide the first comprehensive development, implementation and evaluation of a resilience training programme. The limitations presented in this study are common to training programmes and whilst researchers and practitioners need to be aware of them, their impact is not significant enough to discredit the findings of the resilience training programme.
7.6 Areas for Future Research As mentioned in Section 7.4.4, the present study did not comprise the very large sample size which would be needed to detect very small effect sizes for a resilience training programme. Therefore an area for future research is to conduct such a training
247 Tracey Varker PhD Thesis 7. Study 3 programme again, but using a sample of approximately 250 participants. Also mentioned above was the limited follow-up which was used for the current study. Longitudinal research provides us with valuable information, and future researchers could be well-served to replicate the current study, but evaluate participants over a longer time-period, such as 12 months or even 3 years. An important area of research that is beyond the scope of the current study is the consideration of predictors of who will be best served by resilience training. A number of known vulnerabilities to the development of trauma symptomatology were assessed at the pre-programme assessment to ensure that each group was of equal composition at intake. A novel and exciting area for future researchers would be to consider the vulnerabilities in relation to resilience training, and to look at whether certain characteristics make individuals more likely to display enhanced resilience following resilience training. This area of research could have particularly important implications for areas such as the emergency services and the armed forces, where it is important to enhance individuals’ resilience as far as possible.
7.7 Summary of Study 3 Most studies of resilience to traumatic events consider it solely in terms of a single dimension of psychological function (e.g., trauma symptoms, depression or anxiety). Rarely is resilience considered in terms of a number of domains, although this approach has been recommended by those such as Layne and colleagues (2007). In the current study, resilience has been considered in terms of three domains, and as such a much broader range of psychological measures has been utilised. This has enabled resilience to be broken-down and evaluated in terms of specific elements, in a way that has never been undertaken before. This approach has highlighted the fact that, as has previously been suggested (e.g., Masten, 2001), the vast majority of recruits were resilient to exposure to traumatic events. Only one participant from the control group reported trauma symptomatology. A difference was observed, however, between the number people who exhibited resilience for the domain of Workplace Functioning, with those in the resilience group more likely to show resilience for Workplace Functioning. This result suggests that this domain was most significantly impacted upon by the resilience training. Given that psychological injuries (which include occupational stress claims) make up 8.0% of
248 Tracey Varker PhD Thesis 7. Study 3 workers’ compensation claims in Australian Government agencies, but 29.1% of total claim costs (Australian Government Comcare, 2007), and that the average lifetime cost of claims for psychological injuries sustained in 2005-2006 for Australian Government premium paying agencies was $115, 000, compared to $27, 000 for a non-psychological claim (Australian Government Comcare, 2006), interventions which can reduce psychological injuries can have a significant impact on both the community and the economy. It has been noted that intervention programmes which are designed to enhance resilience tend to be based primarily on speculation, “pet” theories, clinical experience and intuition, which carries a number of disadvantages including the development of an intervention programme that lacks adequate scope, effectiveness or efficiency or that contain therapeutically inert or potentially harmful components (Layne et al., 2007). This resilience training programme represents the first time that a resilience training programme designed for emergency services personnel has been based upon solid, empirical evidence, theories and recommendations by those such as: Keyes (1995); Kozak et al., (1988); Foa and Rothbaum, (1998); Rapee, (1985); and the National Health and Medical Research Council (2001). This resilience training programme has been shown to contain no noxious or harmful elements, and the modular design means that it can be used for a wide range of professions in a variety of settings. The resilience training programme is also a manualised intervention, meaning that it can be disseminated with fidelity, it can be evaluated rigorously, and replicated by other independent researchers. The current study found that at the six month follow-up, 47.7% of all participants reported total substance involvement score which were at risk level (for either substance use/abuse or abuse/dependence), and 47.7% of participants met criteria reported alcohol involvement scores which were at risk level (for either alcohol use/abuse or abuse/dependence). In light of such high percentages, policies and procedures must be put in to place to identify and support those with either substance use problems. There must be a clear, comprehensive substance-use policy that is widely known and equitably applied to all (Martin, Davey, & Mann, 1998). Policies need to clearly outline employee and employer responsibilities regarding alcohol and drugs. Procedures for dealing with specific circumstances of misuse are essential first steps in providing support (Mann, 2006). Supervisors would benefit from training in: identifying
249 Tracey Varker PhD Thesis 7. Study 3 employees who may be at risk of substance use; recognising emerging problems; and developing strategies for timely referral to support services (Mann, 2006). In 2007 it was announced that Victorian police officers would be subject to routine testing for alcohol and drugs after critical incidents such as police shootings or high-speed chases that result in injuries, and that the Chief Commissioner would be given the power to order tests to protect the "good order or discipline of the force" (Silvester, 2007). This will open the door for possible targeted or random testing - including whole squads or stations. Given that the stakes are so high in terms of officers’ professional careers and in terms of officers’ health, it is important that these high levels of drug and alcohol consumption be addressed by Victoria Police.
250 Tracey Varker PhD Thesis 8. Conclusion
Chapter Eight: Conclusion
The current series of three studies investigated methods mitigating stress reactions in at-risk populations. The overall aim of Study 1 was to empirically assess the efficacy of group debriefing using a RCT, and to investigate the effect of group processes upon memory for emotionally laden events. This study was conducted due to the fact that there had only ever been one RCT of group debriefing previously published, and the effects of group debriefing upon memory for emotionally laden events had never been examined before. Participants from the general community were randomly allocated to one of three groups: debriefing; debriefing with an experimenter confederate present (a person who supplied 3 pieces of misinformation to the group regarding the stressful event); and a no-treatment control. The results of Study 1 showed that members of the debriefing group where a confederate provided misinformation were more likely to recall this misinformation as fact than members of the other two groups. The debriefing group was also more accurate in their recall of peripheral content than the confederate group. Across all groups, participants were found to be more accurate at central rather than peripheral recall yet more confident for incorrect memories of the video than correct memories. Although the video was rated as being distressing, it was found that there were no significant differences between the three groups on measures of affective distress. Due to this lack of significant findings in relation to affective distress mitigation, the next logical progression was to trial a newly emerging type of early intervention, which could be capable of mitigating stress reactions. For Study 2 of this thesis, a RCT of resilience training was conducted, which was designed to mitigate the stress reactions of members of the general community who were shown the same stressful video that participants in Study 1 were shown. The aim was to assess the effect of this intervention upon eyewitness stress reactions and eyewitness memory for a stressful event. Participants were randomly allocated to either: resilience training; or control training. Members of the control training group were found to be more accurate in their recall of peripheral content than those in the resilience group however there was also a greater decline over time for memory of peripheral content for those in the control group than for those in the resilience group. Although the video was rated as being distressing, it was found that there were no
251 Tracey Varker PhD Thesis 8. Conclusion significant differences between the three groups on measures of affective distress. The results of Study 2 demonstrated that resilience training did not detrimentally affect the participants, nor did it impair their memory of the stressful video. Based upon the results of this study, it was decided that the resilience training should be further developed and trialled on a real-world at-risk population. New recruit police officers were identified as excellent candidates for such a trial, and this task was undertaken and reported in Study 3. In the final study of this thesis, Study 3, a stratified longitudinal trial of a resilience training programme was presented. This study represents the first ever gold- standard RCT of resilience training specifically designed for emergency services personnel. The overall aim of Study 3 was to assess the efficacy of resilience training upon: (a) resilience; (b) stress reactions; and (c) drug and alcohol consumption. This study utilised a longitudinal design, with entire squads of new recruit police officers allocated to either: resilience training; or control training. Based upon a review of the resilience literature, resilience was conceptualised to consist of three domains: Health and Well-being, Reactivity to Trauma, and Workplace Functioning. Overall, there was no significant difference between the groups for resilience across all three domains. There was, however, a significant difference for Workplace Functioning, with those who received the resilience training showing greater resilience for this domain. All recruits except one showed resilience for the Reactivity to Trauma domain, indicating that resilience in this domain is common. No significant differences were found between the groups for drug and alcohol usage. Importantly, resilience training was not found to have any harmful effects, and the fact that significant findings were found after such a short follow-up period is quite remarkable. These findings have important implications for populations who routinely encounter traumatic situations. Rather than waiting until individuals develop stress reactions and then applying treatment protocols, this thesis has begun to explore the area of preventing stress reactions from occurring in the first place. This thesis has made a significant contribution to this area of research, by demonstrating that it is possible to create and implement a resilience training programme with an at-risk population, and to evaluate the efficacy of such a programme. The finding that the resilience training impacted upon the domain of Workplace Functioning, indicates that there is the potential for significant changes to
252 Tracey Varker PhD Thesis 8. Conclusion personal resilience to be made. It is hoped that this thesis will lead the way for other researchers to explore this newly developing area, and to give them a starting point from which they can launch their research endeavours on the topic of resilience training for at-risk populations.
253 Tracey Varker PhD Thesis References
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Appendices: The Prevention of Trauma Reactions
Tracey Varker
Doctor of Philosophy July 2009
Tracey Varker PhD Thesis Appendices
Appendix 1: Study 1- Glossary of Terms
Term Definition Primary Terms Psychological Debriefing (PD) A generic term for a range of brief crisis intervention models, which primarily aim to mitigate trauma related psychopathology, particularly that of PTSD (Devilly, Wright & Gist, 2003; McNally, Bryant & Ehlers, 2003) Central Memory Memory for any facts or elements directly related to the central character or event. Peripheral Memory Any information associated with the event that is not directly related to the central character or event. This information includes background details. Misinformation Effect When eyewitnesses to a situation are presented with misleading information, which causes their memory to be distorted (Loftus, Miller & Burns, 1978) Memory Conformity The phenomenon whereby an individual’s memory of an event can be influenced by discussion of the event with other individuals who have borne witness to the same event (Memon & Wright, 1999) Memory Confidence The level of confidence that an individual has that their memory is correct. Confederate A person who is part of the research team, who pretends to be a participant. This person provides participants with information that is pre-determined, and serves as an experimental manipulation. Affective Distress Comprises the three related negative emotional states of depression, anxiety and stress. It is measured by summing scores from each of the 3 aforementioned scales of the DASS-21 (Lovibond & Lovibond, 1996). Other Terms Interpersonal Support The participant’s perception of the level of interpersonal support they have available to them, including support for material aid, someone to talk to about problems and someone to do things with.
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Appendix 2: Study 1- Participant Information
Project Title: Videos and Stress Principle Researcher: Professor Grant Devilly
Participation is Voluntary You are invited to take part in this research project. Please read this Participant Information carefully. Feel free to ask questions about any information in the document. You can keep this Information Sheet.
Participation in this research project is voluntary. If you do not wish to take part you are not obliged to. If you decide to take part and later change your mind, you are free to withdraw from the project at any stage and have any data obtained from you removed from our records.
Purpose and Background The purpose of this project is to study the effect of different approaches to providing interventions following watching a stressful video. Through this project we hope to learn which techniques are the most preferred and effective in preventing stress and anxiety. We also expect to derive information on how different approaches affect peoples’ memory of the video.
Procedures The study will evaluate three methods of intervention. If you agree to participate in this project you will be asked to complete a series of questionnaires and you will watch a video of a real-life car accident scene being attended by paramedics. The questionnaires include questions about any past experiences that you found distressing, your current mood and your reactions to and memory of the video. The questionnaires and presentation of the video will be administered over 1 session. However, we ask that you return a one month follow-up questionnaire. You will then be compensated for your time and any expenses with a cheque for $25.
Possible Benefits We hope the knowledge gained from this study will assist in the development of preventative strategies for people who will go through distressing experiences.
Possible Risks This research involves showing paramedics attending the scene of a car crash. It is possible that people will be distressed by the video content. We suggest that those who have experienced a car crash recently (or lost friends / family members from a car crash) may be best served by not taking part in this research.
Privacy, Confidentiality and Disclosure of Information Any information obtained in connection with this project will remain confidential, subject to legal requirements. All participants will be identified by a first name and code number, which will be used to identify questionnaires. The code will be one provided by you (one that you will remember but which only you will know). Any results published will contain only anonymous information. We will not be coupling peoples’ 280 Tracey Varker PhD Thesis Appendices
full names or identifiable information with their questionnaire responses at ANY stage of the research. All questionnaires will be kept in a locked cabinet by Prof Devilly. He is a clinical psychologist and bound by the code of ethics by both the Psychologist’s Registration Board of Victoria and the Australian Psychological Society.
Further Information or Any Problems If any of the material in the questionnaires or the video raise any issues of concern for you, you are welcome to discuss them with the researcher. Likewise, if you require further information or have questions about the project feel free to contact us.
If you have any complaints about any aspects of the project, the way it is being conducted or any questions about your rights as a research participant that the principle researcher has been unable to satisfy for you, then you may contact: The Chair, Human Research Ethics Committee, Swinburne University of Technology, PO Box 218, Hawthorn 3122. Phone: (03) 9214 5223
Contact Numbers for Assistance (should you require any): • Professor Grant Devilly : 03 9214 5920 (Psychologist) • Lifeline : 13 11 14 • Australian Psychological Society (for referral) : 1800 333 497
THIS PAGE IS FOR YOU TO KEEP.
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Appendix 3: Study 1- Consent Form
Title: Videos & Stress
I have read, or have had read to me in my first language, and understood the participant information sheet. Any questions I have asked have been answered to my satisfaction.
I agree to participate in this project, realising that I may withdraw at any time.
I agree that research data collected for the study may be published or provided to other researchers on the condition that anonymity is preserved and that I cannot be identified.
Participant’s Mark ……………………………………………………Date……………………...
Researcher’s Name (printed)…………………………………………………………
Signature……………………………………………………Date…………………
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Appendix 4: Study 1- Intake Questionnaire Package
Before Video
Participant first name: ______
ID Number:______(first three letters of mother’s maiden name, the day of your birth date (e.g., 08 or 24) and your first pet’s name (e.g., Spot). 1. Age:______2. Gender: Male Female
3. How distressing do you think it would be to watch emergency workers attending the scene of road traffic accident ? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
4. Have you been involved in any major road vehicle accidents?
Yes No (go to question 5)
a) If so, how many? ______
b) Would you say you found any of these incidents traumatic? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
5. How anxious are you about watching the video we are going to show you? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
6. We are also interested in people’s handedness and, therefore, need to know which you favour.
a) When I write or throw a ball I (please select one):
Always use Usually use Use either Usually use Always use my left hand my left hand my left or right my right hand my right hand hand b) When I kick a ball I (please select one):
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Always use Usually use Use either Usually use Always use my left foot my left foot my left or right my right foot my right foot foot
7. These questions look at your general levels of depression, anxiety and stress. Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week . There are no right or wrong answers. Do not spend too much time on any statement.
0 = Did not apply to me at all 1 = Applied to me to some degree, or some of the time 2 = Applied to me to a considerable degree, or a good part of time 3 = Applied to me very much, or most of the time
a. I found it hard to wind down 0 1 2 3 b. I was aware of dryness of my mouth 0 1 2 3 c. I couldn't seem to experience any positive feeling at all 0 1 2 3 d. I experienced breathing difficulty (eg., excessively 0 1 2 3 rapid breathing, breathlessness in the absence of physical exertion) e. I found it difficult to work up the initiative to do 0 1 2 3 things f. I tended to over-react to situations 0 1 2 3 g. I experienced trembling (eg., in the hands) 0 1 2 3 h. I felt that I was using a lot of nervous energy 0 1 2 3 i. I was worried about situations in which I might panic 0 1 2 3 and make a fool of myself j. I felt that I had nothing to look forward to 0 1 2 3 k. I found myself getting agitated 0 1 2 3 l. I found it difficult to relax 0 1 2 3 m. I felt down-hearted and blue 0 1 2 3 n. I was intolerant of anything that kept me from getting 0 1 2 3 on with what I was doing o. I felt I was close to panic 0 1 2 3 p. I was unable to become enthusiastic about anything 0 1 2 3 q. I felt I wasn't worth much as a person 0 1 2 3 r. I felt that I was rather touchy 0 1 2 3 s. I was aware of the action of my heart in the absence of 0 1 2 3 physical exertion (eg., sense of heart rate increase, heart missing a beat) t. I felt scared without any good reason 0 1 2 3 u. I felt that life was meaningless 0 1 2 3
ISEL-12
8. Instructions: This scale is made up of a list of statements each of which may or may not be true about you. For each statement circle: 4 for definitely true if you are sure it is true about you and 3 for probably true if you think it is true but are not
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absolutely certain. Similarly, you should circle 1 for definitely false if you are sure the statement is false and 2 for probably false if you think it is false but are not absolutely certain.
1 = Definitely False : if you are sure the statement is false. 2 = Probably False : if you think it is false but are not absolutely certain. 3 = Probably True : if you think it is true but are not absolutely certain. 4 = Definitely True : if you are sure it is true about you.
a. If I wanted to go on a trip for a day (for example, to the country or mountains), I would have a hard time finding someone to go with me. 1 2 3 4 definitely false probably false probably true definitely true
b. I feel that there is no one I can share my most private worries and fears with. 1 2 3 4 definitely false probably false probably true definitely true
c. If I were sick, I could easily find someone to help me with my daily chores. 1 2 3 4 definitely false probably false probably true definitely true
d. There is someone I can turn to for advice about handling problems with my family. 1 2 3 4 definitely false probably false probably true definitely true
e. If I decide one afternoon that I would like to go to a movie that evening, I could easily find someone to go with me. 1 2 3 4 definitely false probably false probably true definitely true
f. When I need suggestions on how to deal with a personal problem, I know someone I can turn to. 1 2 3 4 definitely false probably false probably true definitely true
g. I don't often get invited to do things with others. 1 2 3 4 definitely false probably false probably true definitely true
h. If I had to go out of town for a few weeks, it would be difficult to find someone who would look after my house or apartment (the plants, pets, garden, etc.). 1 2 3 4 definitely false probably false probably true definitely true
i. If I wanted to have lunch with someone, I could easily find someone to join me. 1 2 3 4 definitely false probably false probably true definitely true
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j. If I was stranded 10 miles from home, there is someone I could call who could come and get me. 1 2 3 4 definitely false probably false probably true definitely true
k. If a family crisis arose, it would be difficult to find someone who could give me good advice about how to handle it. 1 2 3 4 definitely false probably false probably true definitely true
l. If I needed some help in moving to a new house or apartment, I would have a hard time finding someone to help me. 1 2 3 4 definitely false probably false probably true definitely true
STOP HERE ! 9. a. ______b. ______c. ______d. ______e. ______f. ______g. ______h. ______i. ______j. ______k. ______l. ______m. ______n. ______o. ______p. ______q. ______r. ______s. ______t. ______u. ______v. ______w. ______x. ______
STOP HERE !
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After Video
10. How serious would you rate this accident? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
11. To what extent did you physically distract yourself from the content of the video (eg. physically didn’t look at the video)? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
12. To what extent did you mentally distract yourself from the content of the video (eg., avoided by thinking of something else)? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
13. How distressing did you find the video? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
14. To what degree could you empathise (feel for) with the people in the video:
a). Emergency workers attending the scene? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
b). The accident victims? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
15. Have you ever seen this film or something like it before?
Never seen anything like it Seen something similar to it I have seen this film before
16. To what degree does the sight of blood make you feel faint? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
STOP HERE !
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After Break Memory Of The Video Content
17. What time (exactly) was the car accident: ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
18. Were there any helicopters circling the accident and, if so, how many? Number: ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
19. What colour was the upturned car? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
20. How many injured (not dead) victims were there? _____ Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
21. How many of the injured victims were male and how many were female? a). ______men Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
b). ______women Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
22. How many of the injured victims were light skinned and how many were dark skinned? a). ______light skinned Confidence: 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
b). ______dark skinned
Confidence: 1 2 3 4 5 288 Tracey Varker PhD Thesis Appendices
Not at A little Somewhat Very Extremely all much
23. What colour were the paramedic hard-hats? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
24. How many dead victims were there? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
25. What material did the stretchers appear to be made of? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
26. What colour was the cover which was placed over the first victim to be put on a trolley? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
27. How many police motorcycles were present? _____ Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
28. How many ambulances were present? _____ Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
29. What colour underwear were all the victims wearing (where this could be seen)? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
30. How many fire trucks were present? ______Confidence: 1 2 3 4 5
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Not at all A little Somewhat Very Extremely much
31. One injured victim was crying when the emergency helpers tried to lift her onto a stretcher. When asked “where is that hurting” to which part of her body did she indicate? ______Confidence: 1 2 3 4 5 Not at A little Somewhat Very Extremely all much
32. How many lanes of traffic (not including hard-shoulders) could the road usually carry in one direction? ____ Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
33. What colour trousers was the deceased wearing? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
34. An ununiformed man wearing a baseball cap was initially helping one of the victims. Can you describe the top he was wearing?
a). Type (e.g., T shirt, shirt, jumper, etc): ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
b). Colour & Style: ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
35. What was the colour of the deceased’s hair? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
36. How many men were wearing hard hats which were white in colour? ______Confidence: 1 2 3 4 5
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Not at all A little Somewhat Very Extremely much
37. What colour hair did the woman have who was first to be removed from the scene on a trolley? Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
38. Roughly, how long was the video (in minutes and seconds; e.g. 1 minute and 10 seconds)? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
Reaction To Video
39. How distressing did you find the video? 1 2 3 4 5 Not at A Somewhat Very Extremely all little much
40. How would you rate your satisfaction with the way you have been treated by the researchers following viewing of the video? 1 2 3 4 5 Not at A Somewhat Very Extremely all little much
41. How appropriate do you think it would be to show clips like the one you have just seen, as part of a driving and speeding / drug / drinking awareness campaign on television?
1 2 3 4 5 Not A Somewhat Very Extremely at all little much
Please feel free to add any comments you have regarding this study:
THANK YOU!!
291 Tracey Varker PhD Thesis Appendices
Appendix 5 : Study 1- Follow-up Questionnaire Package
Four weeks ago you took part in a study looking at the effects of stressful video content on how people react and their interpretations of what they saw. We now wish to complete the final part of the research and collect the follow-up data. For peace of mind, we remind you that all information collected is confidential and is kept in an anonymised form (even the researchers do not know the identities of the people completing the questionnaires).
If you would like to receive a summary of the research results (when they’re available) please send an email to [email protected] (this will ensure that your responses on this questionnaire are anonymous).
Participant first name: ______
ID Number:______(First three letters of mother’s maiden name, the day of your birth date (e.g., 08 or 24) and your first pet’s name (e.g., Spot)).
Reactions To The Video
7. Please estimate how anxious you were about watching the video before you saw it? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
8. How distressing did you find the video? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
9. To what degree did you want to talk about what you saw on the video directly after having viewed it (as a group)? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
10. How would you rate your satisfaction with the way you were treated by the researchers following viewing of the video? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
11. How serious would you rate the accident you saw? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
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12. How often during the last month have you talked about the video with other people? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
13. Would you have liked to have discussed the video more with friends / family over the last month? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
14. Would you have liked to have discussed the video with professional helpers (e.g., counsellors) over the last month? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
15. These following questions look at how having watched the video has affected you over the past month. Please answer the following questions according to what has happened during the past month using the 0-3 scale below. Do not spend too much time on any statement. 0 = Not at all or only one time 1 = Once per week or less/a little bit/once in a while 2 = 2 to 4 times per week/somewhat/half the time 3 = 5 or more times per week/very much/almost always
Have you had upsetting thoughts or images about the 0 1 2 3 a. video that came into your head when you didn’t want them to? b. Have you been having bad dreams or nightmares about 0 1 2 3 the video? c. Have you had the experience of reliving the video, acting 0 1 2 3 or feeling as if you were watching it again? d. Have you been very EMOTIONALLY upset when you 0 1 2 3 were reminded of the video (includes becoming scared, angry, sad, guilty, etc.)? e. Have you been experiencing PHYSICAL reactions when 0 1 2 3 you were reminded of the video (eg. break out in a sweat, heart beats fast)? f. Have you been trying not to think about, talk about or 0 1 2 3 have feelings associated with the video? g. Have you been trying to avoid activities, people or places 0 1 2 3 that you associate with the video? h. Are there any important parts about the video that you 0 1 2 3 still cannot remember?
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i. Have you found that you are much less interested or 0 1 2 3 participate much less often in important activities? j. Have you felt distant or cut off from others around? 0 1 2 3
k. Have you felt emotionally numb (eg. feel sad but cant cry, 0 1 2 3 unable to have loving feelings)? l. Have you felt that your future plans or hopes will not 0 1 2 3 come true (eg. will have no career, marriage, children, or long life)? m. Have you been having problems falling or staying asleep? 0 1 2 3
n. Have you been irritable or having fits of anger? 0 1 2 3
o. Have you been having trouble concentrating (eg. drifting 0 1 2 3 in and out of conversations lose track of storey on TV, forgetting what you read, etc.)? p. Have you been overly alert (eg. checking to see who is 0 1 2 3 around you, uncomfortable with your back to a door, etc.)?
q. Have you been jumpy or easily startled (eg. when 0 1 2 3 someone walks up behind you)?
16. Have the above problems interfered with any of the following areas of your life during the past month ? Please rate (circle) for each life area …
Not A little Definitely Markedl Very Life Area applica Not bit / / often y / very severely / ble at all sometime often continuo s usly a. Work na 2 3 4 5 1 b. Household na 2 3 4 5 chores and 1 duties c. Relationships na 1 2 3 4 5 with friends d. Fun and na 1 2 3 4 5 leisure activities e. Schoolwork na 1 2 3 4 5 f. Relationships na 1 2 3 4 5 with family g. Sex life na 1 2 3 4 5 h. General na 1 2 3 4 5 satisfaction with life
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i. Overall level na 1 of functioning 2 3 4 5 in all areas of your life
17. These questions look at your general levels of depression, anxiety and stress. Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week . There are no right or wrong answers. Do not spend too much time on any statement.
0 = Did not apply to me at all 1 = Applied to me to some degree, or some of the time 2 = Applied to me to a considerable degree, or a good part of time 3 = Applied to me very much, or most of the time
a. I found it hard to wind down 0 1 2 3 b. I was aware of dryness of my mouth 0 1 2 3 c. I couldn't seem to experience any positive feeling at all 0 1 2 3 d. I experienced breathing difficulty (eg., excessively rapid 0 1 2 3 breathing, breathlessness in the absence of physical exertion) e. I found it difficult to work up the initiative to do things 0 1 2 3 f. I tended to over-react to situations 0 1 2 3 g. I experienced trembling (eg., in the hands) 0 1 2 3 h. I felt that I was using a lot of nervous energy 0 1 2 3 i. I was worried about situations in which I might panic 0 1 2 3 and make a fool of myself j. I felt that I had nothing to look forward to 0 1 2 3 k. I found myself getting agitated 0 1 2 3 l. I found it difficult to relax 0 1 2 3 m. I felt down-hearted and blue 0 1 2 3 n. I was intolerant of anything that kept me from getting on 0 1 2 3 with what I was doing o. I felt I was close to panic 0 1 2 3 p. I was unable to become enthusiastic about anything 0 1 2 3 q. I felt I wasn't worth much as a person 0 1 2 3 r. I felt that I was rather touchy 0 1 2 3 s. I was aware of the action of my heart in the absence of 0 1 2 3 physical exertion (eg., sense of heart rate increase, heart missing a beat) t. I felt scared without any good reason 0 1 2 3 u. I felt that life was meaningless 0 1 2 3
12. Have you ever seen anyone for emotional problems in your past? 1 2 3 4 5 Not at A little Somewhat (for a Very much (over Extremely (always all (once or short period of an extended have professional twice) time) period of time) support)
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Memory Of The Video Content These questions relate to the video you saw. Please do your best to answer these questions quickly and don’t think too long on any one question (and please don’t ask others for the answers – if you would like to know the correct answers we will give them to you at the end of the research if you send an email to [email protected] ). Each question has a space for an answer followed by a confidence rating you should circle for that particular answer.
13. What time (exactly) was the car accident: ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
14. Were there any helicopters circling the accident and, if so, how many?
Number: ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
15. What colour was the upturned car? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
16. How many injured (not dead) victims were there? _____ Confidence: 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
17. How many of the injured victims were male and how many were female? a). ______men Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
b). ______women Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
18. How many of the injured victims were light skinned and how many were dark skinned? a). ______light skinned Confidence: 1 2 3 4 5
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Not at all A little Somewhat Very Extremely much
b). ______dark skinned Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
19. What colour were the paramedic hard-hats? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
20. How many dead victims were there? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
21. What material did the stretchers appear to be made of? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
22. What colour was the cover which was placed over the first victim to be put on a trolley? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
23. How many police motorcycles were present? _____ Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
24. How many ambulances were present? _____ Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
25. What colour underwear were all the victims wearing (where this could be seen)? ______Confidence: 1 2 3 4 5
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Not at all A little Somewhat Very Extremely much
26. How many fire trucks were present? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
27. One injured victim was crying when the emergency helpers tried to lift her onto a stretcher. When asked “where is that hurting” to which part of her body did she indicate? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
28. How many lanes of traffic (not including hard-shoulders) could the road usually carry in one direction? ____ Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
29. What colour trousers was the deceased wearing? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
30. An ununiformed man wearing a baseball cap was initially helping one of the victims. Can you describe the top he was wearing?
a). Type (e.g., T shirt, shirt, jumper, etc): ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
b). Colour & Style: ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
31. What was the colour of the deceased’s hair? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much 298 Tracey Varker PhD Thesis Appendices
32. How many men were wearing hard hats which were white in colour? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
33. What colour hair did the woman have who was first to be removed from the scene on a trolley? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
34. Roughly, how long was the video (in minutes and seconds; e.g. 1 minute and 10 seconds)? ______Confidence: 1 2 3 4 5 Not at all A little Somewhat Very Extremely much
Overall 35. Do you regret taking part in this research? 1 2 3 4 5 Not at all A little Somewhat Very much Extremely
36. a). Has taking part in this research changed the way you drive automobiles?
1 2 3 4 5 Not at all A little Somewhat Very much Extremely b). If so (i.e. you rated the above as 2 or more) how?
______
37. How appropriate do you think it would be to show clips like the one you saw on television as part of a driving and speeding / drug / drinking awareness campaign?
1 2 3 4 5 Very Inappropriate Neutral / Appropriate Very Inappropriate don’t know Appropriate
Please feel free to add any comments you have regarding this study:
Thank you for taking part in this research.
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Appendix 6: Study 1 Adherence Rating Template
Group: ______
1) the introductory phase (rules, process and goals outlined);
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
2) the “fact” phase (recitation of what participants saw, did, and heard);
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
3) the “thoughts” phase (recounting of participants’ first thoughts as awareness of the event and its magnitude developed);
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
4) the “reaction” phase (emotional reactions to the experience, sometimes labelled the “feelings” phase);
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
5) the “symptoms” phase (global assessment of physical or psychological symptoms based on participant disclosures);
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
6) the “teaching” phase (educating the participants about common, likely, or possible stress responses);
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
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7) the “re-entry” phase (referral information provided).
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
Overall Rating:
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
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Appendix 7: Study 2- Glossary of Terms
Term Definition Primary Terms Resilience Is defined as “the capacity of a given system to implement early, effective adjustment processes to alleviate strain imposed by exposure to stress, thus efficiently restoring homeostatic balance or adaptive functioning within a given psychological domain following a temporary perturbation therein” (Layne et al., 2007, p. 500). Central Memory Memory for any facts or elements directly related to the central character or event. Peripheral Memory Any information associated with the event that is not directly related to the central character or event. This information includes background details. Misinformation Effect When eyewitnesses to a situation are presented with misleading information, which causes their memory to be distorted (Loftus, Miller & Burns, 1978) Memory Conformity The phenomenon whereby an individual’s memory of an event can be influenced by discussion of the event with other individuals who have borne witness to the same event (Memon & Wright, 1999) Memory Confidence The level of confidence that an individual has that their memory is correct. Affective Distress Comprises the three related negative emotional states of depression, anxiety and stress. It is measured by summing scores from each of the 3 aforementioned scales of the DASS-21 (Lovibond & Lovibond, 1996). Other Terms Interpersonal Support The participant’s perception of the level of interpersonal support they have available to them, including support for material aid, someone to talk to about problems and someone to do things with.
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Appendix 8: Study 2- Participant Information
Project Title: Witnessing stressful situations Principle Researchers: Professor Grant Devilly and Tracey Varker
Participation is Voluntary You are invited to take part in this research project. Please read this Participant Information carefully. Feel free to ask questions about any information in the document. You can keep this Information Sheet.
Participation in this research project is voluntary. If you do not wish to take part you are not obliged to. If you decide to take part and later change your mind, you are free to withdraw from the project at any stage and have any data obtained from you removed from our records.
Purpose and Background The purpose of this project is to study the effect of different approaches to providing interventions before watching a stressful video. Through this project we hope to learn which techniques are the most preferred and effective in preventing stress and anxiety. We also expect to derive information on how different approaches effect peoples’ memory of the video.
Procedures The study will evaluate two methods of intervention. If you agree to participate in this project you will be asked to attend two 1 hour sessions, a week apart. In the first one hour session you will be required to complete a short questionnaire, and you may then receive some training. In the second 1 hour session you will watch a video of a real-life car accident scene being attended by paramedics, and then complete some questionnaires. The questionnaires include questions about any past experiences that you found distressing, your current mood and your reactions to the video. You will be sent in a short follow-up questionnaire one month after your participation in the final session which we ask that you complete and mail back to the researchers. You will then be compensated for your time and any expenses with a cheque for $40.
Possible Benefits We hope the knowledge gained from this study will assist in the development of preventative strategies for people who will go through distressing experiences.
