Chronic Pain Series Part 3: Disarming PTSD & Occupational Stress Injuries
What is subjectivity?
Subjectivity, is a term used to determine a person’s perception, experience, feelings and beliefs. Most often, when it comes to chronic pain and mental health screening the “subjectivity” and indicators of risk, are still a large grey area and can be “subject” to interpretation. Why? Because the reality is – the only person who can truly know 100% how you feel, how an experience has affected you – is you, and you alone. The rest is objective; as health care providers we make the most appropriate call we can based on our assessment; and this is where the grey area resides. As much as subjectivity is a process of individuation, it is equally a process of socialization, taking into context the cultural environment, and the experience of interaction with people, places, and events. These things change a person, and the debate on the best way to form a SOP (standard operating system) for diagnosis, treatment, prevention and programs is one hot topic that continues to be an on going theme in my research.
Over the last several articles, introducing chronic pain, we have used the term `biopsychosocial model;` (bio) means biological, psycho (means psychological) and social (means environment); all of which refers to the body`s physiological, adaptive response to fear, pain and our environment. This model is the cornerstone of my research and although some of us may be born with a biologically determined, heightened sensitivity to stress, this fact alone is insufficient to create an anxiety disorder or even a precautionary risk factor for occupational stress indicators. Yet, it can give us great insight into being more receptive to persons who many be at risk. For instance someone who has had a long standing degree of child abuse, may be greater risk for depression or PTSD if he or she takes on a role involved with law enforcement, social work or combat… or on the flip side, it could be a leading reason they excel at these professions if they have the right coping strategy and insight. Again… there’s that grey area again. There has not been enough data collection to support either side.
Let’s review that model again’ the psychological factors in the biopsychosocial model refer to our thoughts, beliefs, and perceptions about ourselves, our experiences, and our environment. These cognitive patterns affect our perceived sense of control over our environment, and affect the way we assess and interpret events as either threatening or non-threatening; which are highly subjective.
Chronic Pain & PTSD:
Chronic pain and mental health screening, diagnosis, and pathways to direct treatment, are not yet fully standardized in our medical system, but, we have made much progress over the last decade with more health care providers looking at the integrated approach towards programs and services for people living with pain and people with dual diagnosis with mental health or trauma.
In an article written at the United States Department of Veterans Affairs, titled “ The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers,” states a current PTSD prevalence of 35% was seen in a sample of chronic pain patients, compared to 3.5% in the general population. Trauma is not just physical or mental, it is both; all encompassing.
The human body and brain are one of the most complex and quantifiable conundrums, because there is still so much we do not yet understand about why one person can experience chronic lasting pain and another does not. Or, for the purpose of our discussion topic day; why one person can experience a traumatic event and suffer from PTSD, while another does not. It is a question that remains unanswered.
What is PTSD & OSI?
PTSD (Post Traumatic Stress Disorder) is a serious potentially debilitating condition that can occur in people who have experienced or witnessed a natural disaster, serious accident, and sudden death of a loved one, war, violent personal assault such as rape, or other life-threatening event. It can leave the person feeling intense fear, anger, and hopelessness.
Operational Stress Injury (OSI) is best described as any persistent psychological difficulty resulting from operational duties performed while serving in the Canadian Forces or in law enforcement or any emergency response profession. Difficulties may occur during combat duties, after serving in a war zone, in peacekeeping missions, or following other traumatic or serious events not specific to combat.
While it is considered normal to experience some form of distress after being exposed to a traumatic event, for some individuals, the symptoms persist. The long-term consequences can include, but are not limited to problems with interpersonal functioning, cognitive and biopsychosocial functioning, mental health disorders, as well as substance abuse disorders, affective disorders, anxiety disorders, eating disorders, and conduct disorders.
More importantly, for those in professions where high stress is part of the nature of the job, like in military or law enforcement, coming out and saying “I may have PTSD” can seem like a great blow to the ego. Much like mental illness or chronic pain… PTSD comes with a label and the stigmatization attached to that label.
