1. Battling Operational Stress
Injuries
Ottawa OSI Clinic
Michele Boivin, PhD, CPsych
Jakov Shlik, MD, FRCPC

2. Operational Stress Injuries
• Psychological injuries caused by combat,
law enforcement or other operational and
service-related duties.
• Comprised of biological damage to brain
systems, psychological damage to beliefs
and self-esteem, and social disruption.
• Everyone is affected, some injured, many
get better.

3. The effect of war on the mind
 American Civil War -
Soldier’s heart
 WWI – Shell shock
 WWII – Battle fatigue
 Post-Vietnam syndrome
 1980 – DSM-III PTSD
“Thousand Yard Stare” 1944

4. Modern non-medical terms
 Combat stress reaction
 Combat stress injury
 Operational stress injury

5. Mechanisms of stress injury
Combat/operational stress
Trauma Fatigue Grief
Impact
injury
Wear and
tear injury
Loss injury
ASD, PTSD Adjustment
disorder
Depression
Anxiety Disorder
Grief reaction
Depression
Nash, PTSD 101

6. Belief injury
 Safety
 Control
 Moral order
 Righteousness
 Value of life
 Goodness of people

7. Modern warfare factors
• Peacekeeping stressors
• Advanced technology
• Lethality, atrocities
• Lack of frontline
• Land mines, IED
• Suicide attacks
• Extreme environments
Richard Johnson: sketches from front lines

8. Suicide

9. Homecoming
 Distress
hypervigilance, memories
fatigue, insomnia, dreams,
 Identity change
 Anger and impulsivity
 Alcohol and drugs

10. Adjustment
 Family
 Loneliness
 Work
 Health
 Society

11. Leaving the service
 Loss of support
 Loss of goals
 Loss of health
 Loss of financial security
 Bureaucracy
 Civilian life

12. Operational stress in law enforcement
• Critical incidents
• Cumulative stress
• Exposure to crime
and depravity
• Internal and external
pressures

13. Employee well-being within Canada’s
Police Departments
• Multiple competing
unremitting demands
• Expectations for top
performance
• Organizational stressors
• Hindrance to help-seeking
Duxbury L & Higgins C. Caring for and about those who serve: Work-life conflict and employee well being within
Canada`s Police Departments. March 2012

14. OSI clinical manifestations
• PTSD
• Depression
• Anxiety Disorder
• Pain
• Psychosomatic problems
• Sleep-related conditions
• Alcohol and drug abuse
• Gambling, risk-taking, aggression
• Self-harm and suicide

15. OSI treatment
• Mental health care
• Social support
• Medical care
• Vocational recovery
• Physical recovery
• Family functioning

16. OSI Clinic
Mandate:
• Standardized Assessment & Diagnosis
• Empirically Supported Treatment
• Networking & Education
• Research & Program Evaluation

18. Population

19. 3% 3%
9%
5%
12%
59%
9%
WorldWar II
KoreaWar
Afghanistan
Domestic
High Frequency, Short Duration
Deployments*
UNPeacekeeping
No deployments
Deployments

20. Psychiatric diagnoses
15
5
8
12
5
2
67
14
3
10
10
12
69
0 10 20 30 40 50 60 70 80
Other Diagnoses
Pain Disorder
Substance Abuse/Dependence FSR
Subtance Abuse/Dependence
Other Mood Disorder
Bipolar Disorder
Major Depression
Other Anxiety Disorder
Obsessive Compulsive Disorder
Panic Disorder
Generalized Anxiety Disorder
Anxiety Disorder NOS
Posttraumatic Stress Disorder
% of Clients

21. 37
5
7
10
12
13
16
18
18
21
60
63
0 10 20 30 40 50 60 70
Other
Cancer
Respiratory
Diabetes
Migraine/Headac…
Arthritis
Gastrointestinal
Sleep Disorder
Hearing/Vision
Cardiovascular
Chronic Pain
Musculoskeletal
% of Clients
Medical Conditions

22. 30
7
12
16
19
23
30
39
41
42
0 5 10 15 20 25 30 35 40 45
Other
Housing/Moves
Loss/Bereavement
Military Related
Health
Financial
Marital/Romantic
Relationship
Employment/School
Social Relationships
Family
% of Clients
Psychosocial problems

23. Treatment need
• Most officers and vets do not get help for their
symptoms
• Of those who do, treatment is often delayed
• Untreated OSI’s result in significant personal and
societal costs (lost productivity, medical costs,
lives lost)

24. Barriers to help seeking
• Stigma
• Impact on career
• Officer/soldier identity
• Belief about treatment outcome
• Ambivalence about symptoms

25. Effective Treatments are Available
• Based on models of “natural recovery”
• Target maintenance rather than causal factors
• Response rate: 85%

26. Treatment targets
Behaviours
Emotions
Thoughts

27. Treatment modalities
• Psychological treatment
• Emotion Regulation
• Cognitive Behavioural Therapy for anxiety/depression
• PTSD-specific: Prolonged Exposure (PE), Cognitive
Processing Therapy (CPT)
• Psychiatric treatment
• Medication management
• Family support
• Psychoeducation
• Couples therapy

28. Treatment modalities - community
• Social & occupational support
• OSISS
• Referral to vocational rehabilitation
• Physical recovery
• Pain management
• Sleep study
• Adjunct services (yoga)

29. Treatment Planning
Stabilization:
•Safety
•Trust
•Emotion
regulation/
coping skills
Symptom
reduction:
•PTSD therapy
•Depression
•Substance Use
•Related concerns
Transitioning:
•Meaning
•Identity
•Relationships
•Work

30. Recovery
• Full remission is possible
• Defining Recovery
– Being symptom free
– Coping vs. forgetting
– Reestablising identity and relationships
– Living according to goals, values

31. Bill and Alana
Q & A