Possible Risks This research involves showing paramedics attending the scene of a car crash. It is possible that people will be distressed by the video content. We suggest that those who have experienced a car crash recently (or lost friends / family members from a car crash) may be best served by not taking part in this research.
Privacy, Confidentiality and Disclosure of Information
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Any information obtained in connection with this project will remain confidential, subject to legal requirements. All participants will be identified by a first name and code number, which will be used to identify questionnaires. The code will be one provided by you (one that you will remember but which only you will know). Any results published will contain only anonymous information. We will not be coupling peoples’ full names or identifiable information with their questionnaire responses at ANY stage of the research. All questionnaires will be kept in a locked cabinet by Prof Devilly. He is a clinical psychologist and bound by the code of ethics by both the Psychologist’s Registration Board of Victoria and the Australian Psychological Society.
Further Information or Any Problems If any of the material in the questionnaires or the video raise any issues of concern for you, you are welcome to discuss them with the researcher. Likewise, if you require further information or have questions about the project feel free to contact us.
If you have any complaints about any aspects of the project, the way it is being conducted or any questions about your rights as a research participant that the principle researcher has been unable to satisfy for you, then you may contact: The Chair, Human Research Ethics Committee, Swinburne University of Technology, PO Box 218, Hawthorn 3122. Phone: (03) 9214 5223
Contact Numbers for Assistance (should you require any): • Professor Grant Devilly : 03 9214 5920 (Psychologist) • Lifeline : 13 11 14 • Australian Psychological Society (for referral) : 1800 333 497
THIS SHEET IS FOR YOU TO KEEP
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Appendix 9: Study 2- Consent Form
Title: Witnessing stressful situations
I have read, or have had read to me in my first language, and understood the participant information sheet. Any questions I have asked have been answered to my satisfaction.
I agree to participate in this project, realising that I may withdraw at any time.
I agree that research data collected for the study may be published or provided to other researchers on the condition that anonymity is preserved and that I cannot be identified.
Participant’s Mark ……………………………………………………Date……………………...
Researcher’s Name (printed)…………………………………………………………
Signature……………………………………………………Date………………
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Appendix 10: Study 2- The Ten-Item Personality Inventory Here are a number of personality traits that may or may not apply to you. Please circle a number indicating how much you agree or disagree with each statement. You should rate the extent to which the pair of traits applies to you, even if one characteristic applies more strongly than the other.
Disagree Disagree Disagree Neither Agree Agree Agree Strongly moderately a little agree nor a little moderately strongly disagree
1. Extraverted, enthusiastic. 1 2 3 4 5 6 7
2. Critical, quarrelsome. 1 2 3 4 5 6 7
3. Dependable, self-disciplined. 1 2 3 4 5 6 7
4. Anxious, easily upset. 1 2 3 4 5 6 7
5. Open to new experiences, complex 1 2 3 4 5 6 7
6. Reserved, quiet 1 2 3 4 5 6 7
7. Sympathetic, warm 1 2 3 4 5 6 7
8. Disorganised, careless 1 2 3 4 5 6 7
9. Calm, emotionally stable 1 2 3 4 5 6 7
10. Conventional, uncreative 1 2 3 4 5 6 7
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Appendix 11: Study 2- Resilience Training Guidelines
1. Introduction
I’m going to go through with you some tips and strategies for dealing emotionally with a stressful situation (such as witnessing a car accident), both during the event and after. These aren’t to be used instead of helping they’re just to help you cope emotionally at the time.
2. Education about Physical Responses
When you witness something that is stressful or upsetting, sometimes you might experience a physical reaction. Sometimes you’ll experience the “fight flight” reaction, you will start to breathe more rapidly in order for your body to gain extra oxygen to pump to your muscles, to get you ready to fight or flee. But this increased rate of breathing leads to an increase in the amount of carbon dioxide that you produce. Most people think that the problem when you hyper-ventilate is that your taking in too much oxygen. But in fact, that’s not the problem is that your releasing too much carbon dioxide. This leads to an increase in the acidity of your blood, which in turn leads to an increase in the amount of adrenalin being pumped through your body. This in turn leads to an increase in the amount of stress that your experiencing, and so the cycle continues.
3. Breathing and Relaxation Techniques
Controlling your breathing has been shown to help suppress the anxiety response and reduce the consequences of anxiety.
Breathing I’ll go through a breathing exercise that you can use if you find yourself witnessing or being involved in a stressful situation. This will stop you from gulping air if you are feeling stressed.
“Keep breathing at a regular pace, drawing in air through your nose. After inhaling completely pause for a slow count of two, i.e. … one thousand….two thousand. Then exhale and release the air slowly and evenly through your mouth. Let all of the air inside your lungs out. As you exhale let your whole body go limp, and say a calming word to yourself. The word CALM already has good connotations and so many people find this a useful one. Therefore, in your mind, you should be saying CAAAALLLLMMM as you SLOWLY exhale. Breathe like this for ten counts. Count each one after exhaling. Some people prefer to count backwards from ten to one, becoming increasingly relaxed with each breathe.”
Of course, doesn’t need to be obvious.
Muscle Relaxation Although the vast majority of people don’t like the sight of blood, for some people the sight of blood also makes them feel faint. And for a number of these people, the sight of
307 Tracey Varker PhD Thesis Appendices blood actually will make them faint. Of all the phobias, blood, injection and injury phobias are the only phobias associated with fainting in the feared situation.
The common cause of fainting is called a “ vaso-vagal syncope ”, which basically, means that, for some people, when they see blood, their blood pressure begins to increase rapidly, before then crashing dramatically. This drop in blood pressure causes the person to faint.
Research has found that tensing your muscles is a really good way to prevent yourself from fainting. (Demonstrate.. so what I mean is…tense the muscles for the count of 3, and then relax…) By repeatedly tensing muscles, you cause a temporary increase in blood pressure which prevents you from fainting.
There are seven main groups of muscles that you can tense:
1. Calves 2. Thighs 3. Buttocks 4. Shoulders / upper torso 5. Arms (triceps & biceps) 6. Neck 7. Face (tongue, jaw and brow)
You need to tense the chosen muscle holding it for the count of three, before then relaxing it.
4. Thought Stopping
You need to remember, when you are in a really stressful situation, such as being at the scene of a car accident, most people don’t know what to do. People are always really grateful if someone does know what to do, and steps up and takes charge.
Our thoughts can really direct how we feel.
I’ll give you an example.. your lying in bed late at night and you hear a crash come from the living room. Immediately you think, “there must be a burglar out there”. Your heart starts racing, and you feel fearful, anxious, scared. Now think about this. Your lying in bed late at night. You hear a crash. Immediately you think “that bloody cat”. How do you feel then? Annoyed, irritated, angry..
If we tell ourselves that something is terrible, then it will be terrible. If we tell ourselves that something wasn’t nice, but we coped, then we’ll walk away with a greater sense of self-efficacy.
If you think that something is your fault, then you will feel that it is your fault. By concentrating on what you can do in a stressful situation, rather than focusing on what you can’t do, your level of stress and anxiety will be reduced.
5. Exposure / Desensitisation
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I’m now going to show you some photos.
The reason that I’m showing you these is to try and get you used to seeing these types of things. I want to gradually expose you to seeing the scene of an accident.
[At this point, 24 still images were shown, starting with those that were least confronting and progressing to those that were most confronting]
6. Social Support
It is important to talk to other people about when your experience a stressful or traumatic event. Death and tragedy are unfortunately a part of life. Talking to friends and family can help, and has been shown to be a key factor in coping with traumatic events. It is important to identify people in your own support system who have been helpful in the past, and talk to them about what happened to you.
Of course it is important to recognise that may not be easy for everyone. However, research conducted people exposed to trauma has shown than denying grief and bottling up emotions can significantly interfere with recovery.
7. Drugs and Alcohol
Similarly, turning to alcohol as a way of coping, rather than dealing with the emotions that you are experiencing can often be problematic.
Having a beer with mates is fine. If drinking is no more than a vehicle to get some social support, to spend time with your friends and chat about what’s been happening in your life, then that’s fine. A social drink can be a good opportunity for you to chat about your experiences. But, if meeting up with your friends is just an excuse to have a drink, then this is a problem. You know when drinking has become a problem when: - You can’t stop drinking once you start - You fail to do what you are supposed to do at work or at home because of your drinking - Find other people make comments about your drinking
Turning to drugs or alcohol is not a productive coping mechanism. Although in the short term they may numb the pain, they will not help you in the long term, because you have avoiding dealing with the issues at the root of the problem.
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Appendix 12: Study 2- Resilience Training Handouts
Breathing • Witnessing a stressful event can cause you to experience a Witnessing a stressful physical reaction • Controlling your breathing can event suppress the anxiety response
Key points of breathing Avoiding feeling faint • Some people feel faint at the exercise: sight of blood • Breath at regular pace, through • This is caused by the “vaso- your nose vagal syncope” • Inhale then pause for 2 seconds • Tensing your muscles is a good • Release air very slowly and way of stopping yourself from evenly through your mouth fainting • Relax body as you exhale and • Tense muscles and hold for the think CALM thoughts count of three, repeatedly, to • Breathe like this for 10 counts keep your blood pressure up
Thoughts Social Support • Your thoughts direct how you • It is important to talk to friends feel and family • If you focus on what you can’t • This can be a key factor in do, rather than what you can do, coping with a stressful or you will feel helpless, stressed traumatic event and anxious • Denying grief and bottling up • Focus on what you can do- this emotions can interfere with will reduce your stress and recovery anxiety • Identify people who have been helpful in the past, and talk to
them about what happened
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Drugs and Alcohol Drugs and Alcohol • Turning to alcohol as a way of You know your drinking has become coping, rather than dealing with a problem when: your emotions can be problematic – You can’t stop drinking once you • Drinking can become a habit when start you drink to relieve stress or – You fail to do what you are anxiety, or to go to sleep supposed to do at work or home • It can also become a habit if you because of your drinking drink to avoid thinking about – You can’t remember what unpleasant thoughts happened because of your drinking – You find other people make comments about your drinking
Contacts • If you have been bothered by anything that you have seen here and wish to speak to someone, you can contact: – Prof. Grant Devilly: (03) 9214 5920 – Or for someone independent of this study, contact Swinburne Student Counselling Service on: (03) 9214 8025
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Appendix 13: Study 2- Accident Management Training Guidelines
Introduction Over a lifetime, just about everyone will either witness or be involved in a traffic accident. One in twenty people will be involved in a major accident. Over the next half an hour I’m going to outline some practical ways of how to deal with a traffic accident, both when it is serious and people have been injured, and when it is a minor collision with damage only to the cars involved. The aim of this training is to assist in preparing you for how to deal with a traffic accident.
What do I do if I have a traffic Accident? 1) Stop- If there is a chance that your accident has caused injuries or damage to vehicles or property, then you must stop at the scene. If you are involved in a crash causing death or injury and do not stop and give assistance, you can be fined up to $8000 and/or imprisoned for 2 years. You will also lose your licence for at least 2 years.
2) Secure scene- Ensure the scene is safe by moving your car to a safe place at the side of the road if your car is drivable. If the car is not drivable, then switch off the engine, turn on the hazard warning lights and alert oncoming traffic about the accident.
3) If necessary call emergency services- Call 000 immediately if anyone involved in the accident is injured, the collision has caused a hazardous situation, or someone leaves the scene without exchanging details. It is important to give the emergency services all the information that they require about the location of the accident, number of casualties (if any) and types of injuries etc. If there is a damaged powerline the operator should be told, to ensure that the electricity authority is also contacted. There is also a legal requirement to report to police a traffic accident in which someone is injured (or killed), or where there is damage to property.
4) Exchange information- If no-one has been injured, and there is no damage to property (apart from that to the cars involved), then you should provide your name, address, telephone number, driver’s licence number, vehicle licence number and the vehicle owner’s name to the other parties involved in the crash, or their representative, and to the police of they are in attendance. This is a legal obligation, and failure to comply could result in the criminal charge of leaving the scene of an accident. If the accident is serious, the police will attend and gather the necessary information from all of the drivers involved. In this case you do not need to worry about gathering other drivers’ information, and you simply need to request a copy of the “Traffic Incident Report” compiled by the police officers who attended the accident, at a later date.
5) Record important details- Write down any other details that you think might be important, e.g. the use of a mobile phone, if you think the driver of the other vehicle has been drinking, weather conditions etc.
6) Notify insurance company- You must notify your insurance company immediately of any collision that you are involved in, regardless of whether or not a claim is to be made, or whose fault it was. Give them all the details that you collected at the scene.
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What do I do if there is an injury? If there has been an injury, then depending on the nature of the injury, you may be able to take steps to render assistance. At a major accident, having a person on the scene who knows how to manage the situation can be of crucial importance. In urban areas, emergency services usually arrive quickly, but in remote rural locations an individual may have to cope without assistance for an extended period of time. Keeping a person’s airway open and clear, making sure that they are breathing and stopping and heavy bleeding are three things that you can do that may well save a life.
1) Make the crash scene safe Safety is the first consideration- safety of the casualty (person injured), the person providing assistance, and bystanders. Casualties may be on or off the road or in a vehicle. They can be in danger unless the site is made safe. This involves: • Assessing danger • Taking control of accident site • Protecting casualty, people providing assistance and other personnel (e.g. by warning oncoming traffic)
Assessing the danger At an accident site, the person providing assistance must make an assessment of the possible danger to themselves and to the casualties. Dangers to look for include: • Fire or fumes • Damaged vehicles • Spilt fuel or chemicals • Fallen or damaged overhead powerlines • High-voltage electricity • Distraught or potentially violent people • Unstable structures (e.g. powerlines or buildings)
Other traffic Other traffic is always of primary concern. The accident site has to be protected so that no further accidents occur. To warn other vehicles: 1) Safely park a car at a suitable distance from the accident 2) Put on hazard lights 3) If at night, use headlights to illuminate scene 4) Ask bystanders to warn and control oncoming vehicles
Fire or fumes Fire can start in any badly damaged vehicle, particularly if electrical wiring is damaged or fuel spilt. To prevent fires: 1) Switch off vehicle’s ignition 2) Shut off emergency fuel switch of a diesel vehicle 3) Prevent anyone smoking near accident site Fumes from leaking petrol can cause an explosion. Bystanders should be kept well away and no naked flames or smoking allowed.
Damaged vehicle A damaged vehicle can be dangerous so take precautions including: 313 Tracey Varker PhD Thesis Appendices
1) Put on handbrake 2) Put vehicle in gear (if not already)
Spilt fuel or chemicals Where an accident involves a vehicle carrying hazardous materials, the rule is to stay clear of the accident scene. However, emergency services must be notified and care taken by the person providing assistance to secure the safety of the scene. Without putting yourself in danger, note: • Clouds of vapour • Spilt liquids, bottles, gas cylinders • Unusual odours Vehicles containing hazardous substances will have display notices or signs indicating the contents. When notifying emergency services, give: • Code number (HAZCHEM Emergency Action Code) • Type of sign Avoid contact with these substances and stay upwind to avoid breathing any toxic fumes.
High-voltage electricity, fallen powerlines High voltage electricity can be a serious hazard at an accident site. If a car has hit a light or electricity pole, high-voltage powerlines can be knocked down and may even come into contact with the vehicle. If this has happened: • Remain at least 6 meters from any cable (high voltage electricity can arc up to 6 meters) • Ensure bystanders do not go within 6 meters of the cables • Call emergency services • DO NOT attempt to move cables • DO NOT go near a vehicle or try to remove a person from a vehicle being touched by a high-voltage cable There is considerable risk that a vehicle with a fallen cable touching it could catch fire. If it becomes necessary, due to fire- or other external life-threatening situations- for anyone in the vehicle to get out, they should do so only if they can jump clear without touching the vehicle and the ground at the same time . Otherwise, they will act as an earth for the electricity and may be killed.
In most situations, anyone inside the vehicle should be told to remain there until the danger from the electrical cable has been removed.
Distraught or potentially violent person The distraught or potentially violent person may be experiencing a significant emotional reaction to the accident, or a loved-one may be seriously injured, trapped in the vehicle, or even dead. These people need special consideration at a major accident scene. They have to be cared for, and perhaps prevented from interfering with the management and removal of other casualties. If people at the accident scene or physically uninjured, but very agitated, or preventing those providing assistance from attending to serious injuries, they need to be removed gently but firmly. A suitable bystander can be recruited to escort them, then stay to try and calm and reassure them.
Control of the accident site Control of an accident site aims to ensure: 314 Tracey Varker PhD Thesis Appendices
• Casualties are protected from further injury • Those providing assistance are protected from injury • Easier access for emergency services • More efficient treatment and evacuation to hospital • Easier assessment of priorities for casualty management (triage) If the site is well controlled, more lives can be saved.
Resources available at the site Bystanders can an asset: They can: • Call emergency services • Warn traffic to slow down or stop • Run messages for people giving aid • Care for physically uninjured casualties • Help give CPR • Help with triage • Secure area from onlookers • Clear road to allow access by emergency vehicles • Help life casualties
Other cars can be used to warn oncoming vehicles there is an accident ahead. Cars not involved in the accident or not being used to warn oncoming traffic should be cleared from the site if possible.
An accident scene can quickly fall into confusion if no-one takes times to organise. Time can slip away and lives can be lost.
2) Helping victims after a crash Once the site is safe ask if anyone is trained in first aid. If not, and you’re the first one on the scene follow these steps:
Check if the victim(s) are conscious • Start with the quiet victims o Check whether they are conscious. Talk to the victim, tell them your name and reassure them. If there is no response, squeeze their hand to try to get a response. Check for and control any bleeding • Unconscious victims o When a person is unconscious it is vital to place them in a stable side position to assist with keeping the airway open. This must be done regardless of injury, in order to open and maintain the air way. o If the unconscious victim is inside the vehicle, if possible, gently take them out of the vehicle and place them on the ground away from danger. • Conscious victims o Make them comfortable by talking to them, tell them your name and reassure them. Gather any information that you can about the victims or the crash site, because this will be valuable when help arrives. Keep an eye on them to ensure that they remain still. No victim should be moved unless it is absolutely necessary (for example if the victim is unconscious). However, if you have to move an injured person for safety reasons then make a neck brace with rolled up towels, newspaper, or clothing. This will help prevent spinal damage if the
315 Tracey Varker PhD Thesis Appendices
neck is injured.
Check airway • Clear the airway o Check for loose dentures or other obstructions and remove anything in the mouth. Tilt head back gently, supporting the jaw
Check breathing • You can do this by looking for the rise and fall of the chest, listening for breathing or feeling for the victim’s breath on your cheek. o If the person is unconscious and breathing : Keep a close eye on them to make sure they keep breathing o If the person is unconscious and not breathing : If clearing the airway has not started the victim breathing, you will need to apply mouth to mouth resuscitation
Check circulation (pulse) • Feel for the victim’s pulse by placing two fingers on their neck (below their jawbone) or inside their wrist. If you can’t feel a pulse, continue applying mouth to mouth resuscitation
Stopping heavy bleeding Heavy bleeding of any type can be fatal. Heavy external bleeding is easy to stop. • To stop external bleeding: o Locate where the blood is coming from o Apply firm pressure where the blood is coming from, using whatever clean cloth is available such as an item of clothing to make a pad o If possible, tie the pad firmly in place o If the bleeding part is a limb, raise it into the air. This can slow or stop the bleeding. o Care must always be taken, however, to give first aid in ways that protect you and the victim from disease transmission. Use protective barriers such as latex gloves if available, or if they are not available and you have control of the bleeding, ask the victim to help you by applying direct pressure. Alternatively, place a dressing or clean cloth between your hand and the wound. Wash your hands thoroughly as soon as possible after giving first aid. Avoid touching or being splashed by body fluids where possible.
What is the role of the police? 1) Secure the scene- Upon arriving at the scene, the very first step that a police officer must take is to ensure that the accident scene is safe. There is no point in rushing to help those involved in the accident, if there is a significant risk that the police officer, the accident victims or both may be hit by a vehicle travelling on the road. The scene can be secured in a variety of ways such as parking the police vehicle, with its flashing red and blue lights turned on, at a safe distance in front the accident, to alert approaching traffic; witches hats being placed in front of the accident, in order to redirect traffic around the scene; or another police officer may stand in front on the accident scene and redirect traffic. In addition, if there is leaking fuel at the scene, the fire brigade should also be requested to clean up this potential hazard
316 Tracey Varker PhD Thesis Appendices
2) Check if medical attention required- The accident victims must then each be checked in order to ascertain if medical attention is required. If anyone is found to be injured then an ambulance should be immediately requested by the officer.
3) Obtain a brief synopsis- The officer must then speak to the accident victim(s) in order to determine what took place, and to try and find out the cause of the accident. All drivers involved in the accident (both those at fault and those not at fault) are questioned by the police.
4) Breath Test- It is standard practice for the driver at fault to be breath tested by police, and for the police to make behavioral observations to determine if the driver at fault is under the influence of alcohol or drugs.
5) Fine- If the driver at fault is found to have broken one of the road laws, then the police will issue the driver with a fine. Immediate roadside licence suspension may also apply for certain speeding, drink-driving and other serious offences causing death or grievous bodily harm. In some of these cases, the driver may be arrested. If the driver is found to be under the influence of drugs or alcohol they will be taken to the police station for further testing, which may result in he/she being arrested.
6) Submit a report- Based on the investigation conducted at the scene of the accident, and the information gathered, upon return to the police station the police officer will complete and submit a “Traffic Incident Report”, which will include details such as the driver’s names, driver’s licence numbers, and vehicle licence numbers.
317 Tracey Varker PhD Thesis Appendices
Appendix 14: Study 2- Accident Management Training Handouts
What do I do if I have a traffic
accident? • 1) STOP • 2) SECURE THE SCENE • 3) CALL 000 IF Witnessing or being involved in a NECESSARY traffic accident • 4) EXCHANGE INFORMATION • 5) RECORD DETAILS • 6) NOTIFY INSURANCE COMPANY
What do I do if there is an injury? Assessing the danger Make the crash scene safe Dangers to look for include: – Assess the danger – Other traffic – Take control of the accident site – Fire or fumes – Protect the casualty – Damaged vehicles – Spilt fuel or chemicals – Fallen or damaged overhead powerlines – High-voltage electricity – Distraught or potentially violent people
Other traffic Fire or fumes • Safely park a car at a suitable distance from the accident To prevent fires: • Put on hazard lights – Switch off vehicle’s ignition • If at night, use headlights to – Shut off emergency fuel switch illuminate scene of a diesel vehicle • Ask bystanders to warn and – Prevent anyone smoking near control oncoming vehicles accident site
318 Tracey Varker PhD Thesis Appendices
Damaged vehicle Spilt fuel or chemicals • Put on handbrake • Clouds of vapour • Put vehicle in gear (if not • Spilt liquids, bottles, gas cylinders already) • Unusual odours
High-voltage electricity, fallen Distraught or potentially violent
powerlines persons • Remain at least 6 meters from • If people at the accident scene are any cable physically uninjured, but very • Call emergency services agitated, or preventing those • DO NOT attempt to move cables providing assistance from • DO NOT go near a vehicle or attending to serious injuries, they person in a vehicle that is being need to be removed gently but touched by a high-voltage cable firmly
Control of the accident site Resources available at the site • Bystanders Control of an accident site aims to • Other cars ensure: – Casualties are protected from further injury – Those providing assistance are protected from injury – Easy access for emergency services – Efficient treatment and evacuation to hospital
319 Tracey Varker PhD Thesis Appendices
Helping victims after a crash Helping victims • Check airway Check if the victim(s) are conscious – Clear the airway – Start with the quiet victims • Check if conscious, control any bleeding – Check unconscious victims • Ensure that airway is open – Check conscious victims • Make them as comfortable as possible, talk to them No victim should be moved unless
absolutely necessary
Helping victims Helping victims
Check breathing Check circulation (pulse) – Look for the rise and fall of the – Feel for pulse by placing two chest fingers on the victim’s neck, or – If the person is unconscious and inside their wrist breathing keep a close eye on – If you can’t feel a pulse keep them applying mouth to mouth – If the person is unconscious and not breathing , apply mouth to mouth resuscitation
Helping victims What is the role of the
Stopping heavy bleeding police? – Heavy bleeding of any type can be • Check if medical attention is fatal required, and request ambulance • Locate source of bleeding if needed • Apply firm pressure using • Securing the scene clean cloth if possible – Ensure the accident scene is • If a limb is bleeding, raise it in safe the air – Redirect traffic • Try and protect yourself and – Request the fire brigade if the victim from disease necessary transmission
320 Tracey Varker PhD Thesis Appendices
The role of police The role of the police • Obtain a brief synopsis • Issue fine – Speak to accident victims and – If a driver is found to have witnesses broken a road traffic law (or • Sobriety testing any other law) then the police – Accident drivers may be will issue a fine breath tested, or given drug or • Submit a report alcohol field sobriety tests – Based upon the investigation conducted at the scene of the accident, the police will submit a “Traffic Incident Report”
321 Tracey Varker PhD Thesis Appendices
Appendix 15:Study 3- Glossary of Terms
Term Definition Primary Terms Resilience Is defined as “the capacity of a given system to implement early, effective adjustment processes to alleviate strain imposed by exposure to stress, thus efficiently restoring homeostatic balance or adaptive functioning within a given psychological domain following a temporary perturbation therein” (Layne et al., 2007, p. 500). Affective distress Comprises the three related negative emotional states of depression, anxiety and stress. It is measured by summing scores from each of the 3 aforementioned scales of the DASS-21 (Lovibond & Lovibond, 1996). Substance Involvement This variable represents the total amount of drug and alcohol use that has been reported by the individual, as measured by the ASSIST (WHO ASSIST Working Group, 2002). General Health This variable represents the overall total score that the participant obtains for the SF-36, which is a general measure of physical and mental health (Ware & Sherbourne, 1992). Relationship Satisfaction This variable represents the score achieved for the Abbreviated Dyadic Adjustment Scale, which is a 7-item measure of relationship satisfaction (Sharpley & Rogers, 1984) Trauma Symptomatology A trauma symptomatology variable was derived by summing the items from Part 3 of the PDS (Foa, 1995). In the case of Study 3, these items reflect the degree of trauma symptomatology that the participant is currently experiencing in relation to traumatic policing incidents which occurred in the past 6 months. Police Services Access This variable measures how many police help services the recruit accessed over the past 6 months. There were 4 services included in the questionnaire (i.e. clinical services, peer support, chaplain, employee/welfare support). Therefore the maximum score for this variable is 4.
322 Tracey Varker PhD Thesis Appendices
External Services Access This variable measures how many external help services the recruit accessed over the past 6 months. There were 6 services included in the questionnaire (i.e. Psychologist; Psychiatrist; Social Worker; Priest / Spiritual Advisor; G.P.; and Counsellor / Other). Therefore the maximum score for this variable was 6. Other Terms Interpersonal Support The participant’s perception of the level of interpersonal support they have available to them, including support for material aid, someone to talk to about problems and someone to do things with. History of personal trauma The number of personal traumatic events endorsed as having been experienced by the participant. Participants are provided with a list of traumatic events, and are also able to specify their own traumatic event or state that one has occurred without specifying the details. Number of times that a The number of times that participants have professional was seen for seen a professional (i.e. psychologist, emotional problems psychiatrist, counsellor, GP, priest, other ) for emotional problems Family member who has seen a Whether or not the participant has a family mental health professional member who has seen a mental health professional Emotion focused coping Emotion focused coping was assessed using a single non-standardised item. Participants were asked to rate the statement: “ When I am worried about something I talk to friends ”, using a 7-point scale ranging from 1 ( strongly agree ) to 7 ( strongly disagree ). Problem focused coping Problem focused coping was assessed using a single non-standardised item. Participants were asked to rate the statement: “ When I am worried about something I try to do something to fix the situation”, using a 7- point scale ranging from 1 ( strongly agree ) to 7 ( strongly disagree ).
323 Appendix 16: Resilience Training Manual for New Recruit Police Officers
Resilience Training Manual for
New Recruit Police Officers
Grant Devilly & Tracey Varker Swinburne University of Technology January 2008
Table of Contents
Preface...... 331
Part I...... 332
Training Protocol for Recruits Receiving Resilience Training...... 332
Part II...... 334
Training Protocol for Recruits in Control Group...... 334
PART I ...... 336
Training Protocol for Recruits Receiving Resilience Training...... 336
Intake Assessment...... 336 Overview...... 336 Introduction of the researcher and the project ...... 336 Assessment battery ...... 336
Module 1- Introduction ...... 338 Overview...... 338 Theoretical background ...... 338 Introduction ...... 340 Purpose of training ...... 340 Overview of session...... 340 Warning of graphic nature of some material...... 340 Worksheet...... 341
Module 2- Policing Expectations & Serial Approximation / Desensitisation ...... 342 Overview...... 342 Theoretical background ...... 342 Policing expectations ...... 343 Focusing on the task at hand...... 344 Serial approximation / desensitisation ...... 347 Projected still images...... 347 Videos ...... 347 Audio ...... 347 Tracey Varker PhD Thesis Appendices Module 3- Physical Responses to Trauma: Breathing and Muscle Relaxation Techniques...... 348 Overview...... 348 Theoretical background ...... 348 Psycho-education: physical responses to trauma ...... 349 The Anxiety Cycle...... 351 Controlled breathing exercise...... 351 Relaxation (muscle tension) technique ...... 352 Worksheet...... 353
Module 4- Coping Skills: Thought Challenging, Cognitive Restructuring and Guided Self-Dialogue...... 354 Overview...... 354 Theoretical background ...... 354 Thought-challenging and cognitive re-structuring ...... 354 Guided self-dialogue...... 355 Worksheets ...... 356 Thought challenging and cognitive re-structuring...... 357 Guided self-dialogue...... 360 Is it ok to use black humour?...... 361
Module 5- Social Support...... 362 Overview...... 362 Theoretical background ...... 362 Value and benefits of social support...... 362
Module 6- Drugs and Alcohol ...... 364 Overview...... 364 Theoretical background ...... 364 Drugs and alcohol ...... 365 What the research tells us...... 366 Signs of a problem with drinking ...... 366
Module 7- Help Services Available...... 368 Overview...... 368
326
Tracey Varker PhD Thesis Appendices Role of Clinical Services...... 368 Victoria Police chaplaincy...... 369 Peer support...... 369 Independent help services ...... 370 Drugs and alcohol help...... 370
Module 8- Conclusion ...... 371 Overview...... 371 Re-cap of modules ...... 371 Police Resilience Handbook...... 372
Post Training Brief Assessment...... 373
PART II...... 374
Training Protocol for Recruits in Control Group...... 374
Intake Assessment...... 374 Overview...... 374 Introduction of the researcher and the project ...... 374 Assessment battery ...... 374
Module 1- Introduction ...... 376 Overview...... 376 Theoretical background ...... 376 Purpose of training ...... 376 Overview of session...... 377 Warning of graphic nature of some material...... 377 Worksheet...... 377
Module 2- Critical Incidents ...... 378 Overview...... 378 Introduction ...... 378 Projected still images...... 378 Videos ...... 378 Audio ...... 379
327
Tracey Varker PhD Thesis Appendices Module 3- Preserving Evidence and the Crime Scene...... 380 Overview...... 380 Preserving the evidence...... 380 Preserving the crime scene...... 380
Module 4- The Role of Clinical Services ...... 381 Overview...... 381 Introduction to Clinical Services ...... 381 Types of services offered by Clinical Services ...... 381 Victoria Police chaplaincy...... 382 Peer support...... 382 Types of serious incidents attended by Clinical Services ...... 383
Module 5- Dealing with the Victim’s Family and Friends ...... 384 Overview...... 384 Types of situations in which there may be distraught bystanders...... 384 Strategies for dealing with distraught family and friends...... 385
Module 6- Sexual Offenders...... 387 Overview...... 387 Introduction ...... 387 Dispelling myths about sexual offenders ...... 387
Module 7- Victims of Crime...... 393 Overview...... 393 Introduction ...... 393 Who is a victim of crime? ...... 393 The impact of being a victim of crime ...... 395 The Victims’ Charter Principles...... 397
Module 8- Conclusion ...... 398 Overview...... 398 Re-cap of modules ...... 398
Post Training Brief Assessment...... 400
Informal Group Discussion...... 401
328
Tracey Varker PhD Thesis Appendices
References...... 402
Further Reading...... 410 Theory...... 410 Police and Trauma Studies ...... 410 Police, Drugs and Alcohol Studies...... 411
Appendix I- Intake Assessment Battery...... 412
Appendix II – Resilience for Police Trauma Worksheet...... 413
(Resilience Training Group) ...... 413
Appendix III –Coping Skills Worksheet...... 416
Appendix IV – Thought Challenging Questions ...... 417
Appendix V – Challenging Thoughts: ABCD (Foa, 1996) ...... 418
Appendix VI- Self Talk...... 419
Appendix VII- Drugs and Alcohol Worksheet...... 420
Appendix VIII- How to Recognise Problem Drinking ...... 421
Appendix IX- Resilience for Police Trauma Worksheet ...... 422
(Control Group) ...... 422
Appendix X- Sexual Offenders Worksheet...... 423
Appendix XI- Sexual Offenders Fact Sheet...... 424
Appendix XII- Victims of Crime Worksheet...... 425
Appendix XIII- Victims of Crime Fact Sheet...... 426
Appendix XIV- The Victims’ Charter Principles ...... 428
Appendix XV- Post Training Assessment Battery...... 429
Appendix XIV- Post Training Assessment Battery ...... 430
329
Tracey Varker PhD Thesis Appendices Appendix XI- 6- Month Follow-up Assessment Battery (Intervention Condition) ...... 431
Appendix XII- 6- Month Follow-up Assessment Battery (Control Condition).....432
330
Tracey Varker PhD Thesis Appendices
Preface This training manual outlines a number of key modules that, when combined, form the Police Resilience Training Programme. These Modules are designed to be delivered, and be applicable to “real-world” situations. Within limits, it is possible for the training modules to be delivered to the recruits in any order. It is necessary for both the resilience training group and the control group to receive the Introduction first (at the beginning of the programme), and that the Conclusion be delivered last. However, the order in which the remaining modules are delivered can be varied. Both the resilience training programme and the Control programme are designed to be versatile, adaptive and practical. Both the programmes must be conducted in a group situation, in the form of an interactive lesson and group discussion. In such a situation, where group discussion is an integral component, it is not possible to set strict guidelines upon the structure of the lesson due to the fact that in real-life discussions can often take unexpected directions. It is necessary, however, for the trainer to steer the discussion in directions such that each of the modules are covered within the training session. In order to provide trainers with guidelines on how to do this, recommended open- questions will be included for each of the modules that involve group discussion. These modules are designed to be delivered with the assistance and support of a guest speaker. The guest speaker for the session must be carefully selected. An experienced officer, from a well-respected area of policing should be chosen, and it should be someone who has is willing to discuss their personal experiences in an open and honest manner. The experienced officer must come from an area where death, injury, and gruesome scenes are an integral part of their job. The officer should come from an area such as the Major Collision Unit, or the Homicide Unit, for example. This is essential because the guest speaker will show photos and videos of scenes that he/she has attended, and it is necessary (as will be explained in Module 2- Policing Expectations, and Serial Approximation / Desensitisation) that his/her crime scene photos are confronting and even gruesome.
