Traditionally, the concept of a disorder related to trauma has been associated with warfare. As early as 1871, during the American Civil War, Da Costa described a condition, called an "irritable heart," that was characterized by symptoms of anxiety in response to a stressor.⁽¹⁾ During World War I, veterans with these symptoms were thought to be suffering from "shell shock." By World War II, reflecting the influence of psychodynamic theory, the difficulties suffered by combat veterans were thought to be the result of some unresolved conflict rooted in the patient's unconscious. These conflicts, awakened in the theatre of war, were variously called "traumatic war neurosis," "combat neurosis or "gross stress reaction."⁽²⁾

As the literature on war veterans grew, other investigators described similar syndromes in individuals exposed to such stressors as industrial accidents, natural catastrophes or even accidents in the home. The first extensive description of trauma not incurred in combat was done by Alexander Adler,⁽³⁾ who studied the victims of the Coconut Grove fire - people who had been trapped in the locked, burning building. This direction led, in 1952, to the inclusion of "gross stress reaction" in the first version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), a tool commonly used to diagnose mental disorders.

However, when the second version of the DSM was published in 1968, the post-traumatic syndrome category was omitted. This was surprising, given that the syndrome had achieved international recognition and various research investigations were being carried out. This may have occurred because post-traumatic syndrome, until now, was closely associated with war; the DSM-II was written during the relatively tranquil period between World War II and the Vietnam War, and the authors may have assumed that such a category was not relevant in peacetime.⁽⁴⁾

The problems of veterans returning from the Vietnam War provided convincing evidence to the authors of DSM-III that a category for post-traumatic syndrome needed to be reinstated. The category was identified as Post-traumatic Stress Disorder (PTSD), and was defined as being caused by a stressor severe enough to produce psychological trauma in most normal individuals.

In the late 1970s, research literature on victimology began to identify a host of individuals who were experiencing the symptoms of PTSD but who were survivors neither of combat nor of disasters. These were people who had been subjected to such things as physical and sexual violence or abuse. During this time, information on occupational stress was also accumulating from studies of a variety of occupational groups, such as teachers, health care workers, police and correctional workers. Members of these groups were presenting a variety of physiological and emotional difficulties related to stress.

As the 1980s approached, clinical practitioners who worked with individuals experiencing occupational stress began to notice occupational groups where some members were presenting symptoms of traumatic stress. These individuals who, by the nature of their work, were exposed to traumatic events, included police, fire personnel, ambulance and paramedical personnel, hospital emergency-department staff, disaster workers and rape crisis workers.

As part of their job responsibilities, these personnel are exposed to extremely unusual events, such as riots, hostage takings, being shot at, shooting someone in the line of duty, finding murder and suicide victims, watching someone die in spite of rescue efforts and other equally gruesome situations. These occupational events, which fall outside the range of usual human experience and are considered to be extremely distressing to almost anyone, have been defined as "critical incidents."⁽⁵⁾

Clinicians in the field are finding that personnel exposed to such critical incidents may show a variety of physical, behavioural, emotional and cognitive stress symptoms similar to those for PTSD. The main symptoms of PTSD include: intrusive memories of the traumatic event, nightmares, hypervigilance, an exaggerated startle response and intense psychological distress when exposed to things associated with the original trauma.

The differences between critical incident stress and PTSD lie in the number of symptoms experienced by the individual and the duration of the symptoms. Critical incident stress may be thought of as a continuum of severity, with PTSD at the most extreme pole.

Personnel differ widely in their responses to critical incidents.⁽⁶⁾ Some experience little or no effect, others experience short-term impact, while a limited number experience severe and long-term difficulties.⁽⁷⁾

Many of the psychological reactions experienced by persons exposed to traumatic stress are situationally related and disappear over time. However, for some individuals, the effects are severe and long lasting enough to affect their daily functioning. The human and economic costs associated with traumatic stress are significant and include increased absenteeism or resignation from work, increased use of medical services, health deterioration, marriage breakdown and even suicide.⁽⁸⁾

There are major difficulties in attempting to study critical incident stress. It is impossible to predetermine when war, riots or most other traumatic events will occur. Generally, the appropriate baseline information cannot be collected before the event. Thus, if we are to understand traumatic stress, we must compromise and study it retrospectively, asking individuals to recall their past experiences.

The workplace can provide a natural laboratory for learning about the impact of exposure to traumatic stress on high-risk occupational groups.

Correctional officers are one such group. Penal institutions represent an occupational context where exposure to traumatic events is not unusual, where officers are subjected to a variety of critical incidents during the performance of their duties.

The literature identifies certain classes of events as potential triggers for traumatic reactions in an occupational context. For correctional officers, these classes of events are represented by such incidents as suicides, murders, riots, hostage takings and assaults. While not routine, these events are not unexpected in correctional work.

