FIRST RESPONDER’S GUIDE TO ABNORMAL PSYCHOLOGY Applications for Police, Firefighters and Rescue Personnel FIRST RESPONDER’S GUIDE TO ABNORMAL PSYCHOLOGY Applications for Police, Firefighters and Rescue Personnel William I. Dorfman Nova Southeastern University Fort Lauderdale, Florida, USA and Lenore E.A. Walker Nova Southeastern University Fort Lauderdale, Florida, USA William I. Dorfman Center for Psychological Studies 3301 College Avenue Nova Southeastern Uniersity Ft. Lauderdale, Florida 33314 e-mail: [email protected] Lenore E. A. Walker Center for Psychological Studies 3301 College Avenue Nova Southeastern Uniersity Ft. Lauderdale, Florida 33314 e-mail: [email protected] Library of Congress Control Number: 2006929449 ISBN-10: 0-387-35139-6 e-ISBN-10: 0-387-35465-4 ISBN-13: 978-0-387-35139-1 e-ISBN-13: 978-0-387-35465-1 Printed on acid-free paper. © 2007 Springer Science(cid:2)Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science(cid:2)Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. 9 8 7 6 5 4 3 2 1 springer.com TO Phyllis, Karen, Aaron, Will, Zack and Eric Karen & Steven, Max, Benjamin, and Oliver; Michael & Roberta, Micaela and Maya, Sara, Laura & Andrew, Jacob, Anne, and Jonathan AND TO All the First Responderswho make their world a safer place in which to live Table of Contents Introduction........................................................................................... ix Chapter 1 The Role and Importance of First Responders in Dealing with Psychologically Disordered Individuals....................................................................... 1 Chapter 2 Normal vs. Abnormal Behavior: A Continuum.................................................................. 13 Chapter 3 Key Mental Health Issues in the Criminal Justice and Emergency Medical Systems..................... 19 Chapter 4 Disorders of the Brain and Central Nervous System.............................................................. 43 Chapter 5 The Psychotic Disorders................................................ 55 Chapter 6 The Mood Disorders....................................................... 71 Chapter 7 The Anxiety, Somatoform and Dissociative Disorders.......................................................................... 87 Chapter 8 The Personality Disorders............................................. 109 Chapter 9 The Substance Use Disorders........................................ 131 Chapter 10 Crisis, Terrorism and Trauma-Based Disorders........... 149 Chapter 11 Therapeutic Justice......................................................... 169 Chapter 12 Mental Disorders in Youth............................................ 187 Index....................................................................................................... 219 vii Introduction The devastating events of September 11, 2001 crystallized in the national consciousness the critical role of our police, firefighters and emergency medical personnel in dealing with emotional as well as physical trauma. These First Responders played central roles in addressing the over- whelming medical and psychological needs of massive numbers of victims and brought continuous attention to these dedicated public servants over a period of several months. As a result of this crisis, our country has developed a renewed appreciation for the contributions these First Responders make on a daily basis. In particular, we have come to appreciate more fully the important functions these person- nel serve in evaluating and intervening with individuals suffering from chronic psychological and psychiatric impairments as well as traumatic stress resulting from accidents, domestic violence, natural disasters and other life threatening emergencies—all in addition to the more highly publicized disaster. While the psychological literature supporting the edu- cational and training needs of emergency personnel is voluminous, there is relatively little published that is geared to the needs of First Responders covering the range of psychiatric and psychological disorders with which they must deal. We have written First Responder’s Guide to Abnormal Psychologyto address their needs and those of students who aspire to fill those roles. First Responders, personnel who are often first on the scene when an emergency occurs, are police officers on their daily beat, detectives trying to solve a murder case, firefighters responding to a conflagra- tion, or air marshals protecting passengers on a flight. They are trans- portation safety workers, probation officers, FBI agents seeking to identify terrorists, detention center staff, wardens and deputy workers in our jails and prisons as well as military police keeping order after a bomb explodes. Few of these individuals will have had training in understanding people’s emotional responses to stress and trauma or the signs and symptoms of psychological illness. We have written this book to address these critical issues. ix x Introduction The book has been organized so that professors who are teaching courses in criminal justice, psychology, social work, or emergency services can easily adapt material to their syllabi. We offer current infor- mation in clinical and forensic psychology, as well as crisis and trauma theory employing real life examples of the principles discussed in the text, and concise tables summarizing the cardinal features