331
Tracey Varker PhD Thesis Appendices
Part I
Training Protocol for Recruits Receiving Resilience Training Intake Assessment 45 mins • Assessment battery Module 1 - • Theoretical background Introduction 15mins • Introduction • Purpose of training • Overview of session • Warning of graphic nature of some material • Worksheet handed out Module 2 - Policing 2hrs • Theoretical background Expectations, and Serial • Policing expectations Approximation / • Projected still images Desensitisation • Videos • Audio Module 3 - Physical 15mins • Theoretical background Responses to Trauma, • Psycho-education- physical Breathing and responses to trauma Relaxation Techniques • Controlled breathing exercise • Deep muscle relaxation Module 4- Thought 15mins • Theoretical background Challenging, Cognitive • Focusing on the task at hand Re-structuring and • Thought challenging, cognitive Guided Self-dialogue re-structuring • Guided self-dialogue • Is it ok to use black humour? Module 5- Social 15mins • Theoretical background Support • Value and benefits of social support Module 6- Drugs and 30mins • Theoretical background Alcohol • Drugs and alcohol • Signs of problem drinking Module 7- Help Services 15mins • Role of Clinical Services Available • Victoria Police Chaplaincy • Peer support
332
Tracey Varker PhD Thesis Appendices • Independent help services • Drug and alcohol help Module 8- Conclusion 15mins • Re-cap of Modules Post Training 10 mins • Brief assessment 6-month Follow up 45 mins • Assessment battery 12-month Follow up 45 mins • Assessment battery
333
Tracey Varker PhD Thesis Appendices
Part II
Training Protocol for Recruits in Control Group
Intake Assessment 45 mins • Assessment Battery Module 1 - Introduction 15 mins • Theoretical background • Introduction • Purpose of training • Overview of session • Warning of graphic nature of some material • Worksheet handed out Module 2 - Critical 1hr • Guest speakers’ presentation Incidents • Projected still images • Videos • Audio Module 3- Preserving 30min • How to preserve evidence Evidence and the Crime • How to preserve the crime Scene scene Module 4- The role of 15min • Introduction to Clinical Services Clinical Services • Types of services offered by Clinical Services • Types of serious incidents attended by Clinical Services • Contact numbers provided Module 5- Dealing with 45min • Types of situations in which the Victim’s Family and there may be distraught Friends bystanders • Strategies for dealing with distraught family and friends Module 6- Sexual 30mins • Dispelling myths about sexual Offenders offenders Module 7- Victims of 30mins • Who is a victim of crime? Crime • The impact of being a victim of crime • The Victims’ Charter Principles
334
Tracey Varker PhD Thesis Appendices Module 8- Conclusion 15mins • Re-cap of modules • Police Resilience Handbook Post Training 10 mins • Brief assessment 6-month Follow up 45 mins • Assessment battery 12-month Follow up 45 mins • Assessment battery
335
PART I
Training Protocol for Recruits Receiving Resilience Training
Intake Assessment Overview • Introduction of the trainer and the project • Gain written consent • Administer assessment battery (Appendix I)
Introduction of the researcher and the project Briefly outline the course of the research programme. Provide the recruits with the Information Sheet and explain the rights of the participant (e.g. free to withdraw, confidentiality, etc). Take the recruits through the Consent Form gain their written consent before proceeding.
Assessment battery Hand-out the intake assessment battery. An introduction similar to the following is best: “I would like for you now to fill in a questionnaire. There are no right or wrong answers to these questions. Please just fill in the answer that seems to be best for you, and don’t spend too long thinking about any one question. All of your answers to these questions will be kept strictly confidential. In particular, no-one’s individual answers to the questions related to drugs and alcohol will be reported to Victoria Police, only overall group figures will be reported (for example 20% of officers were found to drink alcohol).” The following instruments are recommended for the assessment of individual differences, current functioning, drug & alcohol use and resilience: • Alcohol Substance Involvement Screening Test (ASSIST; WHO ASSIST Working Group, 2002) • ISEL-12 (Cohen, Mermelstein, Kamarck & Hoberman, 1985) • Abbreviated Dyadic Adjustment Scale (ADAS) (Sharpley & Rogers, 1984) • State Trait Anger Expression Inventory (STAXI: Spielberger, 1988)- Anger-Out Subscale Tracey Varker PhD Thesis Appendices • The Life Orientation Test Revised (LOT-R; Scheier, Carver & Bridges, 1994) • The Connor-Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003) • History of Traumatic Events Scale (Devilly & Wright, 2002) • Depression Anxiety Stress Scale (DASS-21) (Lovibond & Lovibond, 1995) • Maslach Burnout Inventory (MBI; Maslach, Jackson & Leiter, 1996) • Ten-Item Personality Inventory (TIPT; Gosling, Rentfrow & Swann, 2003) • The 36-item Short Form Health Survey (SF-36; Ware & Sherbourne, 1992) • Demographics assessment - including gender, marital status, number of children, religion, ethnicity, highest level of education, handedness, footedness etc (see Appendix I).
337
Module 1- Introduction
Overview • Theoretical background • Introduction • Purpose of training • Overview of session • Warning of graphic nature of some material • Handout: “Resilience for Police Trauma” (Resilience training group) worksheet (Appendix II)
Theoretical background The intensity of stress reactions and the ability of police officers to understand their reactions and operate effectively in highly dynamic and ambiguous environments may be influenced by the extent to which they have been prepared for the experience and have realistic expectations about their role and what they will be doing (Paton, 1994). Lack of preparation, suddenness of onset, unrealistic expectations and a tendency to deny or suppress feelings can heighten the subjective experience of loss of control and result in the process of re-establishing control becoming more difficult (Eränen & Liebkind, 1993). A key factor in promoting resilience, that is the ability to impose coherence and meaning on atypical experiences, is training (Driskell & Salas, 1996). The training programme presented in this manual is largely based upon the existing Post Traumatic Stress Disorder (PTSD) literature. Foa and Kozak (1986) suggest that adaptive recovery from trauma depends on two conditions. First, emotional engagement must occur. The fear structure must be activated by fear-relevant information and accessed, so that the cognitive schema can be modified. According to information processing theory, if this activation is sufficiently repetitive and prolonged and conducted in a safe environment, the stimulus-response associations will be weakened and reduce the magnitude and intensity of the fear network. Second, there needs to be an introduction of corrective information that challenges the fear-related schema. This new information facilitates the formation of new cognitive schemas (Foa & Kozak, 1986). The resilience training that will be given to the recruits is based the theory proposed by Foa & Kozak (1986). It is thought that by providing the recruits with fear-relevant information in a repetitive and prolonged manner, and in a safe environment, fears that are associated with events such as seeing a dead body will be Tracey Varker PhD Thesis Appendices weakened and reduced in intensity. Corrective information will be introduced to the recruits that will give them realistic expectations of what to expect on the job, and this information will challenge the fear-related schema. This information will facilitate the formation of new cognitive schemas by the recruits. Training to promote stress resilience should address the need to enhance the capability of workers to render atypical operational events coherent and to understand and manage the psychological impact of emotionally distressing events on themselves and others (Pollock et al 2003). Being involved in a previous traumatic incident does not necessarily prepare a person on how to deal with a similar incident in the future, and if the initial incident is not dealt with and put into perspective, a person may in fact be more susceptible to future traumatic incidents (Williams, 1987). The evidence indicates that there is an association between previous exposure to traumatic experiences and post-traumatic symptomatology resulting from subsequent trauma (Breslau, et al., 1999; Brewin, Andrews, Valentine, 2000; Ozer, Best, Lipsey & Weiss, 2003). This suggests that experience alone, left to chance, is insufficient in preparing officers to deal with the future effects of a critical incident, and may allow officers to pick up inappropriate strategies that will leave them ill- prepared to act or recover and without the requisite variety of appropriate behavioural responses (Garrison, 1991). Mastery of a situation refers to one’s perception of the event as being under control, which in turn reduces the deleterious effects of the resulting stress (Mandler, 1982). Janis (1982) argues that the most promising approach to intervening and countering the disruptive consequences of the stress from a critical incident is to prepare the officers by providing them vivid information as to what they are likely to experience during and after a critical incident while developing skills and strategies for coping. Inoculation training may be looked at as a way of activating new pathways for processing traumatic information and increasing the officers’ ability to respond to a variety of situations with greater flexibility (Garrison, 1991). The objective of pre-trauma training is to lessen the impact of stressful or traumatic incidents on police officers by increasing an officers’ ability to cope with a traumatic incident and their feelings after such an incident (Byatt, 1997).
339
Tracey Varker PhD Thesis Appendices Introduction Here it is important to state that: “Today you will be receiving training that is designed to help you cope with the mental and emotional side of being a police officer. Today’s guest speaker [introduce guest speaker here], is here to talk to you about his/her experiences that he/she has had whilst working as a police officer.
Purpose of training State that: “The majority of the training that you will receive whilst you are at the Academy is designed to prepare you for the physical and operational sides of the job. Today’s session is designed to help prepare you mentally. We know that, when faced with a stressful situation, the more prepared the person is, and the more accurate that their expectations are, the better the person will be able to cope.”
Overview of session State that: “In today’s session the guest speaker will go through crime scene photos of incidents that he/she has attended. The guest speaker will talk to you about what he/she was thinking and feeling when first told about the incident, and then once he/she got to the incident. I will go through with you common thoughts and feelings that you may have when you attend particularly stressful incidents and I will go through some strategies that can help you to deal with these thoughts and feelings. I will also talk to you about what to do if you feel like you are not coping, and what support services are available to you.”
Warning of graphic nature of some material State that: “Some of the photos and videos that you will see here today are extremely graphic, and some people may find them upsetting. If you find this material distressing, you are free to leave at anytime. If you have recently been involved in a serious accident, or if you have lost someone close to you recently, then you may not wish to see the photos or videos.”
340
Tracey Varker PhD Thesis Appendices Worksheet Once the introduction is complete, each recruit should then be handed a worksheet. This worksheet is for the recruits to fill in as the session progresses, and is designed to be used as a reference resource. Worksheets are also useful tools for ensuring that people who are receiving training and education pay attention to what they are being taught. The worksheet asks recruits a number of questions which directly relate to the Policing Expectations, Social Support and Help Services training Modules (see Appendix II).
341
Module 2- Policing Expectations & Serial Approximation / Desensitisation
Overview • Theoretical background • Policing expectations • Projected still images • Videos • Audio
Theoretical background Policing expectations: In this section, the aim is to challenge and change the new recruits’ expectation of the type of work that they will be required to do as a police officer. Often new recruits have an unrealistic expectation of what policing actually entails. They are unaware of some of the duties that they will be required to perform, and they are unaware of the types of physical and emotional reactions that may result from some of the incidents that they will attend. As discussed in the introduction, by providing recruits with skills and techniques to deal with emotionally stressful situations, they are able to have greater mastery over the situation. This in turn reduces the deleterious effects of stress (Mandler, 1982). Exposing the recruits to vivid information about the types of emotionally stressful events that they will face as part of the job (in addition to the information and training that they receive related to operational factors), will enable them to develop realistic expectations and appropriate coping strategies. Anecdotal evidence suggests that many new recruit officers believe that they will not have to touch a deceased person, and that the majority of incidents that they attend will be simple assaults, car accidents, or drug related matters. They fail to take into account the fact that they will inevitably be faced with sad or depressing incidents (for example, finding a corpse or being confronted with severely mutilated victims). In a recent study of new recruit Queensland police officers, Hodgins, Creamer & Bell (2001) found that in their first year on the job, the officers attended an average of 7 critical incidents. The majority of those incidents could be described as depressing or sad, as opposed to violent. The most frequently experienced incidents included traffic accidents where an adult was injured or killed (55% and 28% of participants respectively), finding the corpse of someone who had died a natural death (49%), finding the corpse of a suicide Tracey Varker PhD Thesis Appendices victim (34%), and encounters with mentally disturbed individuals who were threatening (25%). By providing the recruits with testimonials, photographs and videos of real life incidents, they are able to gain a better appreciation of the types of situations that they will be faced with as part of their job. Serial approximation and desensitisation: Serial approximation and desensitisation are exposure based approaches that originate from conditioning theory of fear and anxiety. Exposure based approaches were developed originally for the successful treatment of specific anxiety disorders such as obsessive-compulsive disorder (Kozak et al., 1988; Rabavilas et al., 1976), panic disorder (Agras, 1985; Barlow, 1988; Leskin et al., 1998) and phobia (Heimberg & Barlow, 1988; Steketee, Bransfield, Miller, & Foa, 1989). They involve helping the patient confront fears, and are based on the premise that direct therapeutic exposure to feared, but relatively harmless stimuli, will result in a reduction of PTSD symptoms (Solomon & Johnson, 2002). When serial approximation and desensitisation are applied before a traumatic exposure has occurred, we propose that an individual is able to emotionally process stressful or traumatic stimuli (i.e. the photographs, videos) in an environment that is safe and supportive. Using the principles of classical conditioning, individuals are shown a stimulus that elicits a fear or anxiety response repeatedly, until habituation occurs (i.e. there is a decline in the strength of the anxiety response that is elicited). In keeping with the protocol used to deliver exposure therapy to patients, recruits will be shown a hierarchical series of stimuli. The first stimulus that is shown will be the least anxiety provoking, and the stimuli will sequentially become more severe, and the final stimulus shown is the most anxiety provoking stimulus (Hembree & Foa, 2003).
Policing expectations To begin the first discussion of the session, you will get the recruits to think about the types of traumatic events that an individual may encounter in day-to-day life. Suggested open-ended question to begin the discussion: “What are some traumatic events that a person might encounter during their lifetime?”
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Tracey Varker PhD Thesis Appendices Types of responses that should be elicited from the group: • Car accident, house fire, unexpected death of a loved one, suicide, drowning, murder, workplace accident, natural disaster (e.g. bushfire, flood), medical emergency (e.g. heart attack), domestic violence Open-ended question: “What are some ways in which a person can cope with a traumatic life event?” • Talking to friends, family, colleagues, thinking about how you helped in the situation, thinking about the good job performed by emergency services, doctors etc., having professional detachment, using your sense of humour, having self awareness Open-ended question: “When you joined up as a police officer, what type of work did you think you would be doing?” Types of responses: • Paperwork, natural deaths, car accidents, suicides, unnatural deaths, domestic violence, sexual abuse, crimes against children, destroying animals (especially when posted at a country station), possibly having to arrest friends, delivering death messages, sudden deaths of infants, harm or shooting of a fellow police officer If any of these responses are not drawn from the group, then you should cover the missed responses. New recruits often fail to suggest things such as child sexual abuse, and destroying animals, and it is important that they are made aware that they more than likely will be required to deal with most of the above situations. It is recommended that at this point the guest speaker be introduced. He/she gives his/her personal account of a significant traumatic event (e.g. fatal car accident or murder scene) that he/she was involved in. He/she gives a general overview, continuing to speak until the point where he/she recounts receiving the call to attend the car accident or murder scene.
Focusing on the task at hand Anecdotal reports from many experienced police officers indicate focusing on the task at hand can be one of the most effective
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Tracey Varker PhD Thesis Appendices methods for dealing with a stressful situation. Elicit a group discussion on this topic involving the guest speaker. Suggested open-ended question: “When you are on your way to a major incident, how do you prepare yourself for what you are about to see?” Types of responses that will be elicited from the guest speaker are: • Concentrate on who’s doing what, think about containing the scene, focus on who’s alive, who’s injured, who is deceased, consider if I need to re-direct traffic, ask myself is the offender still at the scene? (particularly in the case of a homicide, think about worst case scenario (i.e. being confronted with an armed offender) and think about how I’ll react, go over visual aspects of what I may see, consider if I will know anyone.
Your aim is to tease out this discussion in such a way that the recruits are aware that it is perfectly acceptable and common to switch into operational mode, even when they are driving to a scene where they know someone has been killed. For the majority of officers, focusing on the pragmatics of the event and focusing on their own personal role in the incident is the easiest way to deal with the situation when they are in the moment. Further this discussion with another question directed to the guest-speaker: Suggested open-ended question: “What thoughts do you have before you arrive at the scene?” Types of responses: • Try and work out from the information that I am receiving over the radio who is the victim and who is the offender, think about if I need to call for back-up. Here it is important to remind recruits that if they are posted at a country police station, often back-up may be a very long way off (sometimes several hours). They must be made aware that in some instances they may be the only officer at the scene for a long time. They may have to protect the scene and guard the bodies for a great length of time. In some cases, the first officer to respond may have to remain at the scene for 10-15 hours.
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Tracey Varker PhD Thesis Appendices If the guest speaker has been involved in an incident where a person has been killed, and the officer knew that there was a deceased person at the scene, further this discussion. Suggested open-ended question: “When you are about to approach the room/car where you know that the body is, what thoughts or feelings do you think that you will have?” Types of responses: • Heart rate is going fast, adrenaline racing, feeling nervous, fearful, worrying about personal safety, shaky, worried about being under scrutiny of peers and supervisors- wanting to perform job well. At this point state: “It is normal for some people, on some occasions to be overwhelmed with nausea and to vomit whilst attending a job. This is completely fine and normal, but is important that if you do feel like you are going to vomit, that you move away from the crime scene. This will ensure that the crime scene is not contaminated.” “You must also be aware, however, that at times you may be required to touch the body of the deceased. You may need to touch the body to check whether the person is in fact alive or dead, or you may need to touch the body to try and find identification.” “In a situation where a person has been killed, you will often be required to help keep highly distressed family members and/or friends away from the deceased person. This can be a distressing job for a police officer, and the compassionate side of you may want to let the family through the barricade. However, in order to preserve the crime scene, friends and family must not be allowed through.” State that: “In some cases it is possible for general patrol officers to receive a form of closure for a particularly distressing case” Open-ended question directed to guest speaker: “Do you find it beneficial emotionally to have closure on a particularly distressing case?” Typical response: “Yes, it helps a lot. For a lot of people, it is a great feeling to know that and offender has been caught, or even to know that every
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Tracey Varker PhD Thesis Appendices effort is being made to catch the offender. I encourage officers that have been involved in cases that have had a significant impact on them, to call me or email me and find out about the progress of the case. I think that you will find that most senior officers are more than happy to give an update on a cases progress.”
Serial approximation / desensitisation
Projected still images Each guest speaker will talk through and show crime scene photos from incidents the guest speaker has personally attended. These photos will be projected onto a big screen, and the lights in the room will be lowered so that there is high visibility. The photos will begin at a low level of stressfulness, showing things such as aerial shots, street photos taken from a distance, photos of the exterior of homes, or photos of the exterior of a murder site (e.g. warehouse or cemetery). These photos will become progressively worse, moving closer and closer to the deceased person. The final photo will be a close-up of the deceased person. Each photo will be displayed for several minutes, and the guest speaker will talk about what he/she was thinking and or feeling at the time. The final photo of the deceased person will be left on the screen for the longest amount of time.
Videos The guest speaker will also show a video of a serious incident that he or she has attended. This video will show the after-math of a serious incident, showing emergency services workers (police, fire, ambulance) attending a scene in which someone has been seriously injured or killed. The video may also show the relatives of a deceased or seriously injured person, in a very distraught or distressed state. The guest speaker will provide a narrative of the event depicted in the video, going through the way the event unfolded.
Audio Some of the videos will be accompanied by audio. The recruits will be able to hear the distress of the victim’s family and friends, and in some cases were a person is injured, the recruits will hear the distress of the injured person.
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Module 3- Physical Responses to Trauma: Breathing and Muscle Relaxation Techniques
Overview • Theoretical background • Psycho-education- physical responses to trauma • Controlled breathing exercise • Deep muscle relaxation • Handout: “Coping Skills” worksheet (Appendix III)
Theoretical background Psycho-education- physical responses to trauma: The aim of psycho-education about the physical responses to trauma, is to teach the recruits about the nature of the physical reactions that they may experience when exposed to a stressful situation. Whilst it is emphasized that physical reactions will not occur for every person in every case, the aim of the psycho-education is to inform the recruits that if a physical reaction does occur, it is not something that is abnormal or cause for alarm. Psycho-education also aims to describe management methods for the physical reactions that occur. The recruits will be taught the anxiety cycle, and will be taught about common physical reactions (such as sweating, nausea, and shakiness) that a person can experience when they are feeling highly anxious. They will also be taught techniques for coping with the physical reactions that sometimes accompany stressful situation. It has been found in studies of patients with anxiety disorders such as panic disorder, social anxiety, and generalised anxiety disorder, that psycho-education can be very beneficial (Chavira & Stein, 2002; Dannon, Iancu, Grunhaus, 2002; Sorby, Reavley, Huber, 1991). It is proposed that psycho-education is successful because it gives the individual a sense of control, and increases their knowledge and understanding about the disorder [or personal reaction] (Dannon, Iancu, Grunhaus, 2002). Psychoeducation serves as an excellent tool which can assist in the development of coping mechanisms. Once an individual is informed about the types of physical reactions that they may experience, they can then go on to learn effective ways to deal with these reactions. Muscle relaxation: The Jacobs (1938) deep muscle relaxation technique is taught, whereby the individual is taught to differentiate between when tense and relaxed. This enables ‘body scanning’ to identify tension, later on. This technique centres on gradually gaining the voluntary control of certain muscle groups through targeted Tracey Varker PhD Thesis Appendices contraction and relaxation of individual muscle groups. Muscle tension can be substantially reduced through alternated contraction and relaxation. Such tension release has been shown to be effective in reducing the amount of anxiety that is experienced by an individual (Luebbert, Dahme, Hasenbring, 2001) Breathing exercise: Controlled breathing (also known as diaphragmatic breathing; Clark, Salkovskis & Chalkley, 1985) has been shown to be an effective way of reducing anxiety (Bonn, Readhead & Timmons, 1984; Clark et al., 1985; Rapee, 1985; Salkovskis, Jones, & Clark, 1986). Sometimes when a person witnesses something that is stressful or upsetting, they experience a physical reaction. As we have previously stated, this reaction is known as the “fight-or-flight” response. One of the effects of the fight or flight response is hyper- ventilation. This is when an individual begins gasping for air, leading to an increase in the amount of carbon dioxide released by the body. An increase in carbon dioxide increases the acidity in the blood, increasing the amount of adrenalin being released, which increases the amount of stress that you are experiencing. This perpetuates the stress cycle. In order to gain control of your breathing and interrupt the stress cycle, it is necessary to slow your breathing down. This is achieved using the controlled breathing exercise that is described below.
Psycho-education: physical responses to trauma The aim of this section is to make the recruits aware of the physical responses that may occur when an individual is stressed or anxious. It must be pointed out to the recruits that each individual reacts to different situations differently, and that there is no “normal” or “abnormal” way to react. Suggested open-ended question: “When you are confronted with a stressful or frightening situation, what types of physical reactions do you think that you might have?” Types of responses that should be elicited from the group: • Nausea, sweating (e.g. sweaty hands), butterflies, heart palpitations, breathing may quicken (or hyperventilation), light headed, dry mouth, difficulty swallowing
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Tracey Varker PhD Thesis Appendices Normalcy of anxiety and stress response Once each of the physical symptoms of stress and anxiety have been suggested by the group, you must then educate the group about anxiety, and the basic principle of the anxiety cycle. State that: “When you experience something that is stressful or upsetting, sometimes you might experience a physical reaction. Anxiety is a natural response that was originally focused as adaptive coping to a threat or challenge. Different individuals react to anxiety in different ways. Sometimes you’ll experience what is known as the “fight-or- flight” reaction. You will start to breathe more rapidly in order for your body to gain extra oxygen to pump to your muscles, to get you ready to fight or flee. But this increased rate of breathing leads to an increase in the amount of carbon dioxide that you produce. Most people think that the problem when you hyper-ventilate is that your taking in too much oxygen. But in fact, that’s not the problem. The problem is that you are releasing too much carbon dioxide. This leads to an increase in the acidity of your blood, which in turn leads to an increase in the amount of adrenalin being pumped through your body. This in turn leads to an increase in the amount of stress that you’re experiencing, and so the cycle continues. The first step in reducing anxiety is to recognise the forms it takes and in particular to identify tension building up in your body. Information about the physiology of stress is essential so that you can identify and correctly attribute the physical sensations that you perceive. Once this has been achieved you can control these sensations before they become excessive and use strategies to reduce them.” Drawing: As the anxiety cycle is being explained, it should also be drawn on a whiteboard in the classroom. ( Draw the diagram shown on the following page )
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The Anxiety Cycle
TRIGGER
↑↑↑ ADRENALIN
PHYSIOLOGICAL HYPERVENTILATION & CHANGE TENSION
PERCEIVE INTERPRETATION (e.g. SOMATIC “catastrophise”) CHANGE
PAST HISTORY
Controlled breathing exercise State that: “Controlling your breathing has been shown to help suppress the anxiety response and reduce the consequences of anxiety. I’ll go through a breathing exercise that you can use if you find yourself witnessing or being involved in a stressful situation. This will stop you from gulping air if you are feeling stressed. Keep breathing at a regular pace, drawing in air through your nose. After inhaling completely pause for a slow count of two, i.e. … one thousand….two thousand. Then exhale and release the air slowly and evenly through your mouth. Let all of the air inside your lungs out. As you exhale let your whole body go limp, and say a calming word to yourself. The word CALM already has good connotations and so many people find this a useful one. Therefore, in your mind, you should be saying CAAAALLLLMMM as you SLOWLY exhale. Breathe like this for ten counts. Count each one after exhaling. Some people prefer to count backwards from ten to one, becoming increasingly relaxed with each breathe.” Tracey Varker PhD Thesis Appendices Of course, doesn’t need to be obvious, and you can do this exercise in such a way that no-one else will know that you are doing it.”
Relaxation (muscle tension) technique State that: “Although the vast majority of people don’t like the sight of blood, for some people the sight of blood also makes them feel faint. And for a number of these people, the sight of blood actually will make them faint. Of all the phobias, blood, injection and injury phobias are the only phobias associated with fainting in the feared situation. The common cause of fainting is called a “ vaso-vagal syncope ”, which basically, means that, for some people, when they see blood, their blood pressure begins to increase rapidly, before then crashing dramatically. This drop in blood pressure causes the person to faint. Research has found that tensing your muscles is a really good way to prevent yourself from fainting. [Demonstrate.. so what I mean is…tense the muscles for the count of 3, and then relax…] By repeatedly tensing muscles, you cause a temporary increase in blood pressure which prevents you from fainting. There are seven main groups of muscles that you can tense (in order): 1. Calves a 2. Thighs 3. Buttocks 4. Shoulders / upper torso 5. Arms (triceps & biceps) 6. Neck 7. Face (tongue, jaw and brow) You need to tense the chosen muscle holding it for the count of three, before then relaxing it.” Get whole group to practice muscle tension with you. NOTE: a. abdominal muscles are not taught as many have found this to interfere with the breathing technique which is applied throughout the relaxation procedure 352
Tracey Varker PhD Thesis Appendices Worksheet Once the breathing and muscle relaxation exercises are complete, each recruit should then be handed a “Coping Skills” worksheet (Appendix III). This worksheet is for the recruits to fill in at the end of the physical responses to trauma session, and will also be filled in during the Thought Challenging, Cognitive Restructuring and Guided Self-Dialogue (Module 4). The worksheet is designed to be used as a reference resource. The worksheet asks recruits a number of questions which directly relate to the Physical Responses to Trauma and Thought Challenging Modules.
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Tracey Varker PhD Thesis Appendices Module 4- Coping Skills: Thought Challenging, Cognitive Restructuring and Guided Self-Dialogue
Overview • Theoretical background • Focusing on the task at hand • Thought challenging, cognitive re-structuring • Guided self-dialogue • Handouts: “Coping Skills” worksheet (Appendix III); “Thought Challenging Questions” information sheet (Appendix IV); “Challenging Thoughts” information sheet (Appendix V) and the “Self Talk” information sheet (Appendix VI)
Theoretical background Anxiety management programmes are therapies that have been developed to provide patients with skills and strategies to deal with anxiety. They are based on the assumption that conditioned emotional reactions to trauma related stimuli always occurs to some extent, therefore people who have experienced trauma need to learn how to manage their responses (Solomon & Johnson, 2002). Strategies include relaxation-training, biofeedback, breathing training, social-skills training, stress-inoculation training, guided self-dialogue, and distraction techniques (e.g. thought challenging). Relaxation and breathing training were discussed in Module 3. In Module 4, the focus will be on guided self-dialogue and the distraction technique of thought challenging.
Thought-challenging and cognitive re-structuring Cognitive restructuring is the process of learning to refute cognitive distortions or fundamental "faulty thinking," with the goal of replacing one's irrational, counter-factual beliefs with more accurate and beneficial ones. Self-defeating or negative self-statements can cause emotional distress and interfere with performance, causing more negative self-statements and thus the cycle repeats again. The cognitive restructuring theory holds that your own unrealistic beliefs are directly responsible for generating dysfunctional emotions and their resultant behaviors, like stress and
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Tracey Varker PhD Thesis Appendices anxiety, and that we can rid ourselves of such emotions and their effects by dismantling the beliefs that give them life. Because one sets unachievable goals — "Everyone must love me; I have to be thoroughly competent; I have to be the best in everything" — a fear of failure results. Cognitive restructuring then advises to change such irrational beliefs and substitute more rational ones: "I can fail. Although it would be nice, I didn't have to be the best in everything." (Ellis and Harper, 1975). To achieve rational thoughts and beliefs, an individual must gain an awareness of detrimental thought habits. They must then learn to challenge them, before finally subtituting these faulty thoughts for life-enhancing, beneficial thoughts. Thought-challenging (Wolpe, 1973) involves identifying distorted thoughts, challenging them, and replacing them with more adaptive thoughts. In the medical field, researchers have consistently found that cognitive strategies such as putting negative thoughts aside and comparing oneself with less fortunate others, are key factors in successful adaptation to chronic illness (Beckham, Keefe, Cladwell & Roodman, 1991; Dakof & Mendelsohn, 1989).
Guided self-dialogue Guided self-dialogue involves teaching an individual statements that a stressed or anxious person can say to themselves while preparing for a stressful event, when confronting or handling a stressful event, when feeling overwhelmed by stress, and when reflecting on coping efforts (Keyes, 1995). It is the process whereby faulty, defeasive and negative self-talk is replaced with more rational, facilitative and task-enhancing dialogue. Guided self-dialogue is based on the premise that a person's internal dialogue is a significant factor in anxiety reactions and that the modification of cognitions is important. People are able to become self-directed by learning how to purposefully control their own thoughts (Neck, Steward, & Manz, 1995). Using positive talk, combined with realistic beliefs and assumptions, people can form constructive, habitual thought patterns. Guided self-dialogue involves telling oneself that one is performing well, and that one can improve performance by trying harder. Such positive thinking is enhanced by becoming aware of self-defeating internal statements (e.g. “I am of no use to anyone” or “I messed up on
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Tracey Varker PhD Thesis Appendices this last time”). Positive self-dialogue can lead to higher levels of reflection, confrontation control and empathy in dealing with others (Richardson & Stone, 1981). There are four phases to self-dialogue. The first phase is preparation. In other words – the self-talk an individual engages in before they are in the situation. The second phase is confrontation and management. This is the self-talk an individual engages in during the situation. The third phase is coping with their feelings and the fourth phase is reviewing and reinforcing their progress. See “Self Talk” information sheet (Appendix V) Building on Ellis’s (1977) concept of rational-emotive processes, rational thoughts result in positive emotional states whilst irrational or maladaptive thoughts result in emotional distress. Thus, changing internalised thoughts (self-dialogue) should affect emotions. It is known that emotional states can influence behavior, learning, perceptions, memory and judgement (Zajonc, 1980). Positive and negative thought patterns can become habitual and thereby influence emotional and behavioural reactions. Positive patterns, such as concentrating on opportunities, worthwhile challenges, and constructive ways of dealing with challenging situations, are more productive than are negative patterns such as concentrating on reasons why a goal can’t be achieved. Optimistic patterns of thought support positive behaviors and drive people to be successful, while pessimistic thoughts presumably have the opposite effect (Seligman, 1991). Optimism plays an important role in a diverse range of behavioural and psychological outcomes, when people are faced with adversity, with optimists displaying better physical and mental well- being than pessimists (Ebert, Tucker & Roth, 2002; Peterson & Bossio, 1991; Schweizer, et al., 1999).