The Multi-Method Model: Screening 101
Psychologists and Psychiatric doctors are taught early in their training that assessment of human behavior and emotion is best done within a “multi-trait, multi-method” model. The bases for this model are (a) the human condition, and (b) statistical limitations on measurement. As care providers we have a difficult time ascertaining the accuracy of patients’ pain severity, because of the nature of subjectivity. This can include chronic pain or mental health indicators. The body’s pain receptors or neuroplasticty just feels pain… it cannot differentiate between physical or mental always.
How do we really know when someone has an occupational stress injury or PTSD? We know that chronic pain, mental health and possible disability that often comes with it can lead to a cognitive reevaluation and reintegration of one’s belief systems, values, emotions, and feelings of self-worth and self responsibility , more importantly, how one feels about the capability of performing their job and living their life.
Assessing PTSD can be tricky and it takes time and patience. Measures vary in their sensitivity, specificity, and clinical utility for different settings and populations. Time permitting, the use of both self-report and interview-based assessments is recommended. Health care providers generally assess by administering cognitive and physical examinations, having patients perform various tasks, if chronic pain is an indicator they could include exercises that help the provider evaluate the patient’s strength, flexibility and reflexes. When it comes to assessing mental health or PTSD risk factors, these exercises can range from one on one interviews where the professional looks for behavioral markers, assesses mental acuity, emotional triggers and cognitive thought processes.
Despite all of our understanding thus far on both chronic pain and mental health, the relationship between traumatic event exposure and adverse emotional or mental triggers/ affects remains still a very large grey area. Despite efforts to fully understand the relationship between traumatic event exposure and adverse mental health outcomes, our ability to quantify why only some trauma-exposed individuals become emotionally affected remains challenged.
Canada Steps Up:
Canada has some of the top tiered standard operating systems in North America, yet as a whole we can only train our officers so much, we can only prepare them so much and it is only until they are placed in real life situations can we truly know if PTSD or mental health risks will be a factor. Over the course of the last half decade Canada has been recognized as a world leader in fighting stigmatization and raising awareness of mental health illnesses.
In fact, through the Canadian Armed Forces, we have the greatest ratio of mental health care workers to soldiers in NATO, however most of what we now know and have implemented has been post deployment and is still a work in progress
Historically, PTSD has been associated with military personnel and the traumatic experiences involving combat and warfare situations, as well as emergency responders such as law enforcement and fire and rescue, but this can occur in any individual who suffers some form of trauma. The prevalence of PTSD is substantially elevated in patients with chronic pain, which is no wonder, as we know the nervous system cannot differentiate stress from the mind or body, all it feels is pain and stress. Officers that are on the front lines, are injured in battle or have had to be deployed for long periods of time have a higher degree of risk for both PTSD and chronic pain. Combat changes people, and pain changes people.
Many officers in law enforcement who are involved in confrontation, who have to work long shifts, operate on little sleep and have to deal with the worst of people’s worst days, day in and day out, also have a higher risk because of the nature of the job. This is not rocket science; and even though it has been very slow, the government is finally recognizing the need for greater resources and prevention nationwide.
The Canadian Armed Forces: Standing at The Front Lines
The first Operational Traumatic Stress Support Centre (OTSSC) opened in 1999. “ Lessons learned about psychiatric casualties from World War I (shell shock) and World War II (combat exhaustion, which comprised up to 25 per cent of all casualties in the Italian campaign) had been forgotten by the Canadian Forces (CF) by the time they were engaged in the first Gulf War in 1991.” Wrote Greg Passey, MD, CD, FRCPC (1)
Canada’s role in the Afghanistan War began in late 2001; where we sent first Canadian soldiers secretly in October 2001 from Joint Task Force 2, and then the first contingents of regular Canadian troops arrived in Afghanistan in January–February 2002. At the height of the war, during 2006, the high level of casualties and injured troops was overwhelming. Since then, the Canadian Armed Forces has made leaps and bounds in providing officers with necessary resources; however, many say there are still not enough professionals to go around. Even though all recruits must undergo rigorous screening both physically and psychologically prior to and post deployment, there are not enough operational stress injury clinics outside of the main facilities.