Although the role of general stress has been studied in the field of corrections, there is currently no research on the impact of exposure to critical incident stress in corrections. However, a major research project examined the impact of exposure to occupationally related traumatic events on correctional officers. The following is a summary of information gathered on the rates and effects of such exposure.

In-depth interviews were conducted with 122 correctional officers employed in six institutions in the Ontario region. Participating personnel were from both maximum- and minimum-security facilities and from male and female institutions. All personnel in minimum-security settings had been previously employed in medium- or maximum-security facilities. Seventy-five percent of participants were employed in male institutions. Males comprised 71% of the sample. This is not surprising, as female staff have only recently been hired as correctional officers in male facilities.

Information was gathered on correctional officers' exposure to job-related traumatic events. These events frequently involved exposure to serious injury or death; multiple casualties; unusual sights, sounds and circumstances; first-hand knowledge of the victim(s); and threats to officers' own safety and security. Only two officers had not been exposed to a job-related critical incident. The average number of exposures among all officers was 27.9. These numbers may seem high, but higher-security institutions have long histories of violent incidents, and most correctional officers have spent some or all of their careers working in these volatile environments.

There was a significant gender difference in the average number of exposures, with males experiencing an average of 32 exposures and females experiencing an average of 16 exposures, a breakdown reflecting the fact that the women had been employed in corrections for a significantly shorter time than the men (6 years versus 17 years).

The frequencies of exposure were collapsed into the following five categories: no exposure, one, two and three occurrences and more than three occurrences. The table lists the different types of events to which officers were exposed and the percentage of officers in each category.

One of the problems with the above type of data is that they rely on the respondent's ability to remember past events and experiences. Officers in this study often referred to events that were known to the author, and they frequently backed up one another's description of events. It is the author's opinion that the figures given here may underestimate actual rates of exposure, as officers were often reluctant to remember these psychologically painful events. In fact, a number of officers commented that it was difficult and painful to recall the unpleasant memories as they made every effort to suppress associations and memories of traumatic events.

Officers were also asked about the impact on them of exposure to critical incidents. The PTSD section of the Diagnostic Interview Schedule was used to assess critical incident stress symptoms.

Twenty-eight percent of officers reported experiencing no symptoms of critical incident stress. As mentioned above, only 2% of officers were not exposed to traumatic events in the correctional work environment. In other words, 26% of exposed officers did not experience symptoms of traumatic stress after the incidents. At the other end of the continuum, 17% of officers in this study experienced effects severe enough to be clinically diagnosed as suffering from PTSD. This is significantly higher than the 1% level found in the general population and is approaching the 20% level found in Vietnam veterans wounded in battle.⁽⁹⁾ In 81% of officers studied, their symptoms disappeared in less than three years. For the rest, however, their symptoms took three years or longer to abate. Most officers continued to perform their duties during these periods, an indication that adaptation is possible even in the presence of severe stress.

The remaining 57% of officers in the sample presented a variety of symptoms different in number and severity. As illustrated in Figure 3, most common symptoms were sleep disturbances, nightmares and an exaggerated startle response. The average number of symptoms experienced by these officers in their lifetime was five. There were no significant gender differences.

Permission was requested from participants to contact their physicians about their general health. Three percent of the sample did not grant this permission.

About two of every five officers in this study (42%) had sought professional help for a traumatic stress-related health problem. Their physicians reported that 34% of the officers currently suffered from a stress-related problem that required medical attention; for half of these, their doctors indicated that the problem was related to exposure to a traumatic event.

Physicians were asked to rate their patients along a continuum of seriousness from mild to severe. Of the 34% of officers identified by their doctors as having a stress-related problem, 18% were considered by their doctors to have a serious problem, 78% a moderate problem, and 9% a mild problem. For 41%, their physicians considered the problem serious enough to interfere with daily living, and 59% required medication.

As stated, only 42% of the officers sought professional help. It is likely that only those with the most severe difficulties discussed their symptoms with their doctors. Officers accept many of the critical incident stress symptoms as an occupational hazard and perceive acknowledging them as a sign of weakness. Further, it has only been within the past five years or so that the impact on personnel of exposure to traumatic events has been discussed in correctional settings. Such information has not been widely disseminated, and many officers are still reluctant to acknowledge any personal effects from such events for fear of a negative reaction by peers or management.

To determine the long-term effect of exposure to critical incidents, officers were also assessed in terms of their current functioning. It was found that the more critical incidents to which persons are exposed over their lifetime, the more likely they are to experience critical incident stress symptoms. Similarly, the more critical incident stress symptoms individuals experience, the more likely they are to be currently experiencing difficulties.

These findings discount the common belief among staff and managers in corrections that individuals become hardened to critical incidents and, over time, are unaffected by such events. Further, the findings provide evidence of a need for intervention procedures after incidents.