Worksheets Whilst working through this Module, the recruits will continue to work through the “Coping Skills” worksheet (Appendix III). They will also be required to refer to the “Thought Challenging Questions” (Appendix IV), “Challenging Thoughts: ABCD” ( Foa, 1996; Appendix V), and “Self Talk” (Appendix VI) information sheets during whilst this Module is worked through. State that:
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Tracey Varker PhD Thesis Appendices “The purpose of this session is to provide people with practical skills and strategies that they can use to cope with some of the more stressful or anxiety provoking aspects of the job”. Provide the following facts: “Stress has been found to be related to impaired physical and psychological well-being (e.g. Beehr, 1995; Newbury-Birch & Kamali, 2001). • Whilst it is impossible to calculate the full personal and economic costs of each of these problems, a recent report produced by the Australian Government provides us with some indication of the cost of workplace “psychological injury” (a classification that includes stress, depression and post- traumatic stress disorder) to the Australian community each year. The report revealed that psychological injuries make up 6.9% of workers’ compensation claims in Australian Government agencies, but 27.1% of total claim costs. • In the past policing has been an occupation that has been well recognised as being highly stressful and hazardous (Alkus & Padesky, 1983; Kroes, 1985), with policing ranked as among the top five most stressful occupations in the world (Dantzer, 1987). • In 2005-2006, Victoria Police paid nearly $8.15 million dollars in compensation for 428 stress claims. In this financial year, there are currently 419 open stress claims, suggesting that once again Victoria Police will be faced with $8 million plus compensation bill.
Thought challenging and cognitive re-structuring State that: “Cognitive restructuring is the process of learning to challenge cognitive distortions or fundamental "faulty thinking," with the goal of replacing one's irrational, counter-factual beliefs with more accurate and beneficial ones. In the medical field, researchers have consistently found that people who are chronically ill adapt much better when they use cognitive strategies such as putting negative thoughts aside and comparing themselves to those less fortunate.
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Tracey Varker PhD Thesis Appendices Self-defeating or negative self-statements can cause emotional distress and interfere with performance. This is turn causes more negative self-statements and thus the cycle repeats again e.g. This is going to be “shit”. Having unrealistic beliefs is directly responsible for generating dysfunctional emotions and maladaptive behaviours such as stress and anxiety. We can rid ourselves of these types of emotions and their effects by dismantling the beliefs that give them life. When you set an unachievable goal — "Everyone must love me; I have to be thoroughly competent; I have to be the best in everything" — a fear of failure results. These irrational beliefs must be changed for more rational ones: "I can fail. Although it would be nice, I don't have to be the best in everything." To achieve rational thoughts and beliefs, you must engage in thought-challenging. Thought-challenging involves identifying distorted thoughts, challenging them, and replacing them with more adaptive life-enhancing thoughts”. [Refer recruits to the “Thought Challenging Questions” information sheet ]
State that: “The “Thought Challenging Questions” handout is a list of questions that people can ask themselves, in order to challenge negative thoughts and engage in cognitive re-structuring. They are practical questions that can help a person to see that a thought is irrational. There are three key questions that you can ask to Test a Negative Belief. These are: • Is it realistic? • Is it flexible? Does it change with different situations? • Does it help you cope? If you get “NO ” for any one of these three questions, then the belief needs to be changed”.
To further explain cognitive restructuring, the A-B-C paradigm should be introduced. 358
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State that: “The A-B-C paradigm is a way in which we can look at how the automatic irrational thoughts that we sometimes have, can affect our reactions. I’ll give you an example: Very often people believe that certain events cause specific reactions. For example, you may believe that riding in an elevator makes you panic. i.e.
A C Activating Event Consequence In an elevator Panic, sweating, paranoia
However the anxiety that you feel is not the result of the event itself. An inanimate object such as an elevator cannot make you anxious by its own doing. It is our interpretation about the situation that creates the anxiety, and this interpretation is based upon beliefs we hold. In the example that I just gave you, the active belief may be that you are in danger of being trapped. Therefore a more realistic representation of the self-talk that created the anxiety may have been”:
Activating Event Belief Consequence In elevator I will be trapped Panic, sweating, paranoia & it will be awful
Refer recruits to the “Challenging Thoughts- ABCD” information sheet
State that: “This handout gives you a way of working through and deciding whether or not a thought is irrational. You must write down the: Situation (Activating Event); Negative Thoughts (Beliefs); Emotions (Consequences); and Rational Response (Disputing Thought)”.
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Tracey Varker PhD Thesis Appendices Guided self-dialogue State that: “Guided self-dialogue, or self talk, involves teaching a person statements that they can say to themselves when: ♦ they are feeling stressed or anxious ♦ they are preparing for a stressful event ♦ they are confronting or handling a stressful event ♦ they are feeling overwhelmed by stress ♦ and when reflecting on coping efforts after the stressful event It is the process whereby faulty, defeatist and negative self- talk is replaced with more rational, facilitative and task-enhancing dialogue. Self-talk involves telling yourself that you are performing well, and you can improve your performance by trying harder and learning from previous mistakes. Such positive thinking is enhanced by becoming aware of self-defeating statements such as “I am of no use to anyone” or “I messed up on this last time”. People tend to ‘minimise’ the positives, and ‘maximise’ the negatives. It is common for people placed in stressful situations to: ♦ overestimate the likelihood of an unpleasant event ♦ overestimate how bad the event would be ♦ underestimate their ability to deal with the event You can also challenge your distortions by comparing your performance to other police officers with the same amount of experience as you. You can critically assess your performance and tally how many things you did well compared to how many things you did poorly. You will soon come to realise that the number of things you did well usually outweighs the number of things you did badly. There are four key stages during which you can use self-talk to minimise the stress and anxiety that you experience. The first phase is preparation. In other words – the self-talk you engage in before you confront a situation. The second phase is confrontation and management. This is the self-talk that you engage in during the situation. The third phase is coping with your feelings and the fourth phase is reviewing and reinforcing your progress. 360
Tracey Varker PhD Thesis Appendices Refer recruits to the “Self Talk” information sheet State that: This handout is a list of a number of different things that you can say to yourself during each of the four phases of self-talk.
Is it ok to use black humour? State that: “Black humour is a completely natural reaction to sometimes horrible events. Even though you may not mean to, sometimes you will find yourself laughing or giggling at something. That is fine for you to do, but make sure you do not do this in front of members of the public, or at times where it is inappropriate. You will now when it is ok and appropriate to laugh, and when it is inappropriate. Just make sure you use your common sense.”
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Tracey Varker PhD Thesis Appendices
Module 5- Social Support
Overview • Theoretical background • Value and benefits of social support
Theoretical background After a traumatic event, those involved are typically in great need of support of all types. They are often very sensitive to how others react to them, and how others describe or make attributions about both the event, and the role the victim played (Johnson et al., 1997). The extent to which a person’s social network validates or invalidates their experience can have an important effect on the victim’s psychological adaptation following a traumatic event. This type of validation, known as social support, is commonly defined as “the degree of emotional and instrumental support received by a person from the people in his or her environment” (Maercker & Müller, 2004, p. 346). A key element of social support is that it provides one with an opportunity to discuss a traumatic event with peers (Buchanan, Stephens & Long, 2000). Social support can be gained from a variety of sources, including family, friends, work colleagues, supervisors and the organisation (in the form of management support). Those victims’ that receive poor or few social support following a traumatic event are more likely to have higher levels of post-trauma symptomatology (Cordova, Cunningham, Carlson & Andrykowski, 2001; Marmar et al., 1999; Southwick, Morgan & Rosenberg, 2000).
Value and benefits of social support Suggested open-ended question: “What personal resources do you have that you can use to deal with the feelings that you may have after a particularly upsetting day?” Types of responses: • Talking to family and friends, exercise, using your sense of humour, alcohol At this point, state that:
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Tracey Varker PhD Thesis Appendices “Exercise is a good way to release some energy, and in particular it may help you release some of the adrenaline that is still pumping through your body. The best kind of exercise to do is aerobic exercise such as walking or swimming. It is best to avoid strenuous exercises such as running or weight lifting, as this can hype you up and result in you feeling more stressed and anxious than before you started.” Continue on, stating that: “It is important to talk to other people when you experience a stressful or traumatic event. Death and tragedy are unfortunately a part of life. Talking to friends and family can help, and has been shown to be a key factor in coping with traumatic events. It is important to identify people in your own support system who have been helpful in the past, and talk to them about what happened to you. “ “For some people, however, they may prefer not to speak to their romantic partner about particularly distressing things that they have seen on the job. Individual factors such as the strength of your relationship, whether you want to take your work home with you, and whether your partner wants to hear about the things you have seen will determine whether you speak to your romantic partner about distressing events. If you would prefer to not speak to your romantic partner, then your partner who you work with may be a good alternative to provide support to you. Similarly, talking to other colleagues and senior officers can be a great support to you.”
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Module 6- Drugs and Alcohol
Overview • Theoretical background • Drugs and alcohol • Signs of problem drinking • Handouts: “Drugs and Alcohol” worksheet (Appendix VII); and “How to Recognise Problem Drinking” information sheet (Appendix VIII)
Theoretical background It is not uncommon for those employed in a high stress occupation, where there is little opportunity to manage stress effectively, to resort to using self-defeating coping tactics. Such maladaptive tactics include self-medication through alcohol or drug use (Amaranto, Steinberg, Castellano & Mitchell, 2003). It is well established that there is a high rate of co-morbidity for substance abuse among individuals who suffer from PTSD (Davidson, Hughes, Blazer & George, 1991). Many people try to alleviate the symptoms of their PTSD by self-medicating with drugs (such as anti-depressants) and alcohol. Even in small quantities alcohol causes dysfunction in an individual, due to its depressive effect on the central nervous system, which in turn causes reaction times to become slow and thinking and co-ordination to become sluggish (McNeill & Wilson, 1993). Alcohol may also cause aggressive behaviour, particularly in the presence of a threat (Zeichner, Allen, Giancola, Lating, 1994). Employee substance use has been found to be associated with excessive absenteeism (Crouch et al., 1989; Normand, Salyards & Mahoney, 1990; Zwerling, Ryan & Orav, 1990), accidents at work (Holcom, Lehman & Simpson, 1993; Taggart, 1989), poor job performance (Blum, Roman & Martin, 1993; Lehman & Simpson, 1992) and turnover (Kandel & Yamaguchi, 1987; Zwerling, Ryan & Orav, 1990). Given the fact that alcohol causes reaction times to slow, thinking and co-ordination to become sluggish, and increases aggression, the presence of alcohol in an officers’ system can greatly impact upon
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Tracey Varker PhD Thesis Appendices police work, placing both police officers and members of the public at unnecessary risk (Davey, Obst and Sheehan, 2001).
Drugs and alcohol Suggested open-ended question: “What do you do, as a group, to cope after a long shift?” Types of responses: • Talk, go to the pub, have a few beers State that: “The purpose of this session is to provide you with information about the effects of the use of drugs and alcohol, and to help you identify if you may have or are developing a problem. We will also provide you with information on how to get help you feel like you may need it. We know that the chances of people having an alcohol problem, if they also have stressful experiences, increases exponentially. We know that you will probably be scraping people off the road, cutting people down from trees, seeing dead babies, and seeing abused children. We also know that there is the possibility that randomised drug and alcohol testing will be introduced to Victoria Police. What I want to do today is to give you information that will help you to make wise decisions”. Provide the following facts: “It is not uncommon for people who are employed in high stress occupations to use drugs and alcohol as coping techniques. Even in small quantities alcohol causes dysfunction in an individual, because of its depressive effect on the central nervous system, which in turn causes reaction times to become slow and thinking and co- ordination to become sluggish. Alcohol may also cause aggressive behaviour, particularly in the presence of a threat. Employee substance use has been found to be associated with excessive absenteeism, accidents at work, poor job performance and turnover. Given these facts, the presence of alcohol in an officers’ system can greatly impact upon police work, placing both police officers and members of the public at unnecessary risk”.
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Tracey Varker PhD Thesis Appendices What the research tells us State that: “Several studies have been carried out looking at the levels of alcohol use in police officers. The results of these studies have been somewhat alarming. In a study of Queensland police, it was found that 23% of the police interviewed reported having been affected by co- workers drinking in some way during the previous year, whilst 14% reported that drinking outside work hours had affected their performance at least once in the past year. Another study found that police officers drank less often during the week than the general Australian population, but on those occasions when they did drink they consumed quantities far greater than the Australian norms. This meant that 32% of female officers and 16% of the male officers in this sample were classified as binge drinkers. This gender difference is probably influenced by a lower “cut-off” for what constitutes binge drinking in women. We also know that drinking habits change from the time that a person enters the police force, to a few years down the track. In a very recent study with Queensland police officers, people were given questionnaires when they first began at the Police Academy, and then they were assessed again after having been on the job for 12 months. It was found that the percentage of people who reported drinking more than once a month went up from 47% to 60%, the amount of people who said that they drank six or more drinks in one sitting once a month went from 25% to 32% and there was a significant increase in the number of officers who reported smoking. So it seems that working as a police officer has an impact on people’s levels of alcohol consumption and smoking. It also gives us an insight into a possible “drinking culture” in the police force. I would like to give you information about drug use and police members, but unfortunately I can’t do so, because currently there are no published studies which have examined drug use among police members. That is one of the key roles of the research study that we are doing- looking at the level of drug use by police members.”
Signs of a problem with drinking State that:
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Tracey Varker PhD Thesis Appendices “Socialising is good, and having a few drinks is fine, if having a few drinks is a vehicle for you getting together and discussing your problems with your mates. For some people having a few drinks with mates can become a regular occurrence and over time drinking can become a problem. On the sheet that you have in front of you is a list of signs that you may have a problem with drinking.”
Refer recruits to the “How to Recognise Problem Drinking ” information sheet Turning to drugs or alcohol is not a productive coping mechanism. Although in the short term they may numb the pain, they will not help you in the long term, because you have avoided dealing with the issues at the root of the problem. After a distressing incident you may feel irritable, angry, have low tolerance, find you don’t know yourself and feel strange for a couple of days. Exercise is very important, you must look after yourself, have interests outside of the police force. It is very important to nurture your relationships, in particular look after your relationships with wives, husbands, partners, and children.”
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Module 7- Help Services Available
Overview • Role of Clinical Services • Victoria Police chaplaincy • Peer support • Independent help services • Drugs and alcohol help
Role of Clinical Services State that: “For some people, sometimes certain events can be too much. There are some things that you may not be able to cope with using your personal resources alone. In these situations, you may wish to access the services provided by Clinical Services. Clinical Services provides confidential counselling and support services and is staffed by experienced social workers and psychologists. Its services include: • A confidential counselling service for employees and their immediate families (internal and external counsellors are available) • A 24 hr on call service for urgent matters involving employee wellbeing • Psychological testing and screening for new recruits and specialist squads • A consultation service for managers seeking advice about employee wellbeing • Assistance to Victoria Police management regarding policies impacting on employee wellbeing Although Clinical Services provides a completely confidential service, under a few select circumstances Clinical Services are required to break confidentiality for mandatory reporting. These circumstances are: • When there is the belief that you may harm yourself • When there is the belief that you may harm another person
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Tracey Varker PhD Thesis Appendices • When there is the belief that a crime is going to be committed (either by yourself or someone else) If you wish to speak with a social worker or psychologist from Clinical Services please call: (03) 9301 6900 It is important to note that Clinical Services does not provide relationship counselling. It will, however, provide external referrals.
Victoria Police chaplaincy The Victoria Police Chaplaincy Unit supports all Victoria Police employees and their families with spiritual support and completely confidential assistance on an inter-denominational basis. Police chaplains are on-call within each region to provide spiritual support after critical incidents and in times of personal stress. Enquiries regarding the Chaplain’s role are welcome and may be directed to Employee Support services on: (03) 9301 6900
Peer support The Peer Support Programme has been established to promote and complement existing resources available to all employees who may be in need of support. Peers are trained colleagues who provide general support. The programme is available to all Victoria Police employees. Peer support personnel: • Provide practical support, education, referral and follow up to Victoria Police employees on request • Assist employees to effectively identify, understand and manage signs and symptoms of stress • Maintain strict confidentiality • Provide a link to other support services, for example; Clinical Services, Chaplaincy, Employee Support and Welfare, Injury Management Officers, The Police Association Welfare Officer and Staff Assistance Programme To be put in contact with your nearest Peer support person, please contact:
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Tracey Varker PhD Thesis Appendices (03) 9301 6900
Independent help services You may wish to seek help or advice from an organisation that is independent of Victoria Police. If you wish to access a 24hr telephone counselling service, you can call Lifeline on 13 11 14 for the cost of a local call. Lifeline's 24-hour telephone counselling service is staffed by around 5000 volunteers, who are trained to provide emotional support in times of crisis. Alternatively, you may wish to speak to your G. P. Your G.P. will listen to your problems, and will provide you with help and guidance on how to deal with these issues. Your G.P. may also provide you with a referral to speak to someone such as a psychologist or psychiatrist. If you wish to speak to a psychologist, you can find an Accredited Psychologist in your local area using the Australian Psychological Society website. The website can be found at: http://www.psychology.org.au/
Drugs and alcohol help If you wish to speak to someone for help related to your use of drugs or alcohol, you can contact Clinical Services on (03) 9301 6900. You can also speak to your G. P. for advice, treatment or referral. Alternatively, you can call the 24-hr counselling service Directline on 1800 888 236. At Directline you talk to professional counsellors who are experienced in alcohol and drug-related matters. The service is free, anonymous and confidential, and it provides information and referral for people wanting to discuss any alcohol or drug related issue.
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Module 8- Conclusion
Overview • Re-cap of Modules • Handout: the “Police Resilience” Handbook [Resilience version]
Re-cap of modules In the conclusion, a re-cap of each of the 8 core Modules must be conducted. The recruits should be reminded of the topics that have been covered as part of the training programme, and the skills and tools that they have been taught which can be utilised to help each recruit cope with a stressful situation. When you are summarising the training programme state that: “When you are out on the job and working as a police officer, and you attend your first major incident, I would like for you to try and recall the things that you have learnt through this training programme. When you are driving to a scene where you know a person has been killed, prepare yourself mentally and think back to the photos, videos and tapes that you have seen and heard here. Remember to focus on the task at hand as much as possible, and think about your importance in the situation. Every police officer attending a serious crime has an important role. When you arrive at the scene and view a deceased person, if you experience any adverse physical reaction, think about the breathing and muscle tension exercises that you have been taught. After the event, when you are trying to un-wind remember that exercise and talking to family, friends and colleagues can be an excellent way to process what has happened emotionally. Having a few beers with work-mates and talking about the day’s events is fine also. However, beware that alcohol will cause you to feel flat and depressed the next day, and will inhibit your ability to process the emotional side of what you talk about over your beer. For a small number of people who find that there is a particular incident that they can’t cope with, staff from Clinical Services are available to provide you with professional help. Alternately you may
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Tracey Varker PhD Thesis Appendices wish to seek professional advice from someone independent of Victoria Police. This is fine. Finally, remember that black humour is ok, but make sure you do not do or say anything inappropriate when the victim’s friends or family, or members of the public are around.”
Police Resilience Handbook Once the re-cap is complete, the recruits should then be given the Police Resilience Handbook. This handbook contains all of the information that was presented to the recruits during the resilience training programme, and is designed to be a valuable resource that the recruits can turn to at a later date.
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Post Training Brief Assessment
Once the Conclusion has been completed, the Post Training Brief Assessment must be administered. An introduction similar to the following is best: “I would now like for you to fill in a brief questionnaire relating the resilience training that you have received. I am interested in what you thought of the training programme, which parts you thought were good, and which parts you thought were bad. Your feedback will be used to further develop this training programme” The questionnaire will take 5-10 minutes to fill in, and should be collected by a researcher once it is completed.
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PART II
Training Protocol for Recruits in Control Group
Intake Assessment
Overview • Introduction of the trainer and the project • Gain written consent • Administer intake assessment battery (Appendix I)
Introduction of the researcher and the project Briefly outline the course of the research programme. Provide the recruits with the information sheet and explain the rights of the participant (e.g. free to withdraw, confidentiality, etc). Take the recruits through the consent form gain their written consent before proceeding.
Assessment battery Hand-out the intake assessment battery. An introduction similar to the following is best: “I would like for you now to fill in a questionnaire. There are no right or wrong answers to these questions. Please just fill in the answer that seems to be best for you, and don’t spend too long thinking about any one question. All of your answers to these questions will be kept strictly confidential. In particular, no-one’s individual answers to the questions related to drugs and alcohol will be reported to Victoria Police, only overall group figures will be reported (for example 20% of officers were found to drink alcohol).” The following instruments are recommended for the assessment of individual differences, current functioning, drug & alcohol use and resilience: • Alcohol Substance Involvement Screening Test (ASSIST; WHO ASSIST Working Group, 2002) • ISEL-12 (Cohen, Mermelstein, Kamarck & Hoberman, 1985)
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Tracey Varker PhD Thesis Appendices • Abbreviated Dyadic Adjustment Scale (ADAS) (Sharpley & Rogers, 1984) • State Trait Anger Expression Inventory (STAXI: Spielberger, 1988)- Anger-Out Subscale • The Life Orientation Test Revised (LOT-R; Scheier, Carver & Bridges, 1994) • The Connor-Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003) • History of Traumatic Events Scale (Devilly & Wright, 2002) • Depression Anxiety Stress Scale (DASS-21) (Lovibond & Lovibond, 1995) • Maslach Burnout Inventory (MBI; Maslach, Jackson & Leiter, 1996) • Ten-Item Personality Inventory (TIPT; Gosling, Rentfrow & Swann, 2003) • The 36-item Short Form Health Survey (SF-36; Ware & Sherbourne, 1992) • Demographics assessment - including gender, marital status, number of children, religion, ethnicity, highest level of education, handedness, footedness etc (see Appendix I).
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Module 1- Introduction
Overview • Theoretical background • Introduction • Purpose of training • Overview of session • Warning of graphic nature of some material • Handout: “Resilience for Police Trauma” (Control Group) worksheet (Appendix IX)
Theoretical background The control group provides a group of new recruit police officers who have not had resilience training, for comparison with those officers who have had resilience training. The purpose of a control group is to assist in eliminating alternate explanations for the experimental results. It is important that the control group has the same level of policing experience as the intervention group therefore the control group must also consist of new recruit officers. Whilst the control group training must be relevant and interesting to new recruit police officers, it must not include elements of resilience training. Resilience training is being trialled via the intervention group therefore the control training will be specific to pragmatic, operational problems that may be encountered by officers attending a serious incident. Introduction Here it is important to state that: “Today you will be receiving training that is designed to show you the types of incidents that you may attend once you begin work as a police officer. Today’s guest speaker [introduce guest speaker here], is here to talk to you about his/her experiences that he/she has had whilst working as a police officer.
Purpose of training State that: “The majority of the training that you will receive whilst you are at the Police Academy is designed to prepare you for the physical and operational parts of the job. Today’s session is
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Tracey Varker PhD Thesis Appendices designed to show you some real-world examples of the types of incidents that you may be required to attend.”
Overview of session State that: “In today’s session the guest speaker will go through crime scene photos of incidents that he/she has attended. The guest speaker will talk to you about the circumstances surrounding the incident, and will talk to you about some ways to preserve evidence and the crime scene. I will also talk to you about how to deal with friends and family of the victim who are at the scene of a serious incident, and who are distraught.”
Warning of graphic nature of some material State that: “Some of the photos and videos that you will see here today are extremely graphic and some people may find them upsetting. If you find this material distressing, you are free to leave at anytime. If you have recently been involved in a serious accident, or if you have lost someone close to you recently, then you may not wish to see the photos or videos.”
Worksheet Once the introduction is complete, each recruit should then be handed a worksheet. This worksheet is for the recruits to fill in as the session progresses, and is designed to be used as a reference resource. Worksheets are also useful tools for ensuring that people who are receiving training and education pay attention to what they are being taught. The worksheet asks recruits a number of questions which directly relate to control group training Modules 1, 2, 3, 4 and 5 (see Appendix IX).
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Module 2- Critical Incidents
Overview • Introduction • Projected still images • Videos • Audio
Introduction The guest speaker will introduce him or herself, and tell the group which unit he/she is from, and how many years of policing experience they have.
Projected still images Each guest speaker will talk through and show crime scene photos from incidents the guest speaker has personally attended. These photos will be projected onto a big screen, and the lights in the room will be lowered so that there is high visibility. The photos will begin at a low level of stressfulness, showing things such as aerial shots, street photos taken from a distance, photos of the exterior of homes, or photos of the exterior of a murder site (e.g. warehouse or cemetery). Each photo will be displayed for several minutes, and the guest speaker will talk about the circumstances that surrounded each of the cases. The guest speaker will describe procedures that were undertaken to preserve the crime scene, and to preserve evidence. The guest speaker will also talk about whether there were any friends or relatives at the scene, who had to be dealt with.
Videos The guest speaker will also show a video of a serious incident that he or she has attended. This video will show the after-math of a serious incident, showing emergency services workers (police, fire, ambulance) attending a scene in which someone has been seriously injured or killed. The video may also show the relatives of a deceased or seriously injured person, in a very distraught or distressed state. The guest speaker will provide a narrative of the event depicted in the video, going through the way the event unfolded.
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Tracey Varker PhD Thesis Appendices Audio Some of the videos will be accompanied by audio. The recruits will be able to hear the distress of the victim’s family and friends, and in some cases where a person is injured, the recruits will hear the distress of the injured person.
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Module 3- Preserving Evidence and the Crime Scene
Overview • Preserving evidence • Preserving the crime scene
Preserving the evidence As mentioned in Module 2, as the guest speaker shows the projected still images and videos of crime scenes that he/she has attended, he/she will also talk about some of the evidence that was at the scene. For example, in crime scenes where the murder weapon was left at the scene, the guest speaker will describe the steps that were taken by the first officers attending the scene to preserve the evidence. The guest speaker will briefly discuss some of the testing that may be done of different types of evidence, such as fingerprinting, DNA testing and tool-mark matching (in cases, for example, when a weapon has been modified using a tool).
Preserving the crime scene Similarly, as mentioned in Module 2, the guest speaker will also discuss how to preserve the crime scene as he/she shows the projected still images and video of some of the crime scenes that he/she has attended. The guest speaker will talk about the usual protocol of securing the scene, so that any evidence that is in the vicinity can be preserved. This evidence may include things such as the body of the deceased, footprints, blood spatter, hairs or fibres. The guest speaker will also talk to the recruits about procedures such as wearing protective gloves or booties (shoe coverings) before entering a scene where it is known that a person has been killed.
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Module 4- The Role of Clinical Services
Overview • Introduction to Clinical Services • Types of services offered by Clinical Services • Types of serious incidents attended by Clinical Services • Contact numbers
Introduction to Clinical Services State that: “For some people, sometimes certain events can be too much. There are some things that you may not be able to cope with using your personal resources alone. In these situations, you may wish to access the services provided by Clinical Services. Clinical Services provides confidential counselling and support services and is staffed by experienced social workers and psychologists.”
Types of services offered by Clinical Services State that: “The services include: • A confidential counselling service for employees and their immediate families (internal and external counsellors are available) • A 24 hr on call service for urgent matters involving employee wellbeing • Psychological testing and screening for new recruits and specialist squads • A consultation service for managers seeking advice about employee wellbeing • Assistance to Victoria Police management regarding policies impacting on employee wellbeing Although Clinical Services provides a completely confidential service, under a few select circumstances Clinical Services are required to break confidentiality for mandatory reporting. These circumstances are:
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Tracey Varker PhD Thesis Appendices • When there is the belief that you may harm yourself • When there is the belief that you may harm another person • When there is the belief that a crime is going to be committed If you wish to speak with a social worker or psychologist from Clinical Services please call: (03) 9301 6900 It is important to note that Clinical Services does not provide relationship counselling. It will, however, provide external referrals.
Victoria Police chaplaincy The Victoria Police Chaplaincy Unit supports all Victoria Police employees and their families with spiritual support and completely confidential assistance on an inter-denominational basis. Police chaplains are on-call within each region to provide spiritual support after critical incidents and in times of personal stress. Enquiries regarding the Chaplain’s role are welcome and may be directed to Employee Support services on: (03) 9301 6900
Peer support The Peer Support Programme has been established to promote and complement existing resources available to all employees who may be in need of support. Peers are trained colleagues who provide general support. The programme is available to all Victoria Police employees. Peer support personnel: • Provide practical support, education, referral and follow up to Victoria Police employees on request • Assist employees to effectively identify, understand and manage signs and symptoms of stress • Maintain strict confidentiality • Provide a link to other support services, for example; Clinical Services, Chaplaincy, Employee Support and Welfare, Injury Management Officers, The Police Association Welfare Officer and Staff Assistance Programme
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Tracey Varker PhD Thesis Appendices To be put in contact with your nearest Peer support person, please contact: (03) 9301 6900
Types of serious incidents attended by Clinical Services Once an overview of Clinical Services has been provided, the person from Clinical Service will then talk about some of the Critical Incidents that he/she has attended, in the capacity of a support staff person. The Clinical Services person will describe the circumstances surrounding the incident. For example, if the Clinical Services person attended the scene of a fatal car accident, he/she would describe the circumstances surrounding how the accident occurred (i.e. the conditions at the time, anything remarkable about the drivers, whether there was any fault in regards to the vehicles), what actually happened to cause impact, and how many people were injured or killed. He/she would then talk about the scene that the fist attending officers were confronted with, and the steps that the officers were required to take (e.g. calling for back-up, securing the scene, notifying relatives). State that: “Clinical Services staff members are often called in to provide support to police officers, directly after they have attended a Critical Incident such as a fatal car accident or a homicide. As such Clinical Services staff members have a detailed knowledge some of the more extreme types of incidents that you may be required to attend.
At this point the Clinical Services person will describe 2-3 Critical Incidents that he/she has attended, in the manner described above.
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Tracey Varker PhD Thesis Appendices Module 5- Dealing with the Victim’s Family and Friends
Overview • Types of situations in which there may be distraught bystanders • Strategies for dealing with distraught family and friends
Types of situations in which there may be distraught bystanders In this section, a member of Clinical Services will tell several stories of serious incidents that Clinical Services have attended, where operational members needed the support of staff from Clinical Services. Examples of such incidents include: Major car accidents where people were killed; train accidents where a number of people were killed; murders where relatives found the body of the victim. State that: “When you attend an incident where someone has been seriously injured or killed, there will often be highly distressed friends and family at the scene who must also be dealt with. For some officers, dealing with distraught relatives can be more confronting than dealing with the victims themselves. Suggested open-ended question: “What types of emotions do you think that the victim’s family and friends may be experiencing?” Types of responses • Grief, anger, sadness, rage, shock, denial, disbelief, hysteria Suggested open-ended question: “What types of reactions may these people have?” Types of responses • Trying to get to the deceased person (if the family is away from the scene); clinging on to the deceased / not wanting to let go (if the family is with the deceased); anger- wanting to confront the person responsible for the death, if this person is present at the scene (for example, at the scene of a car accident); physical illness (some people can be so overcome with grief or shock that they become physically ill)
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Tracey Varker PhD Thesis Appendices Strategies for dealing with distraught family and friends The discussion should then be guided in such a way that strategies to deal with these types of reactions can be brought to the attention of the recruits. Suggested open-ended question: “How can you deal with a family friend or relative that is trying to get to a deceased person?” • If necessary the person, may need to be restrained; another friend or family member who is nearby may be able to come and help restrain the person; another friend or family member may be called. It is important to try and prevent anyone from getting close to the deceased, or touching the deceased because the deceased’s body is now a form of evidence Suggested open-ended question: “How do you deal with a friend or family member who is clinging onto the deceased person?” • If a friend or family member is already touching or holding the deceased person when you arrive at the scene, it is important to move this person away as quickly as possible. The deceased’s body is evidence, it is important to protect the crime scene from contamination Suggested open-ended question: “How do you deal with an angry relative, who wants to confront the person responsible for their loved ones death?” • Relatives and friends of the victim must be kept separate from the offender and friends and family of the offender. This will ensure that no confrontations will occur, and that there will be no violence. In such situations, emotions are extremely heightened, and overwhelming grief and anger can cause some people to lash out Suggested open-ended question: “How do you deal with a friend or relative who has become physically ill at the scene?” • If someone becomes overwhelmed with the grief and shock of the situation, then an ambulance officer should be located to attend to this person. If the person is going into shock, and the
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Tracey Varker PhD Thesis Appendices ambulance crew has not yet arrived, then a blanket or warm covering should be found to place over them.