of the various mental disorders that First Responders encounter. We have chosen to eliminate references to research literature in the text that are so com- mon in traditional psychology textbooks written for professional mental health workers or psychology majors. Rather, we have attempted to enhance readability by emphasizing the clinical and practical nature of the issues we describe, adding source material at the end of each chapter for those who wish to explore any topic more fully. The text includes chapters covering the major psychological and psychiatric impairments, including cognitive disorders; schizophrenia; depression and bipolar disorder; anxiety, somatoform, and dissociative disorders; substance use disorders and personality disorders. Another chapter summarizes the most relevant information on disorders com- mon in children and adolescents including discussions of child abuse, domestic violence, and juvenile justice. Finally, specialized chapters address crisis, terrorism and trauma theories, and intervention strategies useful for First Responders, in addition to the role of therapeutic justice that includes sections on drug, mental health and domestic violence courts, involuntary commitment, and the insanity defense. The National Institute of Mental Health reported in 2006 that mental disorders are the leading cause of disability in the United States and Canada for ages 15 to 44, with an estimated 26.2% of Americans these ages and older—about one in four adults—suffering from a diag- nosable mental disorder in a given year. The Department of Justice claims that over 60% of all inmates in jails and prisons in the United States have experienced a mental illness at some time of their lives. We hope that our book will enable our readers to perform their critical jobs more effectively, more sensitively, and with a fuller appreciation of the very debilitating role stress, trauma, and mental illness play in he lives of citizens they serve. We want to express our appreciation to our editors especially Sharon Panulla at Springer for their support and patience as we developed this text. We offer very special thanks to Dr. Rosemary Timoney who care- fully reviewed and edited preliminary drafts of the manuscript. Our text became more readable under her thoughtful and sensitive direction. WILLIAMI. DORFMAN LENOREE.A. WALKER Ft. Lauderdale, FL January 2007 CHAPTER 1 CHAPTER 1 The Role and Importance of The Jacksonville, Florida, First Responders in Dealing Experience with Psychologically Disordered Individuals WHO ARE FIRST RESPONDERS? The term “first responders” became publicized during the aftermath of the terrorist attack on the World Trade Towers and Pentagon on September 11, 2001. First Responders are trained persons who respond to an emergency or crisis call. They may be police officers, fire fighters, emergency medical technicians, mental health counselors and psycho- logists, medical staff and doctors, crime scene technicians, child protec- tive services workers, security guards, first-line soldiers in combat, and in some cases, office managers and school teachers. First Responders rarely know what they will find when answering a call. Police are trained to intervene in a home invasion but if either the perpetrator or the victim has a mental health problem, his or her behav- ior may well be unpredictable, putting everyone in danger. Firefighters are trained to save a burning building, but how to persuade a mentally ill person that it is safe to leave may require another set of skills. A child protective services worker may have to make a home visit in a building being “guarded” by a paranoid schizophrenic who sees the worker as the enemy. Security guards may find disheveled and disorientated people, but may have no training in how to deal with them. We all became aware of the firefighters who lost their lives on September 11 in NYC when, unaware that the buildings were about to collapse, they ran into the World Trade Towers to save people trapped inside. Many New Yorkers became First Responders that day, trying to help their friends, family, or even strangers standing next to them deal with the magnitude of the tragedy that unfolded before them. Strangers talked to each other, trying to make sense out of what had just tran- spired. Stories of heroes that day emerged; the woman train dispatcher who stopped the NJ Transit trains from going towards the station under the World Trade buildings, the office workers who helped colleagues down the stairs when they became afraid to continue, the people in the 1 2 The Role and Importance of First Responders fourth airplane destined for the White House who went down with the plane rather than comply with the hijackers’ demands, and other brave people just like them. The Red Cross sent hundreds of volunteers to the scene over the next several months. Many learned that providing a listening ear, a blanket, and warm cup of cocoa was critically impor- tant. Later, psychologists and other mental health workers provided crisis counseling for these First Responders to prevent them from devel- oping more serious trauma reactions themselves. We learned during this mass catastrophe what others who were trained to respond in an emergency knew when they first arrived at a disaster scene; caring people make a difference in saving lives and pre- venting further psychological injuries. But what