In 1988, the federal government brought together personnel from a variety of government departments to receive training in the Critical Incident Stress Debriefing (CISD) model developed by Dr. Jeffrey Mitchell,⁽¹⁰⁾ of the University of Maryland. Believing that though the model was developed for use with emergency and public safety personnel, it could also be used with corrections staff, the Correctional Service of Canada sent representatives from the various regional jurisdictions to the training session. These representatives then developed plans to implement critical incident response capabilities in their regions.

The goal of critical incident stress management is to protect and support personnel while minimizing the development of traumatic stress response syndrome, which can cause decreased performance, absenteeism, physical and mental health problems and family difficulties.

Critical incident stress management offers a continuum of interventions:

• on-scene debriefing;
• initial defusing;
• formal CISD; and
• follow-up CISD.⁽¹¹⁾

On-scene debriefing is provided by a trained, designated person who observes the operation and monitors for any acute stress reactions at the site. The intervenor helps affected personnel deal with their reactions, and in most cases personnel are able to return to their duties. The intervenor may also be in a position to offer suggestions to the crisis manager regarding personnel who are exhibiting such strong stress reactions that relief or reassignment to a less stressful role within the situation would be appropriate.

The second level of intervention is the initial defusing, which takes place within a few hours of the incident. It can be led by a mental health professional or by a specially trained peer who is knowledgeable in the field of critical incident stress management. This is a brief intervention that identifies potential stress symptoms with suggestions on how to manage them as well as suggestions regarding prevention techniques.

When a formal debriefing is not required, the initial defusing can be followed up, as necessary, with a brief but discreet contact at the work site or a "check-in" phone call.

The third level of intervention is the formal CISD. This is a structured psycho-educational process led by a qualified mental health professional that should be conducted as soon as possible after the incident. The leader must be knowledgeable and skilled in the areas of group-work techniques and critical incident stress, and understand the unique demands placed on correctional personnel during an incident. The use of a professional leader is imperative because the issues raised during the CISD have the potential to overwhelm an untrained facilitator.⁽¹²⁾

The rules of the process are clarified at the beginning of the Critical Incident Stress Debriefing. Confidentiality is emphasized and personnel are encouraged to participate. This is a supportive process, not a critique.

Next is the fact phase. Group members are asked to share information about what they saw, heard, touched, smelled and did during the incident. This stage allows individual members to form a more complete understanding of what transpired during the critical incident and provides a forum for personnel to begin to process their experience.⁽¹³⁾

The thought phase and the reaction phase follow, allowing personnel to identify and focus on their cognitive response to the most stressful aspects of the incident, and to describe their emotional reactions at the time of the incident and express their present feelings about it.

During the fifth phase, participants are asked if they have had any symptoms, either physical or psychological, since the incident. Participants are reassured that they are experiencing normal human reactions to abnormal events.

Phase six is the teaching phase. The group leader teaches about stress response syndrome, its symptoms, specific coping strategies and prevention techniques. The goal is to normalize the feelings and experiences of the group so the final or re-entry stage can occur. During the re-entry phase, personnel are given the opportunity to interact with one another, and, where necessary, individuals deemed in need of additional support are quietly offered the opportunity.

The follow-up CISD is the final level of intervention. This occurs whenever it appears necessary, at the one-month, six-month or one-year anniversary of the event or at any other time when there seem to be unresolved problems interfering with the individual's ability to function. It may be conducted on a group or an individual basis.

Pre-education on the effects of critical incident stress is an integral component of its management. Training in methods of stress reduction and stress prevention techniques helps protect personnel, both at the time of the event and in the long term. Knowledge of the signs and symptoms of critical incident stress allows for early identification of problems. Early intervention minimizes short-term symptoms and greatly decreases the likelihood of long-term problems.⁽¹⁴⁾

Management alone cannot be responsible for preventing the long-term problems that result from exposure to critical incidents. Staff must also take responsibility for their own wellness and practise stress-prevention techniques such as eating properly, getting adequate sleep and exercise, reducing nicotine and caffeine consumption, controlling alcohol consumption and ensuring a balance between the amount of overtime they do and the amount of time they spend outside the work setting.⁽¹⁵⁾ Participation in pre-education training and in postincident defusings and debriefings are the responsibility of individual staff members. Individuals who recognize stress response syndrome and seek help immediately greatly reduce the likelihood of both short- and long-term problems.

Providing pre-education and postincident intervention can reduce both the short- and long-term impact of traumatic events. Such strategies benefit both the employee and the organization. Employees benefit in that disruptions to their well-being are minimized. The organization benefits from increased employee morale, a positive work orientation, facilitated return to previous levels of work performance and reduced need for long-term sick leave.