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Module 6- Sexual Offenders
Overview • Introduction • Dispelling myths about sexual offenders • Handouts: “Sexual Offenders” worksheet (Appendix X); and “Sexual Offenders Facts” information sheet (Appendix XI)
Introduction This training module on sexual offenders is designed to provide the recruits with information that they may consider interesting and somewhat useful. As this module is part of the control training programme, however, the key purpose is not to increase the recruits’ personal resilience to trauma. State that: “When you begin work as a police officer, there are a number of aspects of the job which some people can find difficult. One part of the job that people can be particularly difficult is sexual offences. There are many misconceptions about sexual offenses, sexual offense victims, and sex offenders in our society. I am going to take you through a series of myths and facts, and hopefully I can dispel some misconceptions that you may have about sex offenders. A lot of these statistics are from America, because there have not been as many studies conducted here in Australia. We know, however, that Australia’s rates are fairly comparable with America.”
Refer recruits to the “Sexual Offenders” worksheet and the “Sexual Offenders Facts” information sheet
Dispelling myths about sexual offenders State that: “Is the following a myth or a fact? -Most sexual assaults are committed by strangers. “ [Ask the group to participate and answer the question ] “In fact- Most sexual assaults are committed by someone known to the victim or the victim's family, regardless of whether the victim is a child or an adult.
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Tracey Varker PhD Thesis Appendices ♦ For Adult Victims: Statistics indicate that the majority of women who have been raped know their assailant. A 1998 U.S. National Violence Against Women Survey revealed that among those women who reported being raped, 76% were victimized by a current or former husband, live-in partner, or date (Tjaden and Thoennes, 1998). Nearly 9 out of 10 rape or sexual assault victimizations involve a single offender with whom the victim has had a prior relationship, such as a family member, friend, or acquaintance (Greenfeld, 1997). ♦ For Child Victims: One study found that 6.2% of professional women were raped as a child (under 16 years of age; Elliot & Briere, 1992). ♦ Approximately 60% of boys and 80% of girls who are sexually victimized are abused by someone known to the child or the child's family (Lieb, Quinsey, and Berliner, 1998). Relatives, friends, baby-sitters, persons in positions of authority over the child, or persons who supervise children are more likely than strangers to commit a sexual assault. Strangers are only responsible for 1 in 10 of all child rapes (Saunders et al., 1999). The most likely assailant for all age groups in a known non- relative.
State that: “Is the following a myth or a fact? - The majority of sexual offenders are caught, convicted, and in prison. [Ask the group to participate and answer the question ] “In fact- Only a fraction of those who commit sexual assault are apprehended and convicted for their crimes. Most convicted sex offenders eventually are released to the community under probation or parole supervision. ♦ Many women who are sexually assaulted by a partner, friend or an acquaintance do not report these crimes to police. Instead, victims are most likely to report being sexually assaulted when the assailant is a stranger, the victim is physically injured during the assault, or a weapon is involved in the commission of the crime. ♦ A 1992 study estimated that only 12% of rapes were reported (Kilpatrick, Edmunds, and Seymour, 1992). In the U.S. the
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Tracey Varker PhD Thesis Appendices National Crime Victimization Survey (1998) indicated that only 32% of sexual assaults against persons 12 or older were reported to law enforcement. (No current studies indicate the rate of reporting for child sexual assault, although it generally is assumed that these assaults are equally under-reported.) The low rate of reporting leads to the conclusion that those sex offenders who are under the authority of corrections agencies represent less than 10% of all sex offenders living in communities nationwide. ♦ While sex offenders constitute a large and increasing population of prison inmates, most are eventually released to the community. Some 60% of convicted sex offenders are supervised in the community, whether directly following sentencing or after a term of incarceration in jail or prison. Short of incarceration, supervision allows the criminal justice system the best means to maintain control over offenders, monitor their residence, and require them to work and participate in treatment.”
State that:
“Is the following a myth or a fact? - All sex offenders are male.”
[Ask the group to participate and answer the question ]
“In fact- The vast majority of sex offenders are male. However, females also commit sexual crimes.
♦ In Australia, research has shown that female offenders are responsible for between 4 and 5% of all sexual offences (Cortoni & Hanson, 2005). Males commit the majority of sex offences but females commit some, particularly against children. Most women abuse children in conjunction with an accomplice (usually a male) while male sex offenders tend to “work alone” (Faller, 1987).”
State that:
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Tracey Varker PhD Thesis Appendices “Is the following a myth or a fact? - Sex offenders commit sexual crimes because they are under the influence of alcohol.”
[Ask the group to participate and answer the question ]
“In fact- It is unlikely that an individual who otherwise would not commit a sexual assault would do so as a direct result of excessive drinking. ♦ Annual crime victim reports indicate that approximately 30% of all reported rapes and sexual assaults involve alcohol use by the offender (Greenfeld, 1998). Alcohol use, therefore, may increase the likelihood that someone already predisposed to commit a sexual assault will act upon those impulses. However, excessive alcohol use is not a primary precipitant to sexual assaults.” State that:
“Is the following a myth or a fact? - Children who are sexually assaulted will sexually assault others when they grow up.”
[Ask the group to participate and answer the question ]
“In fact- Most sex offenders were not sexually assaulted as children and most children who are sexually assaulted do not sexually assault others. ♦ Early childhood sexual victimization does not automatically lead to sexually aggressive behaviour. While sex offenders have higher rates of sexual abuse in their histories than expected in the general population, the majority were not abused. ♦ Among adult sex offenders, approximately 30% have been sexually abused. Some types of offenders, such as those who sexually offend against young boys, have still higher rates of child sexual abuse in their histories (Becker and Murphy, 1998). ♦ While past sexual victimization can increase the likelihood of sexually aggressive behaviour, most children who were sexually victimized never perpetrate against others.” State that:
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Tracey Varker PhD Thesis Appendices “Is the following a myth or a fact? - Adolescents do not commit sex offences.”
[Ask the group to participate and answer the question ]
“In fact- Adolescents are responsible for a significant number of rape and child molestation cases each year. ♦ Sexual assaults committed by adolescents are a growing concern in this country. Currently, it is estimated that adolescents (ages 13 to 17) account for up to one-fifth of all rapes and one-half of It is estimated that adolescent offenders (ages 13 to 17) are responsible for up to 20% of reported rapes and 50% of all cases of child molestation committed each year (Barbaree, Hudson, and Seto, 1993). ♦ It is also suggested that between 50 and 60% of male adolescent sexual offenders have committed a previous sexual offence (Fehrenbach, et al, 1986). However, such estimates are likely to be conservative with many victims and their families reluctant to report these crimes because the offenders are young and usually known to the victim (Groth & Loredo, 1981). ♦ Studies of adult sex offenders indicate that offending escalates in frequency and severity over time (Becker & Abel, 1985).”
Preferential versus Situational Offenders State that: “Child molesters can be divided into two separate groups: preferential and situational offenders. ♦ Preferential offenders have a fixed attraction to children. They have sex with children because they are sexually attracted to and prefer children. They often start offending at an early age; have a large number of victims who are frequently extrafamilial; are more inwardly driven to offend; and have values or beliefs that strongly support an offense life-style. Preferential offenders are more likely to “groom” their victims. This involves 3 general steps - targeting, non-sexual touching and sexual touching.
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Tracey Varker PhD Thesis Appendices ♦ Situational offenders do not have a true sexual preference for children but engage in sex with children for varied and complex reasons. They tend to offend at times of stress; have a later onset of offending; have fewer, often familial victims; and have a general preference for adult partners.”
State that: “Is the following a myth or a fact? - Adolescent sex offenders typically are victims of child sexual abuse and grow up to be adult sex offenders." [Ask the group to participate and answer the question ] “In fact- Multiple factors, not just sexual victimization as a child, are associated with the development of sexually offending behavior in youth. ♦ Recent studies show that rates of physical and sexual abuse vary widely for adolescent sex offenders; 20 to 50% of these youth experienced physical abuse and approximately 40 to 80% experienced sexual abuse (Hunter and Becker, 1998). ♦ While many adolescents who commit sexual offenses have histories of being abused, the majority of these youth do not become adult sex offenders (Becker and Murphy, 1998). ♦ Research suggests that the age of onset and number of incidents of abuse, the period of time elapsing between the abuse and its first report, perceptions of how the family responded to the disclosure of abuse, and exposure to domestic violence all are relevant to why some sexually abused youths go on to sexually perpetrate while others do not (Hunter and Figueredo, 2000). ♦ Once apprehended and convicted, in Australia, 35% of adult sexual offenders will re-offend by committing another sex crime. 35% will re-offend by committing a violent crime, and 55% will commit general offences (Leviore, 2004).”
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Tracey Varker PhD Thesis Appendices Module 7- Victims of Crime
Overview • Introduction • Who is a victim of crime? • The impact of being a victim of crime • The Victims’ Charter Principles • Handouts: “Victims of Crime” worksheet (Appendix XII); “Victims of Crime” fact sheet (Appendix XIII); and “The Victims’ Charter Principles” information sheet (Appendix XIV)
Introduction The Victims of Crime training module is designed to provide the recruits with information that they have not received before as part of their usual police academy training. The purpose is to make them more aware of impact that crime can have upon a victim, and to make them aware of the Victims’ Charter Principles. As this module is part of the control training programme, however, the key purpose is not to increase the recruits’ personal resilience to trauma. State that: “The purpose of this session is to provide you with information about victims of crime. I am sure that you may have heard some of this information before in some of your other classes, but I hope that today you will develop a better understanding of what a person goes through when they are a victim of a crime. I am going to talk to you about the impact that a crime can have on an individual, and I will also talk to you about the Victims Charter.”
Who is a victim of crime? State that: “There are 3 types of victims of crime: primary victims ; secondary victims and related victims. A “primary victim” of an act of violence is defined as a person who is: a) injured or dies as a result of an act of violence committed against him or her b) injured or dies as a direct result of trying to arrest someone who he or she believes on reasonable grounds has committed an act of violence
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Tracey Varker PhD Thesis Appendices c) trying to prevent the commission of an act of violence d) trying to aid or rescue someone he or she believes on reasonable grounds is a victim of an act of violence (Freckleton, 2001).” Ask the group: Who are examples of primary victims? Answers: People injured in a bashing; sexual assault victim; robbery victim State that: “A “ secondary victim” of an act of violence is defined as a person who is present at the scene of an act of violence and who is injured as a direct result of witnessing the act (Freckleton, 2001).” Ask the group: Who are examples of secondary victims? Answers: people such as partners of assault victims; children who witness an attack on a parent; or the families and others close to murder victims “Little research is available to assess the impact of crime upon ‘secondary victims’. However, it is suggested that those close to the victims may suffer some of the same distress that victims experience (Davis et al. 1995, pp. 73–4).”
State that: “A “related victim” of an act of violence is defined to be any person who, at the same time of the occurrence of the act of violence, was a close family member of, or a dependant of, or had a romantic relationship with a primary victim who died as a result of the violent act (Freckleton, 2001).” Ask the group: Who are examples of related victims? Answers: A mother or father; brother or sister; husband or wife; romantic partner (i.e. boyfriend or girlfriend)
Ask the group, “What kind of feelings or symptoms may a victim of crime have?” Answers: - Fear or anxiety - Emptiness and numbness - Nightmares or insomnia - Exhaustion - Sadness or depression
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Tracey Varker PhD Thesis Appendices - Guilt, shame or a feeling or dirtiness - Anger or irritability - Grief and loss - Feelings of loss of privacy and control - Panic and confusion - Helplessness or feeling of being deserted - Physical symptoms of illness Add in any answers that the group misses
In 2005-2006, 34, 275 Victorians were victims of crime against the person (Victoria Police Crime Statistics, 2007). These victims were predominantly male (53.2%). Of all male victims, 84.3% were victims of assault offences, with 4.5% being victims of rape and sex offences. This result contrasts with female victims, where 70.0% were victims of assault and 24.0% were victims of rape and sex offences.
The impact of being a victim of crime State that: “The impacts of crime victimisation can have a long lasting and devastating effect. The consequences of crime can involve financial loss, property damage, physical injury and death. Less obvious, but sometimes more devastating, are the psychological and emotional wounds left in the wake of victimisation (Newburn 1993, Skogan, Lurigio & Davis 1990, p. 7). There is a great deal of research that has explored the psychological and emotional effects of certain crimes, in particular rape, sexual assault and child sexual abuse. Depression, shame and fear are the most commonly identified long-term effects, both amongst direct and indirect victims (Newburn 1993, p. iv). Few studies have attempted to estimate the prevalence of physical injury Reactions to victimization may also often affect everyday behaviours. The research suggests that a proportion of victims of rape or childhood sexual abuse suffer significant and long-lasting behavioural consequences, especially in the area of sexuality, as well as a number of behaviours associated with fear, anxiety and depression. It is not uncommon for child sex abuse victims to have: • Aggressive behaviour
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Tracey Varker PhD Thesis Appendices • Suicidal behaviour • Substance abuse • Impaired social functioning • Personality disorders • Sexuality problems • Relationship problems • Revictimisation • And sometimes the victim becomes a victimiser The majority of these effects do not appear to lessen quickly after the incident, and some are particularly durable (Newburn 1993, p. iv). The key thing to know is that when someone becomes a victim of crime, their view of the world is changed. We know that ‘ subjective appraisal’ is the best predictor of who will do well, and who will not do well. So this means, rather than being how severe you or I would view the crime, and it is how bad the person who it happened to thinks of it. The people that are most affected are the people who have: • Their assumption of invulnerability shattered. They can no longer think “It can’t happen to me” This new perception of vulnerability frequently results in a fear of recurrence (Janoff-Bulman 1985) • Their assumption that the world is meaningful is shattered. The world does not appear meaningful to victims who feel they have been cautious and good people. This is often focused in question: “Why did this happen to me?” (Janoff-Bulman, 1985) • Their positive self-perceptions about themselves are shattered Negative selfimages are activated in the victim—they tend to see themselves as weak, helpless, needy, frightened and out of control (Janoff-Bulman, 1985)
In the aftermath of a crime, victims usually engage in various preventative or avoidance measures, such as participating in self- defence courses, putting new locks on doors, installing alarms, changing their phone number or job, moving, restricting their night time activities or reducing their social contacts (Bard & Sangrey 1979;
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Tracey Varker PhD Thesis Appendices Bard & Johnson 1974; Conklin 1975; Krupnick 1980; Lejeune & Alex 1973; Maguire 1980; Skogan & Maxfield, 1981, all cited in Lurigio 1987). While financial difficulties are generally not the most commonly cited problems faced by crime victims, research suggests that a significant proportion of victims may experience particular financial problems as a result of the offence. For example, there may be costs associated with leaving home or relocating, and with fitting security systems to feel safe; or expenses associated with missing work due to attendance at court proceedings (Bard & Sangrey 1986; Newburn 1993).
The Victims’ Charter Principles Handout (1) the Victims of Crime fact sheet (Appendix XIII), and (2) the Victims’ Charter Principles information sheet (Appendix XIV) State that: “As a worker in the criminal justice system, you have certain principles that you must follow when you are dealing with a victim of crime. These rights are set out in the Victims’ Charter Principles.”
Read through all the points of the Victims’ Charter Principles (Appendix XIV). Answer any questions that may arise.
“I hope that today you will take away with you a greater understanding of the impact that crime victimisation can have on an individual. You should also now all be familiar with the Victims Charter, so keep this in mind every time you deal with a victim crime.”
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Module 8- Conclusion
Overview • Re-cap of Modules • Police Resilience Handbook [Control Group version]
Re-cap of modules In the conclusion, a re-cap of each of the 8 Modules must be conducted. The recruits should be reminded of the topics that have been covered as part of the training programme. State that: “When you are out on the job and working as a police officer, I would like for you to try and recall the things that you have learnt through this training programme. When you arrive at a crime scene, please think about what you have learnt in regards to preserving a crime scene and preventing the contamination of evidence. Many times, the body of a deceased person will also be included as evidence and it may be necessary for to prevent relatives or friends from entering the scene and contaminating this evidence. A task that can be emotionally difficult for many officers is to have to deal with a distressed friend or relative at the scene of a fatality. If there are distraught family and friends at the scene, think about the strategies that we have taught to you that you can then use deal with them. An example of this is to use other friends, family or bystanders at the scene to help comfort a distraught person. During the course of your training you received a talk about sexual offenders, This talk was designed to dispel the myths and misconceptions that are often associated with sexual offending. When working as a police officer, keep in mind that there are many different types of sexual offenders apart from middle aged adult males, including women and adolescents. Most sexual assaults are committed by someone known to the victim or the victims’ family. You also received a talk about victims of crime. During this talk you learnt that there are three different types of victim of crime: primary, secondary and related victims. You were taught about the impact of being a victim of crime, and about the fact that the
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Tracey Varker PhD Thesis Appendices greatest predictor of who will do well, and who will not do well after being victimised, is subjective appraisal. You were also taken through the principles of the Victims’ Charter. Finally, for the small number of you who may find that there is a particular incident that you can’t cope with, staff from Clinical Services are available to provide you with professional help.”
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Post Training Brief Assessment Once the Conclusion has been completed, the Post Training Brief Assessment must be administered. An introduction similar to the following is best: “I would now like for you to fill in a brief questionnaire relating to the training that you have received. I am interested in what you thought of the training programme, which parts you thought were good, and which parts you thought were bad. Your feedback will be used to further develop this training programme” The questionnaire will take 5-10 minutes to fill in, and should be collected by a researcher once it is completed.
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Informal Group Discussion After the Post-Training Assessment, the recruits should then be invited to remain in the session room for an Informal Group Discussion. At this time the recruits will be given the opportunity to discuss the information and events that they have learnt about, and they will be given an opportunity to ask questions of the Guest Speaker. By allowing the recruits the opportunity to ask questions, they are able to further consolidate the information that they have learnt during the session.
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Tracey Varker PhD Thesis Appendices characteristics. American Journal of Orthopsychiatry, 56(2), 225- 233. Freckleton, I. (2001). Criminal Injuries Compensation: Law, practice and policy . Pyrmont, N.S.W.: International Agents & Distributors. Garrison, W. E. (1991). Modeling inoculation training for traumatic incident exposure. In Critical Incidents in Policing , J.T. Reese, J. M. Horn & C. Dunning (Eds.),Washington, D. C.: U. S. Government Printing Office. Gosling, S. D., Rentfrow, P. J. & Swann, W. B. (2003). A very brief measure of the Big-Five personality domains. Journal of Research in Personality, 37, 504-529. Greenfeld, L. A. (1997) Sex offenses and offenders: An analysis of data on rape and sexual assault. Washington, DC: Bureau of Justice Statistics. Greenfeld, L . A. (1998) Alcohol and Crime: An Analysis of National Data on the Prevalence of Alcohol Involvement in Crime . U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Report # NCJ-168632. Groth, A. N., & Loredo, C. M. (1981.) Juvenile sexual offenders: Guidelines for assessment. International Journal of Offender Therapy and Comparative Criminology, 25 , 31-39. Heimberg, R. G. & Barlow, D. H. (1988). Psychosocial treatments for social phobia. Psychosomatics: Journal of Consultation Liaison Psychiatry, 29 (1), 27-37. Hembree, E. A. & Foa, E. B. (2003). Interventions for trauma- related emotional disturbances in adult victims of crime. Journal of Traumatic Stress, 16 (2), 187-199. Hodgins, G. A., Creamer, M. & Bell, R. (2001). Risk factors for posttrauma reactions in police officers: A longitudinal study. The Journal of Nervous and Mental Disease, 189 (8), 541-547. Holcom, M. L., Lehman, W.E.K. & Simpson, D.D. (1993). Employee accidents: influences of personal characteristics, job characteristics, and substance use in jobs differing in accident potential. Journal of Safety Research, 24 , 205-221. Hunter, J. A., & Becker, J. V. (1994). The role of deviant sexual arousal in juvenile sexual offending. Criminal Justice and Behaviour, 21 , 132-149.
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Tracey Varker PhD Thesis Appendices Hunter, J. & Figueredo, A. (2000). The Influence of Personality and History of Sexual Victimization in the Prediction of Juvenile Perpetrated Child Molestation, Behavior Modification, 24 (2), 241-263. Jacobs, E. (1938). Progressive Relaxation . Chicago: University of Chicago Press. Janis, I. (1982). Decision making under stress. In Handbook of Stress: theoretical & clinical aspects , L Goldberg & S. Breznitz (Eds), New York: Free Press. Johnson, D. R., Lubin, H., Rosenheck, R., Fontana, A., Southwick S. & Charney, D. (1997). The impact of the homecoming reception on the development of posttraumatic stress disorder: The West Haven Homecoming Stress Scale (WHHSS). Journal of Traumatic Stress, 10, 259-277. Kandel, D. B. & Yamaguchi, K. (1987). Job mobility and drug use: An event history analysis. American Journal of Sociology, 92 , 836- 878. Keyes, J. B. (1995). Stress Inoculation Training for staff with persons with mental retardation: a model programme. In Job Stress Interventions , L. R. Murphy, J. J. Hurrell, S. L. Sauter & G. P. Keita (Eds.), Washington, D.C: American Psychological Association.
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Kroes, W. (1985). Society's victims- the police: An analysis of job stress in policing. Springfield:Il: Charles Thomas. Lehman, W. E. K. & Simpson, D. D. (1992). Employee substance use and on-the-job behaviors . Journal of Applied Psychology, 77 (3), 309-321. Leskin, G. A., Kaloupek, D. G. & Keane, T. M. (1998). Treatment for traumatic memories: review and recommendations. Clinical Psychology Review, 18 (8), 983-1002.
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Tracey Varker PhD Thesis Appendices Lieb, R., Quinsey, V. & Berliner, L. (1998). Sexual Predators and Social Policy. Crime and Justice , 23 , 143-114. Lievore, D. (2004). Recidivism of sexual assault offenders: Rates, risk factors and treatment efficacy . Canberra: Australian Institute of Criminology. Lovibond, P. F. & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33 , 335-343. Luebbert, K., Dahme, B. & Hasenbring, M. (2001). The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: A meta-analytic review . Psycho-Oncology, 10, 490- 502. Maercker, A. & Müller, J. (2004). Social acknowledgment as a victim or survivor: A scale to measure a recovery factor of PTSD. Journal of Traumatic Stress, 17(4), 345-351. Mandler, G. (1982). Stress and thought processes. In Handbook of Stress: Theoretical and Clinical Aspects , L. Goldberger & S. Breznitz (Eds), NY: Free Press. Marmar, C. R., Weiss, D. S., Metzler, T. J., Delucchi, K. L., Best, S. R. & Wentworth, K. A. (1999). Longitudinal course and predictors of continuing distress following critical incident exposure in emergency services personnel. The Journal of Nervous and Mental Disease, 187(1), 15-22. Maslach, C., Jackson, S. E. & Leiter, M. P. (1996). Maslach Burnout Inventory Manual (3rd Ed .), Palo Alto, California: Consulting Psychologists Press. McNeill, M. & Wilson, C. (1993). Alcohol and the Police Workplace . Payneham, SA, National Police Research Unit. Meichenbaum, D. & Cameron, R. (1973). Sterss inoculation: A skills training approach to anxiety management . Unpublished manuscript: University of Waterloo. Neck, C. P., Steward, G. L. & Manz, C. C. (1995). Thought self- leadership as a framework for enhancing the performance of performance appraisers. Journal of Applied Behavioral Science, 31, 278-302.
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Tracey Varker PhD Thesis Appendices Newbury-Birch, D., & Kamali, F. (2001). Psychological stress, anxiety, depression, job satisfaction, and personality characteristics in preregistration house officers. Postgraduate Medicine, 77 , 109-111. Normand, J., Salyards, S. D. & Mahoney, J. J. (1990). An evaluation of preemployment drug testing. Journal of Applied Psychology, 75 (6), 629-639. Ozer, E. J., Best, S. R., Lipsey, T. L. & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129(1), 52-73. Paton, D. (1994). Disaster relief work: An assessment of training effectiveness. Journal of Traumatic Stress , 7, 275-288. Peterson, C. Bossio L. M. Health and Optimism. New York: Free Press; 1991. Pollock, C., Paton, D., Smith, L. M. & Violanti, J. M. (2003). Team resilience. In Promoting Capabilities to Manage Posttraumatic Stress , D. Paton, L. M. Smith J. M. & Violanti (Eds.), Springfield: Il: Charles C Thomas. Rabavilas, A. D., Boulougouris, J. C. & Stefanis, C. (1976). Duration of flooding sessions in the treatment of obsessive- compulsive patients. Behaviour Research and Therapy, 14 (5), 349-355. Rapee, R. M. (1985). A case of panic disorder treated with breathing retraining. Journal of Behavior Therapy and Experimental Psychiatry,16, 63-65. Richardson, B. & Stone, G. L. (1981). Effects of a cognitive adjunct procedure within a microcounseling situation. Journal of Counseling Psychology, 28 , 168-175. Salkovskis, P. M., Jones, D. R. O. & Clark, D. M. (1986). Respiratory control in the treatment of panic attacks: replication and extension with concurrent measurement of behaviour and pCO2. British Journal of Psychiatry, 148, 526-532. Saunders, B.E., Kilpatrick, D.G., Hanson, R.F., Resnick, H.S., & Walker, M.E. (1999). Prevalence, case characteristics, and long-term psychological correlates of child rape among women: A national survey. Child Maltreatment, 4, 187-200. Scheier, M. F., Carver, C. S. & Bridges, M. W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self- mastery, and self-esteem): A reevaluation of the Life Orientation Test. Journal of Personality and Social Psychology, 67 (6), 1063-1078.
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Tracey Varker PhD Thesis Appendices Schweizer, K., Beck-Seyffer, A. & Schneider, R. (1999). Cognitive bias of optimism and its influence on psychological well- being. Psychological Reports, 84 (2), 627-636. Sharpley, C. F. & Rogers, H. J. (1984). Preliminary validation of the Abbreviated Spanier Dyadic Adjustment Scale: Some psychometric data regarding a screening test of marital adjustment. Educational and Psychological Measurement, 44 , 1045-1049. Solomon, S. D. & Johnson, D. M. (2002). Psychosocial treatment of posttraumatic stress disorder: a practice-friendly review of outcome research. Journal of Clinical Psychology, 58 (8), 947-959. Sorby, N. G., Reavley, W. & Huber, J. W. (1991). Self help programmeme for anxiety in general practice: controlled trial of an anxiety management booklet. The British Journal of General Practice, 41 (351), 417-420. Southwick, S. M., Morgan, C. A. & Rosenberg, R. (2000). Social sharing of Gulf War experiences: Association with trauma-related psychological symptoms. Journal of Nervous and Mental Disease, 188 , 695-700. Spielberger, C. D. (1988). Manual for the State-Trait Anger Expression Inventory (STAXI) . Odessa, FL: Psychological Assessment Resources. Steketee, G., Bransfield, S., Miller, S. M. & Foa, E. B. (1989). The effect of information and coping style on the reduction of phobic anxiety during exposure. Journal of Anxiety Disorders, 3(2), 69-85. Tjaden, P., & Thoennes, N. (1998). Prevalence, Incidence, and Consequences of Violence against Women: Findings from the National Violence against Women Survey . Research in Brief. Ware, J. E. & Sherbourne, C. D. (1992). The MOS 36-item short-form and item selection. Medical Care, 30(6), 473-483. WHO ASSIST Working Group. (2002). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction, 97 ,1183-1194. Williams, C. M. (1987). Diagnosis and treatment of survivor guilt: The bad penny. In Posttraumatic stress disorders: A handbook for clinicians , T. Williams (Ed), Cincinnati: OH: Disabled American Veterans. Wolpe, J. (1973). The practice of behavior therapy (2nd ed.) . New York: Pergamon Press.
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Tracey Varker PhD Thesis Appendices Zajonc, R. B. (1980). Feeling and thinking: Preferences need no inferences. American Psychologist, 35, 151-175. Zeichner, A., Allen, G. D., Giancola, P. R. & Lating, G. M. (1994). Alcohol and aggression: effects of personal threat on human aggression and affective arousal. Alcoholism, Clinical and Experimental Research , 18(3), 657-663. Zwerling, C., Ryan, J. & Orav, E. J. (1990). The efficacy of preemployment drug screening for marijuana and cocaine in predicting employment outcome. The Journal of the American Medical Association, 264 (20), 2639-2644.
Further Reading Theory Davey, G. C. L. (1993). Trauma revaluation, conditioning and anxiety disorders. Behaviour Change, 10 (3), 131-140. Foa, E. B., Steketee, G. & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20, 155-176. Lang, P. J. (1977). Imagery in therapy: An information processing analysis of fear. Behavior Therapy, 8 , 862-868. Mowrer, O. H. (1960). Learning theory and behavior (Vol. xiv). Oxford, England: Wiley. Rachman, S. (1980). Emotional processing. Behaviour Research and Therapy, 18 , 51-60. Rachman, S. (1991). Neo-conditioning and the classical theory of fear acquisition. Clinical Psychology Review, 11, 155-173.
Police and Trauma Studies Adams, K. & Stanwick, J. (2002). Managing the risk of psychological harm for operational police . Payneham, SA: Australasian Centre for Policing Research (Report Series No. 142(1)). Carlier, I. V. E., Lamberts, R. D. & Gersons, B. P. R. (1997). Risk factors for post-traumatic stress symptomatology in police officers: a prospective analysis. Journal of Nervous and Mental Disease, 185 (8), 498-506
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Tracey Varker PhD Thesis Appendices Clohessy, S. & Ehlers, A. (1999). PTSD symptoms, response to intrusive memories, and coping in ambulance service workers. British Journal of Clinical Psychology, 38 , 251-265. Karlsson, I. & Christianson, S. (2003). The phenomenology of traumatic experiences in police work. Policing, 26 (3), 419-438. Robinson, H. M., Sigman, M. R. & Wilson, J. P. (1997). Duty- related stressors and PTSD symptoms in suburban police officers. Psychological Reports, 81 , 835-845.
Police, Drugs and Alcohol Studies Daulby, J. (1991). Research Assessment of Alcohol Problems in the NT Police. Darwin: Northern Territory Police. Davey, J. D., Obst, P. L. & Sheehan, M. C. (2000). Work demographics and officers' perceptions of the work environment which add to the prediction of at risk alcohol consumption within an Australian police sample. Policing, 23 (1), 69-81 Davey, J. D., Obst, P. L. & Sheehan, M. C. (2001). It goes with the job: Officers' insight into the impact of stress and culture on alcohol consumption within the policing occupation. Drugs: Education, Prevention & Policy, 8 (2), 141-149. McNeill, M. & Wilson, C. (1993). Alcohol and the Police Workplace . Payneham, SA: National Police Research Unit (Report Series No. 119(1)). Richmond, R. L., Wodak, A., Kehoe, L. & Heather, N. (1998). How healthy are police? A survey of life-style factors. Addiction, 93 (11), 1729-1737.
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Appendix I [Handbook]- Intake Assessment Battery
This assessment battery is presented in Appendix 19 of this thesis.
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Appendix II – Resilience for Police Trauma Worksheet (Resilience Training Group)
Please complete the items on this worksheet and retain for future reference. Please make the responses as personally relevant as possible. The aim of this session is to help you become aware of your own reactions to Police Trauma, and to develop coping strategies that are relevant to you. You will be examined on some of this material and it could contribute to sustaining you in a challenging and rewarding career.
NAME :______Date :______
1. Have you ever been involved in a potentially traumatic event? ______2. What helped you cope with the event? ______
3. Please list 5 incidents that could have an emotional/psychological impact on Police members (Tick the most relevant for you) 1. ______2. ______3. ______4. ______5. ______
4. Please list 5 common reactions to traumatic incidents (Tick the most relevant for you ) 1. ______2. ______3. ______4. ______5. ______
5. Please list five strategies to cope with Trauma: a) Before you go to the scene 1. ______2. ______3. ______4. ______
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b) While at the scene 1. ______2. ______3. ______4. ______5. ______
c) After the incident 1. ______2. ______3. ______4. ______5. ______
6. List how the Station Unit, Work group can support individuals to cope with: a) general Police duties
b) specific traumatic events
7. List the names of the Units within Victoria Police that provide psychological/emotional support for members.
8. How can you contact these Units (include the phone number)?
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Appendix III –Coping Skills Worksheet
Please complete the items on this worksheet and retain for future reference. The aim of this session is to help you become aware of Coping Skills and Strategies that you can use in stressful situations. You will be examined on some of this material and it could contribute to sustaining you in a challenging and rewarding career. NAME :______Date :______
1. Please list 4 of the physical reactions that you can have when you are feeling stressed 1. ______2. ______3. ______4. ______
2. When you are experiencing an anxiety reaction, does your body release too much oxygen, or too much carbon dioxide? ______
3. “Thought challenging” involves identifying distorted thoughts, challenging them, and replacing them with more adaptive thoughts. What are 3 examples of distorted thoughts that are related to working as a police officer? 1. ______2. ______3. ______
4. What are the three Questions that must be asked when you are Testing a Negative Belief? 1. ______2. ______3. ______
5. If you find yourself feeling faint at the sight of blood or injury, what can you do to stop yourself from fainting? ______
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Appendix IV – Thought Challenging Questions
♦ What evidence do I ♦ Am I forgetting ♦ What are the real have for this relevant facts or and probable thought? focusing too much consequences of the on irrelevant facts? situation?
♦ Is there an ♦ Is this an example of ♦ Am I underestimating alternative way of all-or-nothing or what I can do to deal looking at the black-and-white with the problem or situation? thinking? situation?
♦ Is there any ♦ Am I overestimating ♦ Am I confusing a alternative how much control low-probability event explanation? and responsibility I with one of high have in this probability? situation?