about those whose mental status is not very stable even before tragedy strikes? Or those whose mental illness seems to propel them into the criminal justice system repeatedly? In the following chapters, we attempt to explain what we know about mental illness both before an emergency strikes as well as afterwards. We will describe the impact of crisis situations on individuals; how the brain and nervous system control human behavior; and how mental health professionals use their skills to diag- nose, evaluate and treat psychological dysfunction. We believe that First Responders need this knowledge in order to deal more effectively with patients and victims who may suffer both physical and psycho- logical trauma (Box 1.1). WHAT KINDS OF PEOPLE WILL FIRST RESPONDERS DEAL WITH? Trauma Victims The first responder who answers a crisis call may find people who are traumatized by the current situation or those who were mentally ill pre- viously and then became retraumatized by what they had just experi- enced. Again, September 11 provides good examples. Many people who observed the planes hit the buildings, watched people jumping out win- dows to their death, climbed down smoke-filled staircases to save their own lives or watched the buildings collapse in front of their own eyes developed acute and chronic traumatic stress reactions. Some of them developed the more chronic Post Traumatic Stress Disorder (PTSD). Many who watched the images on television over and over again were traumatized. Those who lost family and close friends in the buildings also developed these reactions. Police and fire-fighters developed trau- matic stress as well. In some cases, these reactions lasted for months and years afterwards. Others were shaken by the experience but moved on with their lives, rarely showing any emotional impact. What was it that motivated people to respond in such widely different ways to the same experience? What Kinds of People will First Responders Deal With? 3 BOX 1.1 disorder often develop the same disorder Other Victims of 9/11: Therapists, themselves. Social Workers To investigate whether this phenome- By Alison McCook non occurred among social workers who offered their services during the NEW YORK (Reuters Health)—Social September 11, 2001 attacks, Boscarino workers who counseled large numbers of and his colleagues mailed questionnaires patients traumatized by the September 11 in May 2003, to 600 social workers who attacks in New York appear to be at risk had addresses in New York City. of developing the same nightmares and Overall, 236 social workers returned flashbacks as their patients, a new study the questionnaires.More than 80 percent reports. said they counseled people during the Study author Dr.Joseph A.Boscarino days following the attacks. explained that this phenomenon, known The investigators found that the as secondary trauma, likely results when more social workers had involved them- therapists or social workers hear descrip- selves in the recovery from the attacks, tions of traumatic events from patients, the more likely they were to have devel- then picture those events and become oped secondary trauma. However, the traumatized themselves. more social workers rated their work "As a therapist, you can be at risk from environment as being supportive, the treating these people," he said. less likely they were to develop second- However, he noted that social workers ary trauma. who said they had a supportive work These findings, reported in the environment—meaning, for instance, International Journal of Emergency that their boss was sensitive to their Mental Health, reinforce the importance needs, orthey received a lot of time off to of creating a good work environment for de-stress—appeared to be protected people exposed to traumatized patients from secondary trauma. on a regular basis, Boscarino noted. For social workers and other thera- He added that although the pists who have already developed sec- September 11 attacks were a unique ondary trauma, "there’s every reason to event, social workers, psychologists and believe they should have counseling psychiatrists who regularly counsel themselves," Boscarino noted."Just like abused women, for instance, may also be a victim who directly experienced (the at risk of secondary trauma. trauma)." "This could be an occupational hazard In an interview, Boscarino, who is that needs to be looked at," he said. based at the New York Academy of Medicine in New York City, explained that SOURCE: International Journal of previous research has shown that Emergency Mental Health, June 2004. spouses and therapists of Vietnam Reuters, July 1, 2004. veterans who have post-traumatic stress It is believed that those who have experienced prior traumatic events may be at a higher risk to develop PTSD from a new event, while those for whom this is the first exposure to a traumatic event may have more emotional resilience to handle it. Some even suggest that there are dif- ferent genetic vulnerabilities in response to stress and trauma. Studies have shown that people who have a more positive outlook on life—that is, those who believe that “a glass is half full rather than half empty”— may have more resilience in handling trauma. Some people learn to shut off their painful emotions so they may not feel emotional pain during a crisis or trauma situation. Others may have developed a very distinct