In 2011, the Canadian Forces released a study noting that of 2,045 randomly chosen personnel who served in Afghanistan between 2001 and 2008, eight per cent were diagnosed with mission-related PTSD. An additional 5.2 per cent were diagnosed with Afghanistan-related mental health disorders other than PTSD, like depression. (1)
In an article written by CTV news, dated July 20th 2011; by Dr. Greg Passey, who is a trauma psychiatrist and a former military medical officer, says the situation (PTSD and suicide) is all too common. He says despite all the progress that has been made in raising awareness of PTSD, the stigma is still there and is a huge obstacle to overcome for many people in and out of the military.
“There remains a lot of misperception and ignorance within the military in regards to issues like post-traumatic stress disorder. They’re often viewed as people who are disciplinary problems,” Passey told Canada AM in this article.
Even the term ‘mental health issues,’ is stigmatizing, because it doesn’t speak to the severity of the illness, nor does it produce metrics to use for treatment. The brain is a physical organ. It has physical abnormalities and diseases processes and injuries. And so we should be talking about brain disorders. While they’re in the military, the resources aren’t too bad. The difficulty is once they’re released. And the reservists who have to depend on civilian resources; they can get lost.” (2)
He goes on to say that even with the recent recognition of PTSD, there are still not enough psychiatric resources and professionals to go around. The situation can become worse once a soldier retires or is discharged because they leave the support system.
In 1991, the majority of military psychiatrists at that time were centralized at the National Defence Medical Centre in Ottawa. Members of the military requiring assessment or treatment had to travel to Ottawa, which added to the stigma of mental health diagnoses. However, since 2006, the CAF has structured operational stress injury clinics all over Canada, all of which provide assessment, treatment, prevention and support to serving CAF members and Veterans. Each OSI clinic operate on an outpatient basis only and include one-on-one therapy sessions and group sessions to address PTSD, and mental health indicators and other issues that are occurring as a result of experiencing one or more traumatic events. Even though the CAF has made many changes and additions to support their troops; there needs to be a higher political agenda pushed forward and pushed up the food chain at the health care systemic level. (1)
Law Enforcement: In The Line of Duty
At the JIBC (Justice Institute of British Columbia), all new recruits undergo block training where they prepare for the stressors and are offered courses/materials to better understand the complexities they could encounter on the job. They offer classes like; critical incident and stress, acute reactions to trauma and grief, incident reduction, front line workers guide and a all supported by the Public Safety Library. This relates to both law enforcement and fire and rescue candidates.
All new recruits with the Vancouver Police Department (VPD) are offered a health and wellness workshop style day at Copeman Healthcare, one of Vancouver’s leading private healthcare facilities; and home to my employer with Fit to Train.
New recruits come to Copeman Healthcare center and are offered preventative tools to ensure their optimal physical and mental health are looked after. Speakers from the physiotherapy and Kinesiology department, as well as the medical and psychology fields speak on topics related to long term health and law enforcement. Dr. Mackoff; a Registered Psychologist consults to a number of police departments both in Canada and internationally. As a psychologist Dr. Mackoff treats individuals experiencing difficulties with anxiety, trauma, depression and relationships. Dr. Mackoff has an interest in providing psychological assistance to individuals who are coping with health related difficulties
The RCMP’s Occupational Health Services, have specialized health practitioners who screen and monitor all members to identify mental health risks, as well as OSI clinics all over Canada, close or within detachments. RCMP officers have direct access to Canadian medical and psychological practitioners of their choice; inclusive of general physicians, psychiatrists, and community-based psychologists; asll of which fall under the RCMP’s Health Care Entitlements and Benefits Programs.