♦ How would ♦ What would be the ♦ Where is the logic in someone else think worst thing that this thought? about the situation? could happen?
♦ Are my judgements ♦ If this is true, what ♦ What are the based on how I felt does that mean, or advantages and rather than what I so what? What disadvantages of did? would be so bad thinking this way? about that?
♦ Am I setting for ♦ How will things look, myself an unrealistic seem, or work in X and unobtainable months? standard?
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Appendix V – Challenging Thoughts: ABCD (Foa, 1996) SITUATION NEGATIVE THOUGHTS EMOTIONS RATIONAL RESPONSE (ACTIVATING EVENT) (BELIEFS) (CONSEQUENCES) (DISPUTING THOUGHT) 1. Actual event leading to Write automatic thought(s) Sad / anxious / angry / Write rational response to unpleasant emotion or / that precede emotion(s) afraid etc. automatic thought(s) and 2. Thoughts or recollections leading to unpleasant emotion
418
Appendix VI- Self Talk
PREPARATION CONFRONTING & HANDLING REVIEWING & • What is it I have to do? • One step at a time; I can REINFORCING • What is the realistic handle this. • It was easier than I likelihood of anything bad • Don’t think about being first thought. happening? anxious or stressed, think • I did it - I got through • Don’t think about how about the task. it; next time will be easier. bad I feel; think about what I • I have been trained for • It will get better and can do about it. situations similar to this. easier each time. • Thinking ONLY about • I can do this; I’m doing it • There is nothing to my feelings won’t help. now. do, I’ve got it together. • I have the support and • I have the skills needed • When I managed the encouragement of my to dela with this. thoughts in my head, I colleagues. • It’s O.K. if I make managed my whole body. • I have already done mistakes; this is how we all • I am avoiding things similar things to this before; I learn. less and less. can do this easily. COPING WITH FEELINGS • Wait until I tell • I just need to take one • When feelings of being ______. step at a time. afraid appear, take a deep • Nothing succeeds • It’s easier once I get breath and exhale SLOWLY. like success. started. • This stress and anxiety • Being active reduced • I will now let only may slow me down at first, the fear. but this will get easier. positive thoughts guide me • There was nothing to through this. • I can manage my stress fear except my own fear. and anxiety. • My expectations are • I should be, and am, what I fear, not the situation. • I have nothing to fear but proud of myself. the fear itself. • My expectations are • Next time will be probably coloured by past • I may feel nauseated easier. experiences. and want to avoid this, but I can cope and succeed. • I’m going to reward myself now with • These feelings will go. ______
419 Appendix VII- Drugs and Alcohol Worksheet
Please complete the items on this worksheet and retain for future reference. The aim of this session is to help inform you about drugs and alcohol, and how to recognise if you or someone you know has a problem. You will be examined on some of this material and it could contribute to sustaining you in a challenging and rewarding career. NAME :______Date :______
1. Please list 3 problems at work that alcohol has been found to be associated with. 1. ______2. ______3. ______
2. One study showed that there was a difference in the drinking habits of people from the time that they began at the police academy, until when they had been on the job for 12 months. a. Did reports of drinking more than once a month increase or decrease? ______
b. Did reports of having more than 6 drinks in a sitting increase or decrease? ______c. Did the number of people who reported smoking increase or decrease? ______
3. How do you tell if you are taking risks with alcohol? ______
4. How do you tell if your drinking has become a habit? ______
5. How do you know if drinking has become a problem? ______
6. Please list 3 ways that you can get help for a drug or alcohol problem 1. ______2. ______3. ______
420 Appendix VIII- How to Recognise Problem Drinking
Am I drinking too much? YES , if you are: • A man who has more than 28 drinks per week or on average has more than 4 drinks per day • A woman who has more than 14 drinks per week or on average has more than 2 drinks per day
Am I drinking heavily? YES , if you are: • A man who has more than 6 drinks per day on more than 3 days a week • A woman who has more than 4 drinks per day on more than 3 days a week
Am I taking risks with alcohol? YES , if you: • Drink and drive, operate machinery, mix alcohol with medicine, or are still under the influence whilst at work • Don’t tell your doctor or pharmacist that you are a regular drinker
Has my drinking become a habit? YES, if you drink regularly to: • Relax, relieve stress or anxiety, or go to sleep • Be more comfortable in social situations • Avoid thinking about sad or unpleasant things • Socialise with other regular drinkers
Has drinking become a problem for me? Yes , if you: • Can’t stop drinking once you start • Fail to do what you should at work or home because of drinking • Find other people make comments about your drinking • Can’t remember what happened while you were drinking • Have hurt someone else as a result of your drinking • Have a drink in the morning to get yourself going
How can I get help for an alcohol problem? If you feel you need help to cut down, you can contact: • Clinical Services on 9301 6900 • Your doctor for advice, treatment or referral • DirectLine on 1800 888 236 , which is a 24 hour telephone counselling, information and referral for people wanting to discuss any alcohol or other drug related issues
421 Appendix IX- Resilience for Police Trauma Worksheet
(Control Group) Please complete the items on this worksheet and retain for future reference. Please make the responses as personally relevant as possible. The aim of this session is to help you become aware of Critical Incidents and the circumstances surrounding these events. The aim is to also raise your awareness of issues concerning crime scenes and evidence. You will be examined on some of this material and it could contribute to sustaining you in a challenging and rewarding career.
NAME :______Date :______
1. Please list five types of critical incidents that could have an impact on Police members 1.______2.______3.______4.______5.______
2. Members of the public will often enter a crime scene. What is 1 way for a police member to keep members of the public away from a crime scene? ______
5. Please list 1 type of commonly used forensic test. ______
4. What is 1 strategy for dealing with distraught family and friends directly after a traumatic event? ______
5. What is the telephone number for Clinical Services? ______
6. Explain the level of confidentiality practiced by Clinical Services. ______
422 Appendix X- Sexual Offenders Worksheet Please complete the items on this worksheet and retain for future reference. The aim of this session is to help inform you about sexual offenders and to dispel some of the commonly held myths about these offenders. You will be examined on some of this material and it could contribute to sustaining you in a challenging and rewarding career. NAME :______Date :______
1. Is it more likely for a woman to be sexually assaulted by a stranger, or by someone they know? ______2. Is a child more likely to be sexually assaulted by a stranger, or by someone they know? ______3. What percentage of sexual offenders are currently under the authority of corrections? ______4. What percentage of sexual offences are committed by female offenders? ______5. Does childhood sexual victimisation lead to sexually aggressive behavior? ______6. What percentage of rapes are committed by adolescent offenders? ______7. What percentage of sexual adult offenders will re-offend by committing a sexual offence? ______
423 Appendix XI- Sexual Offenders Fact Sheet FACTS: ♦ ADULTS: 9 out of 10 rapes or sexual assaults are committed by a current or former husband, partner or date ♦ CHILDREN: 60% of boys and 80% of girls who are sexually victimised, are abused by someone known to the child or the child’s family. Strangers are only responsible for 1 in 10 child rapes ♦ Many women who are assaulted by a partner, friend or acquaintance do not report these crimes to police ♦ Victims are most likely to report when the offender is a stranger ♦ Approximately 12% of rapes, and 32% of sexual assaults against persons 12 or older, are reported ♦ Those sex offenders currently under the authority of corrections represent less than 10% of all offenders living in the community ♦ Most sex offenders are eventually released ♦ 60% of convicted sex offenders are supervised in the community. ♦ Females are responsible for between 4 and 5% of all sexual offences ♦ 30% of all rapes and sexual assaults involve alcohol use by the offender ♦ Childhood sexual victimisation does not automatically lead to sexually aggressive behaviour ♦ Most children who were perpetrated against never perpetrate against others ♦ Adolescents (aged 13 to 17 years) are responsible for up to 20% of rapes, and 50% of child molestation ♦ It is thought that 50 - 60% of adolescent offenders have committed a previous sexual offence ♦ Studies with adult offenders have shown that offending escalates in frequency and severity over time ♦ Research suggests that the age of onset and number of incidents of abuse, the period of time elapsing between the abuse and its first report, perceptions of how the family responded to the disclosure of abuse, and exposure to domestic violence all are relevant to why some sexually abused youths go on to sexually perpetrate while others do not ♦ Once apprehended and convicted, in Australia, 35% of adult sexual offenders will re-offend by committing another sex crime. 35% will re- offend by committing a violent crime, and 55% will commit general offences
424 Appendix XII- Victims of Crime Worksheet Please complete the items on this worksheet and retain for future reference. The aim of this session is to help you become aware of the impact of crime upon victims, and to make you aware of the Victim’s Charter and its principles. You will be examined on some of this material and it could contribute to sustaining you in a challenging and rewarding career.
NAME: ______Date: ______
1. Please give one example of a primary victim. ______
2. Please give one example of a secondary victim. ______
3. Please give one example of a related victim. ______
4. List 3 feelings or symptoms that a victim of crime may experience. a. ______b. ______
5. Is it true or false that ‘subjective appraisal’ is the biggest predictor of who will do well after being the victim of a crime. ______
6. Please give one reason why people sometimes have financial problems after being a victim of crime. ______
425 Appendix XIII- Victims of Crime Fact Sheet
Victims of Crime Facts
A primary victim of an act of violence is defined as person who is: • a) injured or dies as a result of an act of violence committed against him or her • b) injured or dies as a direct result of trying to arrest someone who he or she believes on reasonable grounds has committed an act of violence • c) trying to prevent the commission of an act of violence • d) trying to aid or rescue someone he or she believes on reasonable grounds is a victim of an act of violence.
A “ secondary victim” of an act of violence is defined as a person who is present at the scene of an act of violence and who is injured as a direct result of witnessing the act.
A “related victim” of an act of violence is defined to be any person who, at the same time of the occurrence of the act of violence, was a close family member of, or a dependant of, or had a romantic relationship with a primary victim who died as a result of the violent act.
In 2005-2006, 34, 275 Victorians were victims of crime against the person
The impacts of crime victimisation can have a long lasting and devastating effect. The consequences of crime can involve financial loss, property damage, physical injury and death.
It is not uncommon for child sexual abuse victims to have: aggressive behaviour; suicidal behaviour; substance abuse; impaired social functioning; personality disorders; sexuality problems; relationship problems; and revictimisation.
We know that ‘ subjective appraisal’ is the best predictor of who will do well, and who will not do well. Rather than the crime ‘type’ or someone else’s view of how ‘severe’ the crime was, the best predictor of future functioning is how severe the victim estimated it to be.
People are most affected by a crime when:
• a) Their assumption of invulnerability is shattered • b) Their assumption that the world is meaningful is shattered • c) Their positive self-perceptions about themselves are shattered
426 Tracey Varker PhD Thesis Appendices In the aftermath of a crime victims usually engage in various preventative or avoidance measures.
A significant proportion of victims will face financial problems as a result of the offence.
427
Appendix XIV- The Victims’ Charter Principles
If you are the victim of crime, you have the right to:
1. be treated with courtesy, respect and dignity by all criminal justice and victim support services 2. be given clear, timely and consistent information about your rights and entitlements and, if appropriate, be referred to victims and legal support services 3. be told about the police investigation at key stages - in some cases, the police may not be able to give you all the details if it would jeopardise an investigation, in which case you should be informed accordingly 4. be told about the prosecution, including charges laid and any substantial changes to charges, details of court dates and times when you are required as a witness or have indicated a wish to attend, court outcomes and any appeals lodged 5. be told (if you request it) about the outcome of any bail application and any special conditions of bail which are intended to protect you - your safety can also be taken into account when considering a bail application 6. have the court process explained to you, including your role as a witness 7. as far as practicable, be protected from unnecessary contact with, and intimidation by, the accused and their family and supporters, as well as defence witnesses while you are at court 8. prepare a Victim Impact Statement which may be considered by the court in sentencing the offender, and have access to the assistance you require to prepare a Victim Impact Statement 9. have your personal information, including residential address and telephone number, not disclosed to anybody except in accordance with the Information Privacy Act 2000 10. have your property that is held for investigation or evidence stored and handled in a lawful, respectful and secure manner and, in consultation with you, returned as soon as practicable 11. if you are the victim of a violent crime, request that the court order the offender to pay you compensation. You may also apply for financial assistance from the government for harm resulting from a violent crime 12. apply to be included on the Victims Register if an adult offender is sentenced to prison for a violent crime against you, receive specific information regarding the release of the offender, and have your views taken into account by a Parole Board when any decision about parole of the offender is being considered.
428 Appendix XV- Post Training Assessment Battery
This assessment battery is presented in Appendix 20.
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Appendix XIV- Post Training Assessment Battery
This assessment battery is presented in Appendix 21.
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Appendix XI- 6 Month Follow-up Assessment Battery
This assessment battery is presented in Appendix 22
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Appendix XII- 6- Month Follow-up Assessment Battery This assessment battery is presented in Appendix 23.
[End of Trainer’s Manual]
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Appendix 17: Study 3- Information Sheet
The Prevention of Stress Reactions in New Recruit Police Officers
Investigators: Professor Grant Devilly, Inspector Steve James & Ms Tracey Varker (PhD Student)
We are seeking your participation in the research study entitled “The Prevention of Stress Reactions in New Recruit Police Officers” at Swinburne University of Technology conducted by the above investigators. This research project aims to reduce the occurrence of negative reactions through a controlled trial of preventative measures to build resilience in police officers. This includes providing new recruit police officers with educational information and coping strategies to reduce the negative emotional effects experienced as a result of dealing with traumatic incidents in their day-to-day duties.
Entire squads will be randomly assigned to one of two types of training to deal with stress. New recruit police officers who agree to participate in the research will therefore be randomly assigned to one of these two groups by virtue of the squad that they are in. One group will receive training as normal, with the current teaching regime at the academy. The second group will receive the usual training regime as well, but will also be taken through some strategies related to the pressures that they will experience as police officers. The effectiveness of the resilience training, in relation to coping techniques and emotional well-being will be assessed, as will participant satisfaction. At the beginning of the study, whilst you are training at the academy, you will be asked to complete some questionnaires. You will then be interviewed three times over a period of 3 years, after the completion of your academy training. At each of these interviews, you will simply be asked to complete some questionnaires and to give feedback about how you are finding life as a police officer. The interviews will occur 6 months, 12 months and 3 years after you complete your training at the academy.
Participation in the study will remain confidential. You will be given a numerical identifier and this will be kept in a locked cabinet at Swinburne University of Technology. This information will be kept in the strictest confidence to the full extent of the law. The Victoria Police department will not access or store any of the information collected as part of this study, and will only be provided with summary reports of de-identified information. It is expected that the results of this study will be published in peer-reviewed journals, as part of a PhD and will be presented at Universities and conferences, interested government parties and other Australian emergency response agencies. The identity of participants will not be disclosed and all data will be presented as group data (e.g. “40% of participants reported that…”).
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Your participation in the study is entirely voluntary and you are free to withdraw from the study at any time. You may choose to indicate your decision not to participate by stating so on the “Expression of Interest” form and hence being absent during the research training component of the standard training (if you are in the inoculation group). Alternatively, if you prefer to be more discreet about your decision not to participate, you may indicate so by checking the second option on the “Expression of Interest” form, proceed to complete the questionnaires handed out to all participating officers, but your information will not be used for the research. Your decision will be kept totally confidential, and any questionnaires you return will be destroyed.
Should you have any questions regarding the study, please do not hesitate to ask. Any questions regarding the project entitled “The Prevention of Stress Reactions in New Recruit Police Officers” can be directed to the principal investigator, Professor Grant Devilly at the Brain Sciences Institute on telephone number (03) 9214 5920; or Inspector Steve James, Victoria Police Drug and Alcohol Strategy Unit on telephone number (03) 9247 6724.
Should you experience any discomfort or distress from participating in the research, please contact Victoria Police Clinical Services at (03) 9301 6900 Lifeline (24-hour telephone helpline) 13 11 14, or the Australian Psychological Society at 1800 333 497 for a referral for independent psychologists.
"If you have any concerns or queries about the conduct of this project, please contact: Research Ethics Officer, Office of Research & Graduate Studies (H68), Swinburne University of Technology, P O Box 218, HAWTHORN VIC 3122. Tel (03) 9214 5218 or [email protected] "
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Appendix 18: Study 3- Consent Form
March 2007 Full Project Title: The Prevention of Stress Reactions in New Recruit Police Officers
I have read and I understand the Participant Information sheet .
PLEASE INDICATE YOUR DECISION BY TICKING ONE BOX: I freely agree to participate in this project according to the conditions in the Participant Information sheet, and realise that I may withdraw at any time.
I do not wish to have my information used in the research but will complete the questionnaires and attend the training session. I understand that any questionnaires I return will not be used in the research and will be destroyed.
I do not wish to have my information used in the research, and I will not complete any questionnaires.
I have a copy of the Participant Information Sheet to keep.
I understand that the researcher has agreed not to reveal my identity and personal details if information about this project is published or presented in any public form.
Participant’s Name (printed) ……………………………………………………
Signature …………………………………….……. Date ……………….
Researcher’s Name (printed) ……………………………………………………
Signature …………………………………….……. Date ……………….
Note: All parties signing the Consent Form must date their own signature.
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Appendix 19: Study 3 – Time 1 Questionnaire Package Name______Date______
1. What is your date of birth? ______2. What is your gender? Male Female 3a . What is your marital status? Single Married Widowed Divorced Separated De Facto 3b. If your marital status is anything other than single, indicate the length of time ( in years ) you have been in your current status: ______3c . If you are married , how many previous marriages (excluding your current marriage) have you been in? ______3d . Do you have any children? Yes (go to question 3e) No (go to question 4) 3e . If yes, how many are currently dependant on you? ______4. What is you current religious identification? None Catholic Protestant Generally Christian Muslim Jewish Other 5. Please shade one circle to indicate which culture or ethnic group you feel you most belong (Note: this question relates to status as opposed to geographical locations) Australian Aboriginal or Torres Straight Islander Northern or Western European Southern or Eastern European Asian African North American South American Other
6. What is the highest level of education that you have completed? Some high school Completed Year 12 or equivalent TAFE course Completed Undergraduate Degree Completed Postgraduate Degree
7. We are interested in people's handedness and, therefore, need to know which you favour.
7a. When I write or throw a ball, I (please select one): Always use my left hand Usually use my left hand Use either my left or right hand Usually use my right hand Always use my right hand
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7b. When I kick a ball, I (please select one): Always use my left foot Usually use my left foot Use either my left or right foot Usually use my right foot Always use my right foot
8a. Have you ever seen anybody for emotional problems? Yes (go to question 8b) No (go to question 9)
8b . If yes, please indicate the type of professional (eg, psychologist, GP, priest, etc.) ______8c. How long ago?______8d. How many times?______8e. Do you have any close family members who have seen a mental health professional for support, that you know of? Yes No 8f. Overall, how would you rate your quality of life? (Please circle one number only) 1______2______3______4______5______6______7 Very Good Good Somewhat Neither Good Somewhat Bad Very Good nor Bad Bad Bad 9. Different people cope with situations in different ways. Please circle the number that best describes you. 1 Strongly Agree 2 Agree 3 Somewhat Disagree 4 Neither Agree nor Disagree 5 Somewhat Disagree 6 Disagree 7 Strongly Disagree
9a. When I am worried about something, I talk to friends______1 2 3 4 5 6 7 9b. When I am worried about something, I try to do something to fix the situation ______1 2 3 4 5 6 7
10. In your life, which of the following substances have you ever used ? (NON-MEDICAL USE ONLY) No Yes a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 3 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 3
c. Cannabis (marijuana, pot, grass, hash, etc.) 0 3 d. Cocaine (coke, crack, etc.) 0 3 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 3 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 3 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 3 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 3 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 3 j. Other - specify: ______0 3 If you answered "No" to all items, go straight to Question 18. If you answered "Yes" to any of these items, go on to Question 11 for each substance ever used.
11. In the past three months , how often have you used each of the substances you responded "Yes" to in Question 10? 0 Never 2 Once or Twice
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3 Monthly 4 Weekly 6 Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 2 3 4 6 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 2 3 4 6 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 2 3 4 6 d. Cocaine (coke, crack, etc.) 0 2 3 4 6 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 2 3 4 6 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 2 3 4 6 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 2 3 4 6 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 2 3 4 6 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 2 3 4 6 j. Other - specify:______0 2 3 4 6 If you answered "Never" to all items in Question 11, go straight to Question 15. If any substances in Question 11 were used in the previous 3 months, go on to Question 12, 13 and 14 for each substance used.
12. During the past three months, how often have you had a strong desire or urge to use each of the substances you indicated using in Question 11? 0 Never 3 Once or Twice 4 Monthly 5 Weekly 6 Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 3 4 5 6 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 3 4 5 6 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 3 4 5 6 d. Cocaine (coke, crack, etc.) 0 3 4 5 6 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 3 4 5 6 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 3 4 5 6 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 3 4 5 6 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 3 4 5 6 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 3 4 5 6 j. Other - specify:______0 3 4 5 6
13. During the past three months , how often has your use of each of the substances you indicated using in Question 11 led to health, social, legal, or financial problems? 0 Never 4 Once or Twice 5 Monthly 6 Weekly 7 Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 4 5 6 7 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 4 5 6 7 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 4 5 6 7 d. Cocaine (coke, crack, etc.) 0 4 5 6 7 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 4 5 6 7 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 4 5 6 7 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 4 5 6 7 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 4 5 6 7 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 4 5 6 7 j. Other - specify:______0 4 5 6 7
14. During the past three months , how often have you failed to do what was normally expected of you because of your use of each of the substances you indicated using in Question 11? 0 Never 438
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5 Once or Twice 6 Monthly 7 Weekly 8 Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) XXXXXXXXXXXX b. Alcoholic beverages (beer, wine, spirits, etc.) 0 5 6 7 8 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 5 6 7 8 d. Cocaine (coke, crack, etc.) 0 5 6 7 8 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 5 6 7 8 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 5 6 7 8 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 5 6 7 8 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 5 6 7 8 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 5 6 7 8 j. Other - specify:______0 5 6 7 8
15. Has a friend or relative or anyone else ever expressed concern about your use of each of the substances you have ever used (as indicated in Question 10)?
0 No, Never 6 Yes, in the past 3 months 3 Yes, but not in the past 3 months
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 6 3 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 6 3 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 6 3 d. Cocaine (coke, crack, etc.) 0 6 3 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 6 3 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 6 3 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 6 3 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 6 3 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 6 3 j. Other - specify:______0 6 3
16. Have you ever tried and failed to control, cut down or stop using each of the substances you have ever used (as indicated in Question 10)? 0 No, Never 6 Yes, in the past 3 months 3 Yes, but not in the past 3 months
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 6 3 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 6 3 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 6 3 d. Cocaine (coke, crack, etc.) 0 6 3 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 6 3 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 6 3 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 6 3 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 6 3 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 6 3 j. Other - specify:______0 6 3
17. Have you ever used any drug by injection? (NON-MEDICAL USE ONLY) (Please circle one number) 0______No, Never 2 ______Yes, in the past 3 months 1 ______Yes, but not in the past 3 months
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18. These questions look at your general levels of depression, anxiety and stress. Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week . There are no right or wrong answers. Do not spend too much time on any statement. 0 = Did not apply to me at all 1 = Applied to me to some degree, or some of the time 2 = Applied to me to a considerable degree, or a good part of time 3 = Applied to me very much, or most of the time 1 I found it hard to wind down 0 1 2 3 2 I was aware of dryness of my mouth 0 1 2 3 3 I couldn't seem to experience any positive feeling at all 0 1 2 3 4 I experienced breathing difficulty (eg., excessively rapid breathing, 0 1 2 3 breathlessness in the absence of physical exertion) 5 I found it difficult to work up the initiative to do things 0 1 2 3 6 I tended to over-react to situations 0 1 2 3 7 I experienced trembling (eg., in the hands) 0 1 2 3 8 I felt that I was using a lot of nervous energy 0 1 2 3 9 I was worried about situations in which I might panic and make a 0 1 2 3 fool of myself 10 I felt that I had nothing to look forward to 0 1 2 3 11 I found myself getting agitated 0 1 2 3 12 I found it difficult to relax 0 1 2 3 13 I felt down-hearted and blue 0 1 2 3 14 I was intolerant of anything that kept me from getting on with what 0 1 2 3 I was doing 15 I felt I was close to panic 0 1 2 3 16 I was unable to become enthusiastic about anything 0 1 2 3 17 I felt I wasn't worth much as a person 0 1 2 3 18 I felt that I was rather touchy 0 1 2 3 19 I was aware of the action of my heart in the absence of physical 0 1 2 3 exertion (eg., sense of heart rate increase, heart missing a beat) 20 I felt scared without any good reason 0 1 2 3 21 I felt that life was meaningless 0 1 2 3
19a. Have you ever experienced any event/s (such as those below) that have significantly distressed you? Yes (go to question 19b, directly below) No (go to question 20)
19b. If so, please record the number of times ( Number ) you have experienced the event (use C if the event was experienced continuously over a period of more than 3 months). Also, if any of the events occurred within the last 3 months please put the approximate date next to the event. Please record how distressing all experiences were at the time or immediately after the event, and how much distress you currently experience over the event, by shading a circle (1- 5) under each column. However, should you not wish to specify the actual event but did experience a traumatic event like those below please just complete item 14.
Type of Event (and Level of Distress Level of Distress Date) Experienced Experienced Currently at the Time None Moderate Extreme o None Moderate Extreme 1. Serious accident, 1 2 3 4 5 1 2 3 4 5 fire or explosion 2. Natural disaster 1 2 3 4 5 1 2 3 4 5 (e.g. flood,
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earthquake, hurricane) 3. Non-sexual assaul 1 2 3 4 5 1 2 3 4 5 by someone you know (e.g. being mugged, shot, stabbed, attacked) 4. Non-sexual assault 1 2 3 4 5 1 2 3 4 5 by a stranger (e.g., being mugged, shot, stabbed, attacked) 5. Sexual assault by 1 2 3 4 5 1 2 3 4 5 someone you know (e.g., rape, attempted rape) 6. Sexual assault by a 1 2 3 4 5 1 2 3 4 5 stranger (e.g., rape, attempted rape) 7. Military combat or 1 2 3 4 5 1 2 3 4 5 war zone 8. Imprisonment (e.g., 1 2 3 4 5 1 2 3 4 5 hostage, prison inmate, prisoner of war) 9. Torture 1 2 3 4 5 1 2 3 4 5 10. Life-threatening 1 2 3 4 5 1 2 3 4 5 illness 11. Witnessed any of 1 2 3 4 5 1 2 3 4 5 the above 12. Other: Please 1 2 3 4 5 1 2 3 4 5 specify 13. Other: Please 1 2 3 4 5 1 2 3 4 5 specify 14. I do not wish to 1 2 3 4 5 1 2 3 4 5 specify the event, but one has occurred
20. The following questionnaire is made up of a list of statements each of which may or may not be true about you. For each statement circle "definitely true" if you are sure it is true about you and "probably true" if you think it is true but are not absolutely certain. Similarly, you should circle "definitely false" if you are sure the statement is false and "probably false" if you think it is false but are not absolutely certain. 1 Definitely False 2 Probably False 3 Probably True 4 Definitely True 1 If I wanted to go on a trip for a day (for example, to the country or 1 2 3 4 mountains), I would have a hard time finding someone to go with me 2 I feel that there is no one I can share my most private worries and 1 2 3 4 fears with 3 If I was sick, I could easily find someone to help me with my daily 1 2 3 4 chores. 4 There is someone I can turn to for advice about handling problems 1 2 3 4 with my family. 5 If I decide one afternoon that I would like to go to a movie that 1 2 3 4 evening, I could easily find someone to go with me. 6 When I need suggestions on how to deal with a personal problem, I 1 2 3 4 know someone I can turn to.
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7 I don't often get invited to do things with others. 1 2 3 4 8 If I had to go out of town for a few weeks, it would be difficult to 1 2 3 4 find someone who would look after my house or apartment (the plants, pets, garden, etc.). 9 If I wanted to have lunch with someone, I could easily find 1 2 3 4 someone to join me. 10 If I was stranded 10 miles from home, there is someone I could call 1 2 3 4 who could come and get me. 11 If a family crisis arose, it would be difficult to find someone who 1 2 3 4 could give me good advice about how to handle it. 12 If I needed some help in moving to a new house or apartment, I 1 2 3 4 would have a hard time finding someone to help me.
21a. Most people have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner (or closest friend if you have no romantic partner) for each of the following three items. Please circle the number which best fits your answer.
0 Always Disagree 1 Almost Always Disagree 2 Frequently Disagree 3 Occasionally Agree 4 Almost Always Agree 5 Always Agree
1. Philosophy of life 0 1 2 3 4 5
2. Aims, goals and things believed to be important 0 1 2 3 4 5
3. Amount of time spent together 0 1 2 3 4 5
21b. How often would you say the following events occur between you and your partner (or closest friend if you have no romantic partner)? 0 Never 1 Less than once a month 2 Once or twice a month 3 Once or twice a week 4 Once a day 5 More often
1. Have a stimulating exchange of ideas 0 1 2 3 4 5 2. Calmly discuss something 0 1 2 3 4 5 3. Work together on a project 0 1 2 3 4 5
21c. The numbers below represent different degrees of happiness in intimate relationships. The number 3, "happy", represents the degree of happiness of most relationships. Please circle the number that best describes the degree of happiness, all things considered, of your relationship with your partner or closest friend. 0 Extremely Unhappy 1 Fairly Unhappy 2 A Little Unhappy 3 Happy 4 Very Happy 5 Extremely Happy 6 Perfect
1. Degree of happiness 0 1 2 3 4 5 6
22. A number of statements that people use to describe themselves are given below. Read each statement and then circle the number which indicates how you generally feel. Remember
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that there are no right or wrong answers. Do not spend too much time on any one statement, but give the answer which seems to best describe how you generally feel. 1 Almost Never 2 Sometimes 3 Often 4 Almost Always 1 I am quick tempered 1 2 3 4 2 I have a fiery temper 1 2 3 4 3 I am a hot-headed person 1 2 3 4 4 I get angry when I'm slowed down by others' mistakes 1 2 3 4 5 I feel annoyed when I am not given recognition for doing good 1 2 3 4 work 6 I fly off the handle 1 2 3 4 7 When I get mad, I say nasty things 1 2 3 4 8 It makes me furious when I am criticised in front of others 1 2 3 4 9 When I get frustrated, I feel like hitting someone 1 2 3 4 10 I feel infuriated when I do a good job and get a poor evaluation 1 2 3 4
23. Please read each of the following statements and circle the number 0, 1, 2, 3, or 4 to indicate the extent to which you agree with the statement. Try to be as accurate and honest as possible, and try not to let your answer to one question influence your answers to the other questions. There are no right or wrong answers. 0 Strongly Disagree 1 Disagree 2 Neutral 3 Agree 4 Strongly Agree 1 In uncertain times, I usually expect the best 0 1 2 3 4 2 It's easy for me to relax 0 1 2 3 4 3 If something can go wrong for me it will 0 1 2 3 4 4 I'm always optimistic about my future 0 1 2 3 4 5 I enjoy my friends a lot 0 1 2 3 4 6 It's important for me to keep busy 0 1 2 3 4 7 I hardly ever expect things to go my way 0 1 2 3 4 8 I don't get upset too easily 0 1 2 3 4 9 I rarely count on good things happening to me 0 1 2 3 4 10 Overall, I expect more good things to happen to me than bad 0 1 2 3 4
24. Please read each of the following statements and circle the number 1, 2, 3, 4, 5, 6, or 7 to indicate the extent to which you agree or disagree with the statement. Try and be as accurate and honest as possible, and try not to let your answer to one question influence your answers to the other questions. There are no right or wrong answers.
Disagree Agree 1 2 4 4 5 6 7 1 When I make plans I follow through with them 0 1 2 3 4 5 6 7 2 I usually manage one way or another 0 1 2 3 4 5 6 7 3 I am able to depend on myself more than anyone else 0 1 2 3 4 5 6 7 4 Keeping interested in things is important to me 0 1 2 3 4 5 6 7 5 I can be on my own if I have to 0 1 2 3 4 5 6 7 6 I feel proud that I have accomplished things in my life 0 1 2 3 4 5 6 7 7 I usually take things in stride 0 1 2 3 4 5 6 7 8 I am friends with myself 0 1 2 3 4 5 6 7 9 I feel that I can handle many things at a time 0 1 2 3 4 5 6 7 10 I am determined 0 1 2 3 4 5 6 7 11 I seldom wonder what the point of it all is 0 1 2 3 4 5 6 7
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12 I take things one day at a time 0 1 2 3 4 5 6 7 13 I can get through difficult times because I've experienced 0 1 2 3 4 5 6 7 difficulty before 14 I have self-discipline 0 1 2 3 4 5 6 7 15 I keep interested in things 0 1 2 3 4 5 6 7 16 I can usually find something to laugh about 0 1 2 3 4 5 6 7 17 My belief in myself gets me through hard times 0 1 2 3 4 5 6 7 18 In an emergency, I'm somebody people generally can rely on 0 1 2 3 4 5 6 7 19 I can usually look at a situation in a number of ways 0 1 2 3 4 5 6 7 20 Sometimes I make myself do things whether I want to or not 0 1 2 3 4 5 6 7 21 My life has meaning 0 1 2 3 4 5 6 7 22 I do not dwell on things that I can't do anything about 0 1 2 3 4 5 6 7 23 When I am in a difficult situation, I can usually find my way out 0 1 2 3 4 5 6 7 of it 24 I have enough energy to do what I have to do 0 1 2 3 4 5 6 7 25 It's okay if there are people who don't like me 0 1 2 3 4 5 6 7
25. Here are a number of personality traits that may or may not apply to you. Please circle the number that indicates how much you agree or disagree with each statement. You should rate the extent to which the pair of traits applies to you, even if one characteristic applies more strongly than the other. 1 Disagree strongly 2 Disagree moderately 3 Disagree a little 4 Neither agree nor disagree 5 Agree a little 6 Agree moderately 7 Agree strongly
1 Extraverted, enthusiastic 0 1 2 3 4 5 6 7 2 Critical, quarrelsome 0 1 2 3 4 5 6 7 3 Dependable, self-disciplined 0 1 2 3 4 5 6 7 4 Anxious, easily upset 0 1 2 3 4 5 6 7 5 Open to new experiences, complex 0 1 2 3 4 5 6 7 6 Reserved, quiet 0 1 2 3 4 5 6 7 7 Sympathetic, warm 0 1 2 3 4 5 6 7 8 Disorganised, careless 0 1 2 3 4 5 6 7 9 Calm, emotionally stable 0 1 2 3 4 5 6 7 10 Conventional, uncreative 0 1 2 3 4 5 6 7
27. Below is a set of questions that asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Answer every question by marking the answer as indicated. If you are unsure about how to answer a question please give the best answer you can.
1. In general, would you say your health is: (Please tick one box) Excellent Very Good Good Fair Poor
2. Compared to one year ago , how would you rate your health in general now? (Please tick one box.) Much better than one year ago Somewhat better now than one year ago About the same as one year ago
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Somewhat worse now than one year ago Much worse now than one year ago
3. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Please circle one number on each line.) Activities Yes, Yes, Not Limited Limited Limited at A Lot A All Little
1 Vigorous activities , such as running, lifting heavy 1 2 3 objects, participating in strenuous sports 2 Moderate activities , such as moving a table, 1 2 3 pushing a vacuum cleaner, bowling, or playing golf 3 Lifting or carrying groceries 1 2 3 4 Climbing several flights of stairs 1 2 3 5 Climbing one flight of stairs 1 2 3 6 Bending, kneeling, or stooping 1 2 3 7 Walking more than a mile 1 2 3 8 Walking several blocks 1 2 3 9 Walking one block 1 2 3 10 Bathing or dressing yourself 1 2 3
4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (Please circle one number on each line.)
Yes No 1 Cut down on the amount of time you spent on work or other activities 1 2 2 Accomplished less than you would like 1 2 3 Were limited in the kind of work or other activities 1 2 4 Had difficulty performing the work or other activities (for example, it 1 2 took extra effort)
5. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (e.g. feeling depressed or anxious)? (Please circle one number on each line.) Yes No 1 Cut down on the amount of time you spent on work or other activities 1 2 2 Accomplished less than you would like 1 2 3 Didn’t do work or other activities as carefully as usual 1 2
6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours, or groups? (Please tick one box.) Not at all Slightly Moderately Quite a bit Extremely
7. How much physical pain have you had during the past 4 weeks? (Please tick one box.) None Very mild
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Mild Moderate Severe Very Severe
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? (Please tick one box.) Not at all A little bit Moderately Quite a bit Extremely
9. These questions are about how you feel and how things have been with you during the past 4 weeks. Please give the one answer that is closest to the way you have been feeling for each item. (Please circle one number on each line.) 1 All of the Time 2 Most of the Time 3 A Good Bit of the Time 4 Some of the Time 5 A Little of the Time 6 None of the Time 1 Did you feel full of life? 1 2 3 4 5 6 2 Have you been a very nervous person? 1 2 3 4 5 6 3 Have you felt so down in the dumps that nothing could 1 2 3 4 5 6 cheer you up? 4 Have you felt calm and peaceful? 1 2 3 4 5 6 5 Did you have a lot of energy? 1 2 3 4 5 6 6 Have you felt downhearted and blue? 1 2 3 4 5 6 7 Did you feel worn out? 1 2 3 4 5 6 8 Have you been a happy person? 1 2 3 4 5 6 9 Did you feel tired? 1 2 3 4 5 6
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives etc.) (Please tick one box.) All of the time Most of the time Some of the time A little of the time None of the time
11. How TRUE or FALSE is each of the following statements for you? (Please circle one number on each line) 1 Definitely True 2 Mostly True 3 Don’t Know 4 Mostly 5 False 6 Definitely False 1 I seem to get sick a little easier than other people 1 2 3 4 5 6 2 I am as healthy as anybody I know 1 2 3 4 5 6 3 I expect my health to get worse 1 2 3 4 5 6 4 My health is excellent 1 2 3 4 5 6
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE
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Appendix 20: Study 3 – Time 2 Questionnaire Package- Intervention Condition
Name: ______Date: ______
SECTION 1 We would like to know how upsetting you found the resilience training which you have received from Swinburne University. This is not a judgment of your convenors, but rather a judgment of the course training and its methods.
1 Not at all 5 Somewhat distressed 9 Very distressed
1 How much distress did you experience during 1 2 3 4 5 6 7 8 9 the first assessment (i.e., when you filled in the questionnaire)? 2 How much distress did you experience during 1 2 3 4 5 6 7 8 9 the first training session (i.e., when the officer from the Homicide or Major Collisions Unit) spoke to you? 3 On leaving the first training session, how much 1 2 3 4 5 6 7 8 9 distress did you experience over the next few hours? (This is a rating of the distress caused by the first session, as opposed to your normal levels of distress)
1 Not at all 5 Somewhat anxious 9 Very anxious 4 How anxious were you about returning for the 1 2 3 4 5 6 7 8 9 second training session (i.e., the Coping Skills training)?
1 Not at all 5 Somewhat intrusive 9 Very intrusive 5 Overall, how intrusive did you find the whole 1 2 3 4 5 6 7 8 9 of the resilience training programme?
1 Not at all 5 Somewhat distressing 9 Very distressing 6 Overall, how distressing did you find the 1 2 3 4 5 6 7 8 9 whole of the resilience training programme?
1 Not at all 5 Somewhat exhausting 9 Very exhausting 7 Overall, how exhausting did you find the 1 2 3 4 5 6 7 8 9 whole of the resilience training programme?
1 Not at all 5 Somewhat inclined 9 Very inclined 8 If at the beginning of the course you knew as 1 2 3 4 5 6 7 8 9
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much about the resilience training programme as you do now, how inclined would you have been in still participating?
1 Not at all 5 Somewhat likely 9 Very likely 9 How likely are you to recommend this type of 1 2 3 4 5 6 7 8 9 training programme to someone else who is beginning at the Police Academy?
1 Not at all 5 Somewhat 9 Very much so 10 Do you believe that the resilience training 1 2 3 4 5 6 7 8 9 programme was a valuable use of your time?
SECTION 2 When evaluating a training programme, we know that it is important to look at how satisfied people were with the different training elements and how important they thought each of the training elements were. Below are two sections which look at: a) your satisfaction with different aspects of the training; and b) how important you think are each of the training elements. a) Below is a list of questions. We would like for you to rate your satisfaction in regards to a number of the resilience training elements. Please shade the circle (1 poor, 5 adequate, 9 excellent) that best describes your opinion.
1 Not at all 5 Somewhat 9 Very much so Can’t remember
11 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on Policing Expectations (i.e., the types of incidents that you should expect when you are working as a police officer)? 12 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on the Common Responses that people have to Serious Incidents? 13 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1, on Social Support (i.e. the benefit of talking about problems to friends, family and colleagues)? 14 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided during Session 1 on the Help Services that are available to you (e.g., Clinical Services, Peer Support) ? 15 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 2 on Coping Strategies? 16 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during
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Session 3 on Drugs and Alcohol? 17 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 4, when you received a re-cap of the training programme? b) Below is a list of questions. We would like for you to rate the importance of a number of the training elements. Please shade the circle (1 poor, 5 adequate, 9 excellent) that best describes your opinion. 1 Not at all 5 Somewhat 9 Very much so Can’t remember 18 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on Policing Expectations (i.e. the types of incidents that you should expect when you are working as a police officer)? 19 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on the Common Responses that people have to Serious Incidents? 20 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on Social Support (i.e., the benefit of talking about problems to friends, family and colleagues)?
21 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on the Help Services (e.g. Clinical Services, Peer Support) that are available to you? 22 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 2 on Coping Strategies? 23 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 3, on Drugs and Alcohol? 24 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 4, when you received a re-cap of the training programme?
SECTION 3 We would like you to indicate below how much you believe, right now , that the resilience training you received will help you to deal with stress and trauma. Belief usually has two aspects to it: (1) what one thinks will happen and (2) what one feels will happen. Sometimes these are similar, sometimes they are different. Please answer the questions below. In the first set, answer in terms of what you think. In the second set answer in terms of what really and truly feel.
SET I 1 Not at all 5 Somewhat logical 9 Very logical
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1 At this point, how logical does the resilience 1 2 3 4 5 6 7 8 9 training provided to you seem?
1 Not at all 5 Somewhat useful 9 Very useful 2 At this point, how useful do you think the 1 2 3 4 5 6 7 8 9 resilience training will be in helping you avoid stress and trauma symptoms?
1 Not at all 5 Somewhat 9 Very much 3 If you think that the resilience training will 1 2 3 4 5 6 7 8 9 help, how much do you think that it will help?
SET II For this set, close your eyes for a few moment and try to identify what you really feel about the resilience training and its likely success. Then answer the following questions.
1 Not at all 5 Somewhat useful 9 Very useful 4 At this point, how useful do you feel that the 1 2 3 4 5 6 7 8 9 resilience training will be in helping you to avoid stress and trauma symptoms?
1 Not at all 5 Somewhat 9 Very much 5 If you feel that the resilience training will help, 1 2 3 4 5 6 7 8 9 how much do you feel that it will help?
SECTION 4 These questions look at your general levels of depression, anxiety and stress. Please read each statement and shade the circle (0, 1, 2 or 3) which indicates how much the statement applied to you over the past week . There are no right or wrong answers. Do not spend too much time on any statement. 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time
1 I found it hard to wind down 0 1 2 3 2 I was aware of dryness of my mouth 0 1 2 3 3 I couldn't seem to experience any positive feeling at all 0 1 2 3 4 I experienced breathing difficulty (eg., excessively rapid breathing, 0 1 2 3 breathlessness in the absence of physical exertion) 5 I found it difficult to work up the initiative to do things 0 1 2 3 6 I tended to over-react to situations 0 1 2 3 7 I experienced trembling (eg., in the hands) 0 1 2 3 8 I felt that I was using a lot of nervous energy 0 1 2 3 9 I was worried about situations in which I might panic and make a 0 1 2 3 fool of myself
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10 I felt that I had nothing to look forward to 0 1 2 3 11 I found myself getting agitated 0 1 2 3 12 I found it difficult to relax 0 1 2 3 13 I felt down-hearted and blue 0 1 2 3 14 I was intolerant of anything that kept me from getting on with what 0 1 2 3 I was doing 15 I felt I was close to panic 0 1 2 3 16 I was unable to become enthusiastic about anything 0 1 2 3 17 I felt I wasn't worth much as a person 0 1 2 3 18 I felt that I was rather touchy 0 1 2 3 19 I was aware of the action of my heart in the absence of physical 0 1 2 3 exertion (eg., sense of heart rate increase, heart missing a beat) 20 I felt scared without any good reason 0 1 2 3 21 I felt that life was meaningless 0 1 2 3
Please feel free to add any other comments. ______
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Appendix 21: Study 3 –Time 2 Questionnaire Package- Control Condition
Name: ______Date: ______
SECTION 1 We would like to know how upsetting you found the resilience training which you have received from Swinburne University. This is not a judgment of your convenors, but rather a judgment of the course training and its methods.
1 Not at all 5 Somewhat distressed 9 Very distressed
1 How much distress did you experience during 1 2 3 4 5 6 7 8 9 the first assessment (i.e., when you filled in the questionnaire)? 2 How much distress did you experience during 1 2 3 4 5 6 7 8 9 the first training session (i.e., when the officer from the Homicide or Major Collisions Unit) spoke to you? 3 On leaving the first training session, how much 1 2 3 4 5 6 7 8 9 distress did you experience over the next few hours? (This is a rating of the distress caused by the first session, as opposed to your normal levels of distress)
1 Not at all 5 Somewhat anxious 9 Very anxious 4 How anxious were you about returning for the 1 2 3 4 5 6 7 8 9 second training session (i.e., the Sexual Offenders session)?
1 Not at all 5 Somewhat intrusive 9 Very intrusive 5 Overall, how intrusive did you find the whole 1 2 3 4 5 6 7 8 9 of the resilience training programme?
1 Not at all 5 Somewhat distressing 9 Very distressing 6 Overall, how distressing did you find the 1 2 3 4 5 6 7 8 9 whole of the resilience training programme?
1 Not at all 5 Somewhat exhausting 9 Very exhausting 7 Overall, how exhausting did you find the 1 2 3 4 5 6 7 8 9 whole of the resilience training programme?
1 Not at all 5 Somewhat inclined 9 Very inclined
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8 If at the beginning of the course you knew as 1 2 3 4 5 6 7 8 9 much about the resilience training programme as you do now, how inclined would you have been in still participating?
1 Not at all 5 Somewhat likely 9 Very likely 9 How likely are you to recommend this type of 1 2 3 4 5 6 7 8 9 training programme to someone else who is beginning at the Police Academy?
1 Not at all 5 Somewhat 9 Very much so 10 Do you believe that the resilience training 1 2 3 4 5 6 7 8 9 programme was a valuable use of your time?
SECTION 2 When evaluating a training programme, we know that it is important to look at how satisfied people were with the different training elements and how important they thought each of the training elements were. Below are two sections which look at: a) your satisfaction with different aspects of the training; and b) how important you think are each of the training elements. a) Below is a list of questions. We would like for you to rate your satisfaction in regards to a number of the resilience training elements. Please shade the circle (1 poor, 5 adequate, 9 excellent) that best describes your opinion.
1 Not at all 5 Somewhat 9 Very much so Can’t remember
11 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on Critical Incidents (i.e., the types of incidents that you should expect when you are working as a police officer)? 12 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on how to Preserve Evidence and the Crime Scene? 13 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on the role of Clinical Services? 14 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on how to deal with the Family and Friends of a Victim? 15 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 2 on Sexual Offenders? 16 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 3 on Victims of Crime? 17 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during
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Session 4 when you received a re-cap of the training programme? b) Below is a list of questions. We would like for you to rate the importance of a number of the training elements. Please shade the circle (1 poor, 5 adequate, 9 excellent) that best describes your opinion. 1 Not at all 5 Somewhat 9 Very much so Can’t remember 18 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on Critical Incidents (i.e., the types of incidents that you should expect when you are working as a police officer)? 19 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on how to Preserve Evidence and the Crime Scene? 20 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on the role of Clinical Services? 21 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on how to deal with the Family and Friends of a Victim? 22 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 2 on Sexual Offenders? 23 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 3 on Victims of Crime? 24 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 4 when you received a re-cap of the training programme?
SECTION 3 We would like you to indicate below how much you believe, right now , that the resilience training you received will help you to deal with stress and trauma. Belief usually has two aspects to it: (1) what one thinks will happen and (2) what one feels will happen. Sometimes these are similar, sometimes they are different. Please answer the questions below. In the first set, answer in terms of what you think. In the second set answer in terms of what really and truly feel.
SET I 1 Not at all 5 Somewhat logical 9 Very logical 1 At this point, how logical does the resilience 1 2 3 4 5 6 7 8 9 training provided to you seem?
1 Not at all 5 Somewhat useful 9 Very useful 2 At this point, how useful do you think the 1 2 3 4 5 6 7 8 9 resilience training will be in helping you avoid
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stress and trauma symptoms?
1 Not at all 5 Somewhat 9 Very much 3 If you think that the resilience training 1 2 3 4 5 6 7 8 9 will help, how much do you think that it will help?
SET II For this set, close your eyes for a few moment and try to identify what you really feel about the resilience training and its likely success. Then answer the following questions.
1 Not at all 5 Somewhat useful 9 Very useful 4 At this point, how useful do you feel that the 1 2 3 4 5 6 7 8 9 resilience training will be in helping you to avoid stress and trauma symptoms?
1 Not at all 5 Somewhat 9 Very much 5 If you feel that the resilience training will help, 1 2 3 4 5 6 7 8 9 how much do you feel that it will help?
SECTION 4 These questions look at your general levels of depression, anxiety and stress. Please read each statement and shade the circle (0, 1, 2 or 3 ) which indicates how much the statement applied to you over the past week . There are no right or wrong answers. Do not spend too much time on any statement. 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time
1 I found it hard to wind down 0 1 2 3 2 I was aware of dryness of my mouth 0 1 2 3 3 I couldn't seem to experience any positive feeling at all 0 1 2 3 4 I experienced breathing difficulty (eg., excessively rapid breathing, 0 1 2 3 breathlessness in the absence of physical exertion) 5 I found it difficult to work up the initiative to do things 0 1 2 3 6 I tended to over-react to situations 0 1 2 3 7 I experienced trembling (eg., in the hands) 0 1 2 3 8 I felt that I was using a lot of nervous energy 0 1 2 3 9 I was worried about situations in which I might panic and make a 0 1 2 3 fool of myself 10 I felt that I had nothing to look forward to 0 1 2 3 11 I found myself getting agitated 0 1 2 3 12 I found it difficult to relax 0 1 2 3 13 I felt down-hearted and blue 0 1 2 3 14 I was intolerant of anything that kept me from getting on with what 0 1 2 3 I was doing 15 I felt I was close to panic 0 1 2 3 16 I was unable to become enthusiastic about anything 0 1 2 3
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17 I felt I wasn't worth much as a person 0 1 2 3 18 I felt that I was rather touchy 0 1 2 3 19 I was aware of the action of my heart in the absence of physical 0 1 2 3 exertion (eg., sense of heart rate increase, heart missing a beat) 20 I felt scared without any good reason 0 1 2 3 21 I felt that life was meaningless 0 1 2 3
Please feel free to add any other comments. ______
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Appendix 22: Study 3 – Time 3 Questionnaire Package- Intervention Condition
Name: ______Date :______
1. What is your current rank?
Constable Senior Constable
2. On average, how many hours do you work per week?
Less than 40 hours 40-49 hours 50-64 hours 65-79 hours 80 hours +
3. In the previous 6 months, please indicate for each of the following 4 VicPol Services, whether you have accessed them and if so, how satisfied you were with the service.
1. Clinical Services 2.Welfare/Employee Support 3. Chaplin Did not access Did not access Did not access Very Dissatisfied Very Dissatisfied Very Dissatisfied Slightly Dissatisfied Slightly Dissatisfied Slightly Dissatisfied Neither Neither Neither Slightly Satisfied Slightly Satisfied Slightly Satisfied Very Satisfied Very Satisfied Very Satisfied
4. Peer Support Did not access Slightly Dissatisfied Neither Slightly Satisfied Very Satisfied
4. In the previous 6 months, please indicate for each of the following 6 services, whether you have accessed them and if so, how satisfied you were with the service.
1. Psychologist 2. Psychiatrist 3. Social Worker Did not access Did not access Did not access Very Dissatisfied Very Dissatisfied Very Dissatisfied Slightly Dissatisfied Slightly Dissatisfied Slightly Dissatisfied Neither Neither Neither Slightly Satisfied Slightly Satisfied Slightly Satisfied Very Satisfied Very Satisfied Very Satisfied
4. Priest/Spiritual Advisor 5. GP 6. Counsellor/Other Did not access Did not access Did not access Very Dissatisfied Very Dissatisfied Very Dissatisfied Slightly Dissatisfied Slightly Dissatisfied Slightly Dissatisfied Neither Neither Neither Slightly Satisfied Slightly Satisfied Slightly Satisfied Very Satisfied Very Satisfied Very Satisfied
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5. You will now be asked questions relating to the Resilience Training that you received when you were at the Police Academy 6 months ago. When evaluating a training programme, we know that it is important to look at how satisfied people were with the different training elements and how important they thought each of the training elements were. Below are two sections which look at: a) your satisfaction with different aspects of the training; and b) how important you think each of the training elements are. a) Below is a list of questions. We would like for you to rate your satisfaction in regards to a number of the resilience training elements. Please shade the circle (1 poor, 5 adequate, 9 excellent) that best describes your opinion.
1 Not at all 5 Somewhat 9 Very much so Can’t remember 1 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on Policing Expectations (i.e., the types of incidents that you should expect when you are working as a police officer)? 2 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on the Common Responses that people have to Serious Incidents? 3 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1, on Social Support (i.e. the benefit of talking about problems to friends, family and colleagues)? 4 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided during Session 1 on the Help Services that are available to you (e.g., Clinical Services, Peer Support) ? 5 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 2 on Coping Strategies? 6 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 3 on Drugs and Alcohol? 7 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 4, when you received a re-cap of the training programme? b) Below is a list of questions. We would like for you to rate the importance of a number of the training elements. Please shade the circle (1 poor, 5 adequate, 9 excellent) that best describes your opinion. 1 Not at all 5 Somewhat 9 Very much so Can’t remember 8 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on Policing Expectations (i.e. the types of incidents that you should expect when you are working as a police officer)?
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9 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on the Common Responses that people have to Serious Incidents? 10 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on Social Support (i.e., the benefit of talking about problems to friends, family and colleagues)?
11 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on the Help Services (e.g. Clinical Services, Peer Support) that are available to you? 12 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 2 on Coping Strategies? 13 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 3, on Drugs and Alcohol? 14 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 4, when you received a re-cap of the training programme?
6. 1 Not at all 2 A little 3 Somewhat 4 Very much 5 Extremely
1 In the past 6 months, how often did you practice the 1 2 3 4 5 breathing technique and muscle relaxation skills (e.g. clenching fists etc), that you were taught when you went to the Coroner's Court? 2 Overall, how helpful were the handouts that you received as 1 2 3 4 5 part of the resilience training? 3 Overall, how helpful was the Police Resilience Handbook ? 1 2 3 4 5
7. The following questions relate to your knowledge of victims of crime. Please read each statement carefully, and shade the appropriate circle (0, 1, 2, 3, 4 or 5).
0 Not at all 1 Very small degree 2 Small degree 3 Moderate degree 4 A great degree 5 A very great degree
1 Victims of crime are usually implicated in their own 0 1 2 3 4 5 victimhood to some extent 2 I am aware of the practical needs of victims of crime 0 1 2 3 4 5 3 I am aware of the emotional needs of victims of crime 0 1 2 3 4 5 4 I am aware of referral procedures and options for 0 1 2 3 4 5 different types of victims of crime
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5 I refer victims of crime on to other professionals 0 1 2 3 4 5 6 I try to provide support to victims of crime at a personal 0 1 2 3 4 5 level 7 I try to provide support to victims of crime at a 0 1 2 3 4 5 professional level
8. The following questions look relate to your knowledge of sexual offenders. Please read each statement carefully, and shade the appropriate circle. 1 Yes 2 No
1 Have you had to have interaction with sexual offenders while working 1 2 as a police officer? 2 Have you had to have interaction with SOCAU (Sexual Offence and 1 2 Child Abuse Unit)?
0 Not at all 1 Very small degree 2 Small degree 3 Moderate degree 4 A great degree 5 A very great degree
3 To what degree do you believe child sexual offenders 0 1 2 3 4 5 (adults who offend sexually against children) can be rehabilitated? 4 To what degree do you believe adult sexual offenders 0 1 2 3 4 5 who offend against other adults can be rehabilitated? 5 To what degree do you believe adolescent sexual 0 1 2 3 4 5 offenders who offend against other children can be rehabilitated?
9. These questions look at your general levels of depression, anxiety and stress. Please read each statement and shade the circle (0, 1, 2 or 3) which indicates how much the statement applied to you over the past week . There are no right or wrong answers. Do not spend too much time on any statement. 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time
1 I found it hard to wind down 0 1 2 3 2 I was aware of dryness of my mouth 0 1 2 3 3 I couldn't seem to experience any positive feeling at all 0 1 2 3 4 I experienced breathing difficulty (eg., excessively rapid 0 1 2 3 breathing, breathlessness in the absence of physical exertion) 5 I found it difficult to work up the initiative to do things 0 1 2 3 6 I tended to over-react to situations 0 1 2 3 7 I experienced trembling (eg., in the hands) 0 1 2 3 8 I felt that I was using a lot of nervous energy 0 1 2 3 9 I was worried about situations in which I might panic and make a 0 1 2 3 fool of myself 10 I felt that I had nothing to look forward to 0 1 2 3 11 I found myself getting agitated 0 1 2 3 12 I found it difficult to relax 0 1 2 3
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13 I felt down-hearted and blue 0 1 2 3 14 I was intolerant of anything that kept me from getting on with 0 1 2 3 what I was doing 15 I felt I was close to panic 0 1 2 3 16 I was unable to become enthusiastic about anything 0 1 2 3 17 I felt I wasn't worth much as a person 0 1 2 3 18 I felt that I was rather touchy 0 1 2 3 19 I was aware of the action of my heart in the absence of physical 0 1 2 3 exertion (eg., sense of heart rate increase, heart missing a beat) 20 I felt scared without any good reason 0 1 2 3 21 I felt that life was meaningless 0 1 2 3
10. The following questionnaire is made up of a list of statements each of which may or may not be true about you. For each statement circle "definitely true" if you are sure it is true about you and "probably true" if you think it is true but are not absolutely certain. Similarly, you should circle "definitely false" if you are sure the statement is false and "probably false" if you think it is false but are not absolutely certain. 1 Definitely False 2 Probably False 3 Probably True 4 Definitely True 1 If I wanted to go on a trip for a day (for example, to the country or 1 2 3 4 mountains), I would have a hard time finding someone to go with me 2 I feel that there is no one I can share my most private worries and 1 2 3 4 fears with 3 If I was sick, I could easily find someone to help me with my daily 1 2 3 4 chores. 4 There is someone I can turn to for advice about handling problems 1 2 3 4 with my family. 5 If I decide one afternoon that I would like to go to a movie that 1 2 3 4 evening, I could easily find someone to go with me. 6 When I need suggestions on how to deal with a personal problem, I 1 2 3 4 know someone I can turn to. 7 I don't often get invited to do things with others. 1 2 3 4 8 If I had to go out of town for a few weeks, it would be difficult to 1 2 3 4 find someone who would look after my house or apartment (the plants, pets, garden, etc.). 9 If I wanted to have lunch with someone, I could easily find 1 2 3 4 someone to join me. 10 If I was stranded 10 miles from home, there is someone I could call 1 2 3 4 who could come and get me. 11 If a family crisis arose, it would be difficult to find someone who 1 2 3 4 could give me good advice about how to handle it. 12 If I needed some help in moving to a new house or apartment, I 1 2 3 4 would have a hard time finding someone to help me.
11. In your life, which of the following substances have you ever used ? (NON-MEDICAL USE ONLY) No Yes a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 3 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 3 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 3 d. Cocaine (coke, crack, etc.) 0 3 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 3
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f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 3 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 3 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 3 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 3 j. Other - specify: ______0 3 If you answered "No" to all items, go straight to Question 19. If you answered "Yes" to any of these items, go on to Question 12 for each substance ever used.
12. In the past three months , how often have you used each of the substances you responded "Yes" to in Question 10? 0 Never 2 Once or Twice 3 Monthly 4 Weekly 6 Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 2 3 4 6 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 2 3 4 6 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 2 3 4 6 d. Cocaine (coke, crack, etc.) 0 2 3 4 6 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 2 3 4 6 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 2 3 4 6 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 2 3 4 6 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 2 3 4 6 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 2 3 4 6 j. Other - specify:______0 2 3 4 6 If you answered "Never" to all items in Question 12, go straight to Question 16. If any substances in Question 12 were used in the previous 3 months, go on to Question 13, 14 and 15 for each substance used.
13. During the past three months, how often have you had a strong desire or urge to use each of the substances you indicated using in Question 11?
0 Never 3 Once or Twice 4 Monthly 5 Weekly 6 Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 3 4 5 6 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 3 4 5 6 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 3 4 5 6 d. Cocaine (coke, crack, etc.) 0 3 4 5 6 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 3 4 5 6 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 3 4 5 6 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 3 4 5 6 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 3 4 5 6 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 3 4 5 6 j. Other - specify:______0 3 4 5 6
14. During the past three months , how often has your use of each of the substances you indicated using in Question 11 led to health, social, legal, or financial problems? 0 Never 4 Once or Twice 5 Monthly 6 Weekly 7 Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 4 5 6 7 462
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b. Alcoholic beverages (beer, wine, spirits, etc.) 0 4 5 6 7 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 4 5 6 7 d. Cocaine (coke, crack, etc.) 0 4 5 6 7 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 4 5 6 7 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 4 5 6 7 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 4 5 6 7 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 4 5 6 7 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 4 5 6 7 j. Other - specify:______0 4 5 6 7
15. During the past three months , how often have you failed to do what was normally expected of you because of your use of each of the substances you indicated using in Question 11?
0 Never 5 Once or Twice 6 Monthly 7 Weekly 8 Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) XXXXXXXXXXXX b. Alcoholic beverages (beer, wine, spirits, etc.) 0 5 6 7 8 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 5 6 7 8 d. Cocaine (coke, crack, etc.) 0 5 6 7 8 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 5 6 7 8 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 5 6 7 8 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 5 6 7 8 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 5 6 7 8 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 5 6 7 8 j. Other - specify:______0 5 6 7 8
16. Has a friend or relative or anyone else ever expressed concern about your use of each of the substances you have ever used (as indicated in Question 10)?
1 No, Never 6 Yes, in the past 3 months 3 Yes, but not in the past 3 months
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 6 3 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 6 3 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 6 3 d. Cocaine (coke, crack, etc.) 0 6 3 e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 6 3 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 6 3 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 6 3 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 6 3 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 6 3 j. Other - specify:______0 6 3
17. Have you ever tried and failed to control, cut down or stop using each of the substances you have ever used (as indicated in Question 10)? 0 No, Never 6 Yes, in the past 3 months 3 Yes, but not in the past 3 months
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 6 3 b. Alcoholic beverages (beer, wine, spirits, etc.) 0 6 3 c. Cannabis (marijuana, pot, grass, hash, etc.) 0 6 3 d. Cocaine (coke, crack, etc.) 0 6 3
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e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 6 3 f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 6 3 g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 6 3 h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 6 3 i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 6 3 j. Other - specify:______0 6 3
18. Have you ever used any drug by injection? (NON-MEDICAL USE ONLY) (Please circle one number) 0______No, Never 2 ______Yes, in the past 3 months 1 ______Yes, but not in the past 3 months
19. Below is a set of questions that asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Answer every question by marking the answer as indicated. If you are unsure about how to answer a question please give the best answer you can.
1. In general, would you say your health is: (Please tick one box) Excellent Very Good Good Fair Poor
2. Compared to one year ago , how would you rate your health in general now? (Please tick one box.) Much better than one year ago Somewhat better now than one year ago About the same as one year ago Somewhat worse now than one year ago Much worse now than one year ago
3. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Please circle one number on each line.) Activities Yes, Yes, Not Limited Limited Limite A Lot A d at Little All
1 Vigorous activities , such as running, lifting 1 2 3 heavy objects, participating in strenuous sports 2 Moderate activities , such as moving a table, 1 2 3 pushing a vacuum cleaner, bowling, or playing golf 3 Lifting or carrying groceries 1 2 3 4 Climbing several flights of stairs 1 2 3 5 Climbing one flight of stairs 1 2 3 6 Bending, kneeling, or stooping 1 2 3 7 Walking more than a mile 1 2 3 8 Walking several blocks 1 2 3 9 Walking one block 1 2 3 10 Bathing or dressing yourself 1 2 3
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4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (Please circle one number on each line.)
Yes No 1 Cut down on the amount of time you spent on work or other activities 1 2 2 Accomplished less than you would like 1 2 3 Were limited in the kind of work or other activities 1 2 4 Had difficulty performing the work or other activities (for 1 2 example, it took extra effort)
5. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (e.g. feeling depressed or anxious)? (Please circle one number on each line.) Yes No 1 Cut down on the amount of time you spent on work or other activities 1 2 2 Accomplished less than you would like 1 2 3 Didn’t do work or other activities as carefully as usual 1 2
6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours, or groups? (Please tick one box.) Not at all Slightly Moderately Quite a bit Extremely
7. How much physical pain have you had during the past 4 weeks? (Please tick one box.) None Very mild Mild Moderate Severe Very Severe
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? (Please tick one box.) Not at all A little bit Moderately Quite a bit Extremely
9. These questions are about how you feel and how things have been with you during the past 4 weeks. Please give the one answer that is closest to the way you have been feeling for each item. (Please circle one number on each line.) 1 All of the Time 2 Most of the Time 3 A Good Bit of the Time 4 Some of the Time 5 A Little of the Time 6 None of the Time 1 Did you feel full of life? 1 2 3 4 5 6 2 Have you been a very nervous person? 1 2 3 4 5 6 3 Have you felt so down in the dumps that nothing could 1 2 3 4 5 6
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cheer you up? 4 Have you felt calm and peaceful? 1 2 3 4 5 6 5 Did you have a lot of energy? 1 2 3 4 5 6 6 Have you felt downhearted and blue? 1 2 3 4 5 6 7 Did you feel worn out? 1 2 3 4 5 6 8 Have you been a happy person? 1 2 3 4 5 6 9 Did you feel tired? 1 2 3 4 5 6
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives etc.) (Please tick one box.) All of the time Most of the time Some of the time A little of the time None of the time
11. How TRUE or FALSE is each of the following statements for you? (Please circle one number on each line.) 1 Definitely True 2 Mostly True 3 Don’t Know 4 Mostly 5 False 6 Definitely False 1 I seem to get sick a little easier than other people 1 2 3 4 5 6 2 I am as healthy as anybody I know 1 2 3 4 5 6 3 I expect my health to get worse 1 2 3 4 5 6 4 My health is excellent 1 2 3 4 5 6
20. Below you will see a list of statements. Please read each one carefully, and shade the circle (0, 1, 2, 3, 4, 5 or 6) that best describes you.