In October 2012; the Ontario Ombudsman released a report, “In the Line of Duty” in which was an investigation into how the Ontario Provincial Police and the Ministry of Community Safety and Correctional Services have addressed operational stress injuries affecting police officers; where 34 recommendations were outlined.
Much like the RCMP the OPP found that one of the obstacles facing police is that the force has not done any significant research into the OSIs among its officers, that the periodic screening is voluntary and there is a high level of stigma associated with OSI.
In the BOLC “Badge of Life Canada” online blog; they featured 2 of those recommendations (3) :
The Ontario Provincial Police should take additional steps to reduce the stigma associated with operational stress injuries existing within its organization, including:
- conducting a comprehensive review of its education, training, peer support, employee assistance and other programming related to these injuries
- consulting with experts, police stakeholders, the Canadian Forces, Veterans Affairs Canada, and other police organizations
- researching best practices relating to addressing operational stress injuries in policing; and
- developing and implementing a comprehensive and co-ordinated program relating to operational stress injuries. Subsection 21(3)(g) Ombudsman Act
Furthermore, a study from Carleton University found that officers in Canada are facing greater pressures at work that may be taking a greater physical and mental toll on police than previously believed.
A PTSD Mobile Coach:
The use of technology has also been a great turning point in chronic pain and mental health. The new OSI mobile app is a new channel for Veterans and serving personnel in the Canadian Armed Forces and the RCMP to get information and resources on operational stress injuries.
The PTSD Coach Canada app is designed to help you learn about and manage symptoms that can occur after trauma. Features include; reliable information on PTSD and treatments that work, tools for screening and tracking your symptoms, easy-to-use tools to help you handle stress symptoms, direct links to support and help and is always with you when you need it. Form more information please visit this (link).
A Local Hero: Captain John Croucher, PPCLI officer working at 1CMBG
This is a story that deserves its own headliner, its own article. Captain John Croucher’ otherwise known as “The Sir,” to his men served in Afghanistan in 2006. The platoon captain of the 1st Battalion, Princess Patricia’s Canadian Light Infantry; who on May 25th, 2006 was severly injured after an he and his 20 officers, and their LAV was struck by an IED. The third to hit Alpha’s second platoon, or the 1-2 as it’s called; Capt. Croucher underwent eight surgeries at three different hospitals in three different countries, first in Afghanistan at the Canadian-led base hospital at Kandahar Air Field, then at the U.S. military hospital in Landstuhl, Germany, and finally in Canada at the U of A.
In 2006 Cpt. Croucher came to Vancouver to receive treatment for PTSD and further rehabilitation and I was the lucky Movement Coach who was given the privilege to work with Captain Croucher weekly for nearly 2 years. He remains one of my dearest friends and is one of my hero’s.
Next week hear Captain Croucher’s story and his first hand accounts of overcoming injury, breaking the stigma of PTSD and his role back in active duty, as well as some of the positive changes our government is making in OSI standardization, as well as some of the gaps that may still need bridging.
June is PTSD National Awareness Month, let’s support our troops!
- (1) Mental Health; A mounting priority for Canada’s Armed Forces, by Dr. Greg Passey, Feb 2002 http://publications.cpa-apc.org/browse/documents/44
- (2) CTV News: Read more: http://www.ctvnews.ca/family-still-seeking-answers-after-soldier-s-suicide-1.672845#ixzz2WaBmOdby
- (3) BOLC: http://badgeoflifecanada.com/2013/05/22/rcmp-urged-to-do-more-for-officers-with-post-traumatic-stress-disorder/
- British Columbia Occupational Stress Clinics: http://www.bcosi.ca/research/research-links/
- RCMP Vets Association: http://www.rcmpvetsnational.ca/BrokenLance/WhigPTSD/Whig-e.php
- Globe and Mail: http://www.theglobeandmail.com/news/national/absence-from-his-men-adds-salt-to-his-wounds/article1106075/
- Dr. Randy Mackoff : http://www.copemanhealthcare.com/about-us/staff/vancouver-psychology-neuropsychology/dr-randy-mackoff/