1 2 3 4 THESE ITEMS HAVE BEEN REMOVED DUE TO COPYRIGHT RESTRICTIONS 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 466
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21 22
21. Below is a list of events that you may have experienced in your career as a police officer . If you have experienced any of these events over the past 6 months , please record the number of times ( Number ) you have been in this situation. Please record how distressing all the events which you have experienced were at the time (or immediately after) the event, and how much distress you currently experience over the event, by shading a circle (1-5) under each column.
If you did not experience any of the events below, continue on to Question 28
Level of Distress Level of Distress Type of Event Experienced Experienced Currently at the Time No None Moderate Extreme None Moderate Extreme 1. Violent death of a 1 2 3 4 5 1 2 3 4 5 friend in the course of work 2. Violent death of a 1 2 3 4 5 1 2 3 4 5 colleague in the course of work 3. You were wounded 1 2 3 4 5 1 2 3 4 5 in a violent incident (shooting) 4. You were wounded 1 2 3 4 5 1 2 3 4 5 in a violent incident (non-shooting incident, e.g. riot control) 5. You were injured in 1 2 3 4 5 1 2 3 4 5 an accident 6. A colleague was 1 2 3 4 5 1 2 3 4 5 wounded in a violent incident 7. Suicide of a 1 2 3 4 5 1 2 3 4 5 colleague you were friendly with 8. Suicide of a 1 2 3 4 5 1 2 3 4 5 colleague 9. You killed someone 1 2 3 4 5 1 2 3 4 5 in the course of your work 10. You shot at 1 2 3 4 5 1 2 3 4 5 someone in the course of your work 11. You pursued an 1 2 3 4 5 1 2 3 4 5 armed suspect 12. Riot or crowd 1 2 3 4 5 1 2 3 4 5 control: made baton charges in which people were injured, you pulled your gun, or you were under serious threat 13. Took part in a raid 1 2 3 4 5 1 2 3 4 5 involving an armed and dangerous suspect
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14. Took part in a 1 2 3 4 5 1 2 3 4 5 raid/arrest/eviction accompanied by violence or injury 15. Personal 1 2 3 4 5 1 2 3 4 5 involvement in a shooting incident 16. Colleague was 1 2 3 4 5 1 2 3 4 5 involved in a shooting incident 17. Confrontation with 1 2 3 4 5 1 2 3 4 5 violence, e.g. threatened with a knife or a drug user's needle 18. You were 1 2 3 4 5 1 2 3 4 5 threatened by someone with a gun 19. Taken hostage 1 2 3 4 5 1 2 3 4 5 20. Police action in a 1 2 3 4 5 1 2 3 4 5 situation where a child was killed by a violent act 21. Police action at a 1 2 3 4 5 1 2 3 4 5 fatal accident involving a child 22. Involvement in a 1 2 3 4 5 1 2 3 4 5 traffic accident in which a child was seriously injured 23. The first police 1 2 3 4 5 1 2 3 4 5 intervention in a situation of sexual or physical abuse of a child 24. Encounter with a 1 2 3 4 5 1 2 3 4 5 mentally disturbed individual who threatened you 25. The first police 1 2 3 4 5 1 2 3 4 5 intervention in a situation of sexual or physical abuse of an adult 26. Police action at the 1 2 3 4 5 1 2 3 4 5 scene of a fatal accident involving an adult 27. Police action at the 1 2 3 4 5 1 2 3 4 5 scene of a traffic accident in which an adult was injured 28. Traffic accident in 1 2 3 4 5 1 2 3 4 5 which someone was run over by a streetcar or a train 29. Large fire involving 1 2 3 4 5 1 2 3 4 5 deaths and/or injuries 30. Finding the corpse 1 2 3 4 5 1 2 3 4 5
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of a murder victim 31. Finding the corpse 1 2 3 4 5 1 2 3 4 5 of a suicide victim 32. Finding the corpse 1 2 3 4 5 1 2 3 4 5 of someone who died a natural death 33. Dredging up a 1 2 3 4 5 1 2 3 4 5 corpse 34. Arriving too late to 1 2 3 4 5 1 2 3 4 5 help at a drowning or other accident 35. Police action in 1 2 3 4 5 1 2 3 4 5 sad social circumstances such as the deportation of refugees or foreigners 36. Trying to 1 2 3 4 5 1 2 3 4 5 resuscitate a victim but failing 37. Police action 1 2 3 4 5 1 2 3 4 5 against aggressive dogs 38. Being charged with 1 2 3 4 5 1 2 3 4 5 a criminal offence 39. Accident with a 1 2 3 4 5 1 2 3 4 5 police car in which someone was killed or seriously injured 40. Charges were 1 2 3 4 5 1 2 3 4 5 pressed against a colleague after a shooting incident 41. Assistance in 1 2 3 4 5 1 2 3 4 5 disaster relief, other than the abovementioned 42. Other incident: 1 2 3 4 5 1 2 3 4 5 Please state:
43. Other incident: 1 2 3 4 5 1 2 3 4 5 Please state:
44. Other incident: 1 2 3 4 5 1 2 3 4 5 Please state:
22. Please pick the event from the previous question which bothers you the most and complete the following questions: a) Which event will you be rating (which number from previous question)? ______
b) How long ago did this event occur? Months: ______Weeks: ______
Yes No 1. Were you physically injured?
2. Was someone else physically injured?
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3. Did you think your life was in danger?
4. Did you think someone elses life was in danger?
5. Did you feel helpless?
6. Did you feel terrified?
7. Was there blood involved in the incident? 23. These following questions look at how having watched the video has affected you over the past month. Please answer the following questions according to what has happened during the past month using the 0-3 scale below. Do not spend too much time on any statement. 0 Not at all or only one time 1 Once per week or less/a little bit/once in a while 2 2 to 4 times per week/somewhat/half the time 3 5 or more times per week/very much/almost always Have you had upsetting thoughts or images about the video that 0 1 2 3 r. came into your head when you didn’t want them to? Have you been having bad dreams or nightmares about the video? 0 1 2 3 s.
Have you had the experience of reliving the video, acting or feeling 0 1 2 3 t. as if you were watching it again?
Have you been very EMOTIONALLY upset when you were 0 1 2 3 u. reminded of the video (includes becoming scared, angry, sad, guilty, etc.)? Have you been experiencing PHYSICAL reactions when you were 0 1 2 3 v. reminded of the video (eg. break out in a sweat, heart beats fast)?
Have you been trying not to think about, talk about or have feelings 0 1 2 3 w. associated with the video?
Have you been trying to avoid activities, people or places that you 0 1 2 3 x. associate with the video?
Are there any important parts about the video that you still cannot 0 1 2 3 y. remember?
Have you found that you are much less interested or participate 0 1 2 3 z. much less often in important activities?
Have you felt distant or cut off from others around? 0 1 2 3 aa.
Have you felt emotionally numb (eg. feel sad but cant cry, unable to 0 1 2 3 bb. have loving feelings)?
Have you felt that your future plans or hopes will not come true (eg. 0 1 2 3 cc. will have no career, marriage, children, or long life)?
Have you been having problems falling or staying asleep? 0 1 2 3 dd.
Have you been irritable or having fits of anger? 0 1 2 3 ee.
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Have you been having trouble concentrating (eg. drifting in and out 0 1 2 3 ff. of conversations lose track of storey on TV, forgetting what you read, etc.)? Have you been overly alert (eg. checking to see who is around you, 0 1 2 3 uncomfortable with your back to a door, etc.)? gg.
Have you been jumpy or easily startled (eg. when someone walks up 0 1 2 3 behind you)? hh.
24. How long have you experienced the problems that you have reported above? Less than 1 month 1 - 3 months 3 - 6 months More than 6 months
25. How long after the event did these problems begin? Less than 1 month 1 - 3 months 3 - 6 months More than 6 months
26. Have the above problems interfered with any of the following areas of your life during the past month ? Please rate (circle) for each life area.
Not Not at A little bit Definit Markedly Very Life Area applica all / ely / / very severely / ble sometim often often continuousl es y a. Work na 1 2 3 4 5 b. Household na 1 2 3 4 5 chores and duties c. Relationships na 1 2 3 4 5 with friends d. Fun and leisure na 1 2 3 4 5 activities e. Schoolwork na 1 2 3 4 5 f. Relationships na 1 2 3 4 5 with family g. Sex life na 1 2 3 4 5 h. General na 1 2 3 4 5 satisfaction with life i. Overall level of na functioning in all 1 2 3 4 5 areas of your life
27. Since the trauma, have you ever thought that life is not worth living, or thought seriously about suicide?
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No Once Twice Three or more times
28. Most people have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner (or closest friend if you have no romantic partner) for each of the following three items. Please circle the number which best fits your answer. 0 Always Disagree 1 Almost Always Disagree 2 Frequently Disagree 3 Occasionally Agree 4 Almost Always Agree 5 Always Agree
1. Philosophy of life 0 1 2 3 4 5
2. Aims, goals and things believed to be important 0 1 2 3 4 5 3. Amount of time spent together 0 1 2 3 4 5 21b. How often would you say the following events occur between you and your partner (or closest friend if you have no romantic partner)? 0 Never 1 Less than once a month 2 Once or twice a month 3 Once or twice a week 4 Once a day 5 More often
1. Have a stimulating exchange of ideas 0 1 2 3 4 5 2. Calmly discuss something 0 1 2 3 4 5 3. Work together on a project 0 1 2 3 4 5 21c. The numbers below represent different degrees of happiness in intimate relationships. The number 3, "happy", represents the degree of happiness of most relationships. Please circle the number that best describes the degree of happiness, all things considered, of your relationship with your partner or closest friend. 0 Extremely Unhappy 1 Fairly Unhappy 2 A Little Unhappy 3 Happy 4 Very Happy 5 Extremely Happy 6 Perfect
1. Degree of happiness 0 1 2 3 4 5 6
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Appendix 23: Study 3 – Time 3 Questionnaire Package- Control Condition
[This questionnaire package was exactly the same as the Intervention Condition package, except for the Question (5) which was the intervention satisfaction and intervention importance questions. The control package version of this question is provided below.]
5. When evaluating a training programme, we know that it is important to look at how satisfied people were with the different training elements and how important they thought each of the training elements were. Below are two sections which look at: a) your satisfaction with different aspects of the training; and b) how important you think are each of the training elements. a) Below is a list of questions. We would like for you to rate your satisfaction in regards to a number of the resilience training elements. Please shade the circle (1 poor, 5 adequate, 9 excellent) that best describes your opinion. 1 Not at all 5 Somewhat 9 Very much so Can’t remember
11 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on Critical Incidents (i.e., the types of incidents that you should expect when you are working as a police officer)? 12 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on how to Preserve Evidence and the Crime Scene? 13 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on the role of Clinical Services? 14 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 1 on how to deal with the Family and Friends of a Victim? 15 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 2 on Sexual Offenders? 16 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 3 on Victims of Crime? 17 How satisfied were you with the 1 2 3 4 5 6 7 8 9 information that was provided to you during Session 4 when you received a re-cap of the training programme? b) Below is a list of questions. We would like for you to rate the importance of a number of the training elements. Please shade the circle (1 poor, 5 adequate, 9 excellent) that best describes your opinion. 1 Not at all 5 Somewhat 9 Very much so Can’t remember
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18 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on Critical Incidents (i.e., the types of incidents that you should expect when you are working as a police officer)? 19 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on how to Preserve Evidence and the Crime Scene? 20 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on the role of Clinical Services? 21 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 1 on how to deal with the Family and Friends of a Victim? 22 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 2 on Sexual Offenders? 23 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 3 on Victims of Crime? 24 How important was the information that 1 2 3 4 5 6 7 8 9 was provided to you during Session 4 when you received a re-cap of the training programme?
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Appendix 24: Study 3- Integrity Summaries
Session 1, Intervention Condition Policing Expectations Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number):
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Policing Expectations ____ The recruits were introduced to resilience training. They were told that it is designed to help them deal with the emotional and psychological side of the job. ____ Guest speaker was introduced. ____ The recruits were warned about the graphic nature of the photos. ____ There was a group discussion of what types of traumatic incident a person may encounter in their life ____ There was a group discussion of ways in which a person can cope with a traumatic life event. ____ There was a group discussion of what types of incidents a person may have to be attended when working as a police officer. ____ The recruits were shown graphic crime scene photos. ____ The recruits talked through each of the crime scenes (this was done by the Homicide or Major Collisions police officer)
Thoughts and Feelings ____ The recruits were told about the importance of focussing on the task at hand (when attending an incident) ____ The recruits were told about the types of thoughts that can help to prepare a recruit before arriving at a scene ____ It was explained that is normal to have a physical reaction to a distressing scene (e.g. vomiting)
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Social Support ____ There was a group discussion about the types of personal resources that a recruit may have available to them. ____ The importance of using social support such as colleagues, friends and family, was talked about ____ The importance of recruits looking after themselves (e.g. exercise, sleep, diet), was discussed
Drugs and Alcohol ____ The dangers of using alcohol as a coping mechanism was discussed. ____ Talked about the idea that it is ok to have one or two drinks with friends, but it is not ok to meet with friends so that you have an excuse to drink.
Clinical Services ____ The recruits were told that they can call Clinical Services for help and advice in relation to stress issues and feelings of not coping. ____ The recruits were told about the services offered by Clinical Services. ____ The recruits were told about the limits of confidentiality for Clinical Services ____ The Clinical Services phone number (9301 6900) was provided
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Session 2, Intervention Condition Coping Skills Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number):
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Introduction ____ The recruits were told that stress can affect their physical and emotional well-being. ____ Guest speaker was introduced. ____ Provided stress statistics. Included the statistic regarding the cost of stress claims for Victoria Police.
Physical Responses to Trauma ____ Asked the group what types of physical responses may occur when stressed. ____ At least 5 key physical reactions were covered (e.g. dry mouth, sweaty hands, light-headed, shaky, nausea, butterflies, heart palpitations, difficulty swallowing).
The Anxiety Cycle ____ Explained “fight-or-flight”. ____ Explained the anxiety cycle (and stated that increased carbon dioxide causes physical reactions).
Thought Challenging and Cognitive Re-Structuring ____ Explained cognitive re-structuring. ____ Gave medical field example. ____ Talked about the problems with self-defeating or negative self- statements. ____ Talked about thought-challenging. ____ Gave the recruits the “Though Challenging Questions” handout. ____ Told the recruits about the 3 questions that can be used to test a negative belief. ____ Talked about the A-B-C paradigm. Gave the elevator example.
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____ Gave the recruits the “Challenging Thoughts- ABCD” handout.
Guided Self-Dialogue ____ Explained guided self-dialogue or self-talk. ____ Stated that people minimise the positives and maximise the negatives. ____ Talked about how people overestimate and underestimate aspects of the event. ____ Talked about the 4 key stages in which you can use self-talk: preparation; confrontation and management; coping; reviewing and reinforcing. ____ Gave the recruits the “Self-Talk” handout.
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Session 3, Intervention Condition Coroner’s Court Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number):
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Introduction ____ Told the recruits that they would be shown a couple of exercises to help them with stressful situations
Calm Breathing Exercise ____ Explained the purpose of calm breathing. ____ Demonstrated calm breathing exercise (normal breath in, long slow breath out). ____ Got the recruits to practice calm breathing.
Muscle Relaxation Exercise ____ Explained the purpose of muscle relaxation (tension) ____ Demonstrated the muscle relaxation (tension) ____ Got the recruits to practice muscle relaxation.
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Session 4, Intervention Condition Drugs and Alcohol Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number):
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Introduction ____ The recruits were told that the purpose of the session is to provide them with information about drugs and alcohol, and how to identify a problem in themselves. ____ Provided alcohol statistics. ____ Asked the group what effect alcohol can have on the body. ____ Talked about the dysfunction in the body that alcohol can cause (e.g. slow reaction times) ____ Talked about the link between alcohol and aggressive behaviour. ____ Talked about the link between substance use and work performance (e.g. poor performance, absenteeism)
What the Research Tells Us ____ Gave statistics for police who were affected by alcohol at work ____ Gave statistics for the percentage of male and female police officers who were classified as binge drinkers ____ Gave statistics about the change in police’s drinking and smoking levels from the time they begin at the academy compared to 12 months down the track. ____ Told the recruits that there are no drug statistics available.
How to Recognise a Problem ____ Stated that having a few dinks to socialise is fine, but socialising as an excuse to drink is not fine. ____ Gave the recruits the “How to Recognise Problem Drinking” handout. ____ Went through each of the points on the handout.
How to Get Help
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____ Stated that recruits can get help from Clinical Services ____ Stated that recruits can get help from Directline ____ Stated that recruits can get help from their GP.
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Session 5, Intervention Condition Final Session Re-Cap Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number):
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Policing Expectations ____ Reminded recruits of the session that they had with Homicide or Major Collisions, and of the graphic photos that they were shown.
Social Support ____ Reminded recruits of the importance of using social support such as colleagues, friends and family. ____ Reminded recruits of the importance of looking after themselves in terms of exercise and diet.
Help Services ____ Reminded recruits that they can call Clinical Services for help and advice in relation to stress issues and feelings of not coping, or in relation to drugs and alcohol. ____ Reminded recruits of the limits of confidentiality. ____ Reminded recruits they can also access services such as their own G.P. or Directline (24-hr drug and alcohol telephone counselling service)
Coping Skills ____ Reminded recruits of the physical responses we can have to trauma (i.e. fight-or-flight) ____ Reminded recruits of positive self-talk ____ Reminded recruits of cognitive re-structuring and thought challenging.
Coroner’s Court ____ Reminded recruits of muscle relaxation exercise ____ Reminded recruits of breathing exercise Drugs and Alcohol ____ Reminded recruits of the harm that alcohol and drugs can cause
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____ Reminded recruits of how to identify problem drinking ____ Reminded recruits that drinking in moderation when socialising is ok, but that drinking to get drunk is not ok.
Handbook ____ Police Resilience handbook handed out.
Questionnaire ____ Training satisfaction questionnaire administered
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Session 1, Control Condition Critical Incidents Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number).
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Critical Incidents ____ The recruits were introduced to the training. ____ The guest speaker was introduced. ____ The recruits were warned about the graphic nature of the photos. ____ There was a group discussion of what types of incidents a person may have to be attended when working as a police officer. ____ The recruits were shown graphic crime scene photos. ____ The recruits talked through each of the crime scenes (this was done by the Homicide or Major Collisions police officer)
Preserving Evidence and the Crime Scene ____ The guest speaker spoke to the recruits about how to preserve evidence and the crime scene, when he/she talked the recruits through the crime scene photos.
Dealing with the Victim’s Family and Friends ____ The recruits were told by Clinical Services about the difficulties that may be associated with dealing with the victim’s family and friends. ____ The recruits were told about ways in which they can deal with distraught people. ____ The guest speaker spoke to the recruits about the difficulties of dealing with distraught people
Clinical Services ____ The recruits were told that they can call Clinical Services for help and advice in relation to stress issues and feelings of not coping. ____ The recruits were told about the services offered by Clinical Services. ____ The Clinical Services phone number (9301 6900) was provided
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Session 2, Control Condition Sexual Offenders Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number):
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Introduction ____ The recruits were given an introduction regarding the purpose of the sexual offenders training session. ____ The recruits were given the “Sexual Offenders Facts” information sheet
Dispelling Myths About Sexual Offenders ____ The recruits were informed that most sexual assaults are committed by someone known to the victim or the victims family. ____ The recruits were told that only a fraction of those who commit sexual offences are apprehended and convicted. ____ The recruits were told that females may commit sexual offences ____ The recruits were told that sexual assaults do not occur as a direct result of alcohol. ____ The recruits were told that most children who are sexually assaulted do not go own to sexually offend against others. ____ The recruits were told that adolescents may be responsible for sexual offences ____ The recruits were told about the difference between situational and preferential child molesters. ____ The recruits were told that multiple factors are responsible for sexual offending behaviour
Questions ____ The recruits were provided with an opportunity to ask any questions that they may have had, and these questions were answered.
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Session 3, Control Condition Victims of Crime Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number):
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Introduction ____ The recruits were given an introduction regarding the purpose of the victims of crime training session. ____ The recruits were given the “Victims of Crime Facts” information sheet.
Who is a Victim of Crime? ____ The recruits were informed about a “primary” victim of crime ____ The recruits were informed about a “secondary” victim of crime ____ The recruits were informed about a “related” victim of crime ____ The recruits were asked to suggest what types of feelings or symptoms a victim of crime may have. They were informed about any feelings or symptoms that they did not suggest. The Impact ____ The recruits were informed about the types of reactions that a victim of crime may have (e.g. aggressive behaviour, suicidal behaviour, relationship problems) ____ The recruits were informed about subjective appraisal ____ The recruits were informed about: 1) the assumption of invulnerability; 2) the assumption that the world is meaningful; and 3) positive self- perceptions being shattered. ____ The recruits were informed about avoidance measures that victims take. ____ The recruits were informed that victims also sometimes encounter financial problems.
The Victims Charter ____ The recruits were given the “Victims Charter” handout ____ The victims charter was read through with the recruits.
Questions
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____ The recruits were provided with an opportunity to ask any questions that they may have had, and these questions were answered.
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Session 4, Control Condition Final Session Re-Cap Training Integrity Summary
Squad Number: Session Date: Trainer’s Name: Rater Signature:
Overall rating of session. Please rate the integrity of the training conducted in this session (circle appropriate number):
0 1 2 3 4 5 6 NA Unacceptable Marginal Low ------Acceptable------High
If unacceptable or marginal, call the researcher director at (03) 9214 5920 or 0412 157 591, specify reasons below.
Comments:
Critical Incidents ____ Reminded recruits of the session that they had with Homicide or Major Collisions, and of the graphic photos that they were shown.
Preserving Evidence and the Crime Scene ____ Reminded recruits of the importance of protecting the crime scene and being aware of the evidence ____ Reminded the recruits that a deceased person must also be considered as evidence.
Dealing with the Victims Family and Friends ____ Reminded recruits that dealing with the victims family and friends can be one of the most difficult aspects of the job. ____ Reminded the recruits that when dealing with a distraught person, other people can be a very valuable resource. They can help comfort the distraught person.
Sexual Offenders ____ Reminded recruits that they received a talk about sexual offenders ____ Reminded recruits that most sexual assaults are committed be someone known to the victim or the victims family ____ Reminded recruits that different types of sexual offenders, other than adult males (e.g. adolescent offenders, female offenders)
Victims of Crime ____ Reminded recruits about primary, secondary and related victims ____ Reminded recruits about the impact of being victimised ____ Reminded recruits about subjective appraisal ____ Reminded recruits about the Victims Charter
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Help Services ____ Reminded recruits that they can call Clinical Services for help and advice in relation to stress issues and feelings of not coping, or in relation to drugs and alcohol. ____ Reminded recruits that they can go to their own GP, and get referred for 12 free counselling sessions. ____ Told recruits that there are help services which can assist: 1) sexual assault victims; and 2) sexual offenders. The recruits were told that the numbers for these services are provided in the handbook.
Handbook ____ Police Resilience handbook handed out.
Questionnaire ____ Training satisfaction questionnaire administered
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Appendix 25: Skewness & Kurtosis Statistics for Data, Pre & Post Transformation
Table 1 Skewness & Kurtosis Statistics for Data, Pre & Post Transformation Untransformed Transformed Variable S K S K T1 a ASSIST total score 1.56 1.64 0.87 0.30 Emotion focused coping 1.17 1.23 0.57 0.65 Problem focused coping 1.43 4.37 0.02 -0.48 T1 DASS total score 1.84 3.99 0.24 0.23 T1 DASS depression 2.78 8.69 0.99 -0.17 T1 DASS anxiety 1.86 3.77 0.34 -0.59 T1 DASS stress 1.77 4.77 0.00 -0.25 T1 ISEL total score -1.71 3.01 0.94 0.38 T1 ISEL appraisal -1.68 2.10 -0.71 -0.05 T1 ISEL belonging -1.28 2.33 0.80 1.25 T1 ISEL tangible -1.52 1.66 1.06 0.04 ADAS total score -0.91 2.35 -0.15 1.17 CD-RISC total score -0.45 0.69 -0.74 0.08 TIPI-Emotional Stability -092 0.40 0.32 -0.48 TIPI- Extraversion -0.39 -0.50 -0.11 -0.91 TIPI- Conscientiousness -1.09 0.70 0.53 -0.60 TIPI- Openness to Experience -0.17 -0.98 -0.25 -0.94 SF-36 total score -1.70 -0.88 0.23 -0.25 DEVS Distress 1.45 1.75 0.66 -.41 T2 b DASS total score 1.62 2.74 0.28 -0.41 T2 DASS depression 2.73 8.12 0.99 0.48 T2 DASS anxiety 1.54 2.20 0.42 -1.03 T2 DASS stress 1.51 2.85 0.03 -0.62 T3 c ASSIST total score 1.85 4.28 0.74 0.87 T3 DASS total score 3.03 14.27 -0.40 -0.30 T3 DASS depression 3.46 14.19 0.82 0.00 T3 DASS anxiety 3.85 21.60 0.71 -0.05 T3 DASS stress 1.13 1.83 -0.52 -0.69 T3 ISEL total score -1.01 0.09 -0.43 -0.85 T3 ISEL appraisal -0.89 -0.22 0.52 -1.09 T3 ISEL belonging -0.99 0.52 0.46 -0.85 T3 ISEL tangible -0.94 0.39 0.02 -1.44 SF-36 total score -2.25 5.52 0.64 0.06 MBI Emotional Exhaustion 1.29 1.54 0.20 0.00 MBI Personal Accomplishment -0.90 0.44 -0.26 0.01 PDS total score 3.63 15.81 0.75 -0.27 PDS Intrusions 5.14 32.54 1.99 3.98 PDS Avoidance 4.23 18.38 0.60 -1.35 PDS Arousal 3.11 9.98 0.32 -1.65 aTime 1; bTime 2; c Time 3
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Appendix 26: Means and Standard Deviations for the Dependent Variables Table. 1 Means and Standard Deviations for Gender on the Dependent Variables T3 ‘Affective Distress’, T3 ‘Substance Involvement’, T3 ‘General Health’ , T3 ‘Relationship Satisfaction’, ‘Trauma Symptomatology’, MBI Emotional Exhaustion, MBI Depersonalisation, MBI Personal Accomplishment, ‘Police Services Access’, and ‘External Services Access’ (N=89) DV Mean Std. Deviation Gender Male T3 Affective Distress 15.26 19.74 T3 Substance Involvement 19.37 17.16 T3 General Health 85.78 13.93 T3 Relationship Satisfaction 25.94 5.62 Trauma Symptomatology 1.35 3.44 MBI Emotional Exhaustion 14.54 12.17 MBI Depersonalisation 8.67 7.37 MBI Personal Accomplishment 37.64 8.66 Police Services Access 0.31 0.83 External Services Access 0.21 0.98 Female T3 Affective Distress 11.16 12.24 T3 Substance Involvement 21.06 16.13 T3 General Health 85.97 11.21 T3 Relationship Satisfaction 25.87 4.75 Trauma Symptomatology 1.42 2.96 MBI Emotional Exhaustion 12.02 8.66 MBI Depersonalisation 6.51 4.37 MBI Personal Accomplishment 35.55 8.45 Police Services Access 0.26 0.75 External Services Access 0.25 0.90
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Table. 2 Means and Standard Deviations for Relationship Status on the Dependent Variables T3 ‘Affective Distress’, T3 ‘Substance Involvement’, T3 ‘General Health’ , T3 ‘Relationship Satisfaction’,’ Trauma Symptomatology’, MBI Emotional Exhaustion, MBI Depersonalisation, MBI Personal Accomplishment, ‘Police Services Access’, and ‘External Services Access’ (N=89) Relationship DV Mean Std. Deviation Status Single T3 Affective Distress 15.16 18.38 T3 Substance Involvement 20.43 18.97 T3 General Health 84.86 12.78 T3 Relationship Satisfaction 25.07 5.17 Trauma Symptomatology 2.03 3.80 MBI Emotional Exhaustion 14.94 11.27 MBI Depersonalisation 8.12 5.84 MBI Personal Accomplishment 35.36 8.43 Police Services Access 0.35 0.18 External Services Access 0.34 1.21 In a relationship T3 Affective Distress 10.00 11.62 T3 Substance Involvement 20.16 12.82 T3 General Health 87.26 11.89 T3 Relationship Satisfaction 26.89 4.95 Trauma Symptomatology 0.69 2.04 MBI Emotional Exhaustion 10.76 8.63 MBI Depersonalisation 6.61 6.06 MBI Personal Accomplishment 37.53 8.73 Police Services Access 0.18 0.56 External Services Access 0.08 0.27
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Table. 3 Means and Standard Deviations for Station Location on the Dependent Variables T3 ‘Affective Distress’, T3 ‘Substance Involvement’, T3 ‘General Health’ , T3 ‘Relationship Satisfaction’,’ Trauma Symptomatology’, MBI Emotional Exhaustion, MBI Depersonalisation, MBI Personal Accomplishment ‘Police Services Access’, and ‘External Services Access’ (N=88) Station Location DV Mean Std. Deviation Metropolitan T3 Affective Distress 13.28 16.11 T3 Substance Involvement 20.11 17.07 T3 General Health 85.68 12.14 T3 Relationship 25.87 4.84 Satisfaction Trauma Symptomatology 1.44 3.30 MBI Emotional 13.80 10.21 Exhaustion MBI Depersonalisation 7.89 6.08 MBI Personal 36.61 8.23 Accomplishment Police Services Access 0.25 0.70 External Services Access 0.19 0.75 Rural T3 Affective Distress 10.92 15.44 T3 Substance Involvement 21.58 13.07 T3 General Health 87.00 14.14 T3 Relationship 26.09 6.93 Satisfaction Trauma Symptomatology 1.17 2.33 MBI Emotional 9.64 10.92 Exhaustion MBI Depersonalisation 5.21 4.82 MBI Personal 34.64 10.43 Accomplishment Police Services Access 0.43 1.16 External Services Access 0.46 1.66
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Table. 4 Means and Standard Deviations for Religious Belief on the Dependent Variables T3 ‘Affective Distress’, T3 ‘Substance Involvement’, T3 ‘General Health’ , T3 ‘Relationship Satisfaction’,’ Trauma Symptomatology’, MBI Emotional Exhaustion, MBI Depersonalisation, MBI Personal Accomplishment, ‘Police Services Access’, and ‘External Services Access’ (N=89) Religious Belief DV Mean Std. Deviation Has Religious Belief T3 Affective Distress 13.63 18.99 T3 Substance Involvement 19.68 17.31 T3 General Health 85.55 13.73 T3 Relationship 25.79 4.95 Satisfaction Trauma Symptomatology 1.12 2.62 MBI Emotional 12.35 9.73 Exhaustion MBI Depersonalisation 6.45 5.44 MBI Personal 35.94 8.69 Accomplishment Police Services Access 0.39 0.86 External Services Access 0.31 1.21 No Religious Belief T3 Affective Distress 12.10 11.45 T3 Substance Involvement 21.08 15.70 T3 General Health 86.29 10.70 T3 Relationship 26.03 5.38 Satisfaction Trauma Symptomatology 1.73 3.72 MBI Emotional 14.13 11.17 Exhaustion MBI Depersonalisation 8.74 6.38 MBI Personal 36.74 8.53 Accomplishment Police Services Access 0.15 0.66 External Services Access 0.13 0.34
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Table. 5 Means and Standard Deviations for Ethnicity on the Dependent Variables T3 ‘Affective Distress’, T3 ‘Substance Involvement’, T3 ‘General Health’ , T3 ‘Relationship Satisfaction’,’ Trauma Symptomatology’, MBI Emotional Exhaustion, MBI Depersonalisation, MBI Personal Accomplishment,‘Police Services Access’, and ‘External Services Access’ (N=88) Ethnicity DV Mean Std. Deviation Australian T3 Affective Distress 12.84 16.27 T3 Substance Involvement 19.76 16.68 T3 General Health 86.18 12.38 T3 Relationship 25.72 5.09 Satisfaction Trauma Symptomatology 1.52 3.32 MBI Emotional 13.10 10.88 Exhaustion MBI Depersonalisation 7.92 6.03 MBI Personal 36.28 8.52 Accomplishment Other T3 Affective Distress 14.50 14.33 T3 Substance Involvement 25.78 15.71 T3 General Health 82.78 13.48 T3 Relationship 27.38 5.80 Satisfaction Trauma Symptomatology 0.50 1.07 MBI Emotional 13.89 5.23 Exhaustion MBI Depersonalisation 4.00 4.09 MBI Personal 37.56 9.33 Accomplishment
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Appendix 27: Human Ethics Clearance for the Research Projects
Human Ethics clearance was required for this research project. Evidence of ethical clearance is attached in the following pages.
All conditions pertaining to the clearance were properly met and annual/final reports have been submitted.
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