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Professional Psychology: Research and Practice 2011, Vol. 42, No. 1, 94 104 In the public domain DOI: 10.1037/a0022365

FOCUS ON ETHICS Jeffrey E. Barnett, Editor

Psychology in Extremis: Preventing Problems of Professional Competence in Dangerous Practice Settings

W. Brad Johnson
United States Naval Academy

Shannon J. Johnson
Naval Hospital, Camp Pendleton, California

Glenn R. Sullivan
Virginia Military Institute

Bruce Bongar
Pacific Graduate School of Psychology, Palo Alto University, and Stanford University School of Medicine

Laurence Miller
Boca Raton, Florida

Morgan T. Sammons
California School of Professional Psychology

When a psychologist provides services in a dangerous contexta work setting defined by persistent threat to the psychologists own personal safety and well-beingthe psychologist is said to practice in extremis. Psychologists who routinely function in extremis, such as those in correctional, disaster response, military, and police psychologyamong other specialtiesmay be at increased risk for troubling experiences such as direct or vicarious traumatization, compassion fatigue, and empathy failure. Over time, in extremis experiences may contribute to decrements in professional competence. When psychologists become aware of personal problems that interfere with their work, they must take steps to ameliorate the problem while protecting consumers. In this Focus on Ethics, we discuss the difficulty inherent in self-identifying and correcting problems of professional competence when working in a high-threat environment. Three expert commentaries further elucidate in extremis competency concerns from the perspective of disaster response, police, and military psychology. The authors provide numerous recommendations for helping psychologists to ensure ongoing competence in in extremis jobs.

Keywords: competence, ethics, psychologist, professional, in extremis

W. BRAD JOHNSON received his PhD in clinical psychology from Fuller Theological Seminary. His is a professor in the department of Leadership, Ethics & Law, United States Naval Academy, and a faculty associate in the Graduate School of Education, Johns Hopkins University. Research interests include mentor relationships, professional ethics, and leadership. SHANNON J. JOHNSON received her PhD in clinical psychology from Rosemead School of Psychology. She is a Navy psychologist, currently stationed at Marine Corps Base, Camp Pendleton. Research and clinical interests include operational psychology, military leadership, and health care ethics. GLENN R. SULLIVAN received his PhD in clinical psychology from the Pacific Graduate School of Psychology. He is an assistant professor in the Department of Psychology and Philosophy, Virginia Military Institute. He also has an independent practice in Lexington, Virginia. Research and clinical interests include combat-related PTSD, suicide, and forensic assessment. BRUCE BONGAR received his PhD from the University of Southern California in 1977. He is the Calvin Professor of Psychology at the Pacific Graduate School of Psychology at Palo Alto University and consulting professor in the Department of Psychiatry and the Behavioral Sciences at Stanford University 94

School of Medicine. Dr. Bongars main research focus for many years has been on suicidal behavior and other clinical emergencies, with a particular interest on standards of care and risk management. LAURENCE MILLER is a clinical and forensic psychologist in Boca Raton, Florida. He is a police psychologist with the West Palm Beach Police Department, the Palm Beach County Sheriffs Office, and Troop L of the Florida Highway Patrol. He is a court-appointed psychological examiner for the Palm Beach County Court and an adjunct professor at Palm Beach State College and Florida Atlantic University. MORGAN T. SAMMONS received his PhD in Counseling Psychology from Arizona State University. He is a retired captain in the US Navy. He is currently the Dean of the California School of Professional Psychology at Alliant International University and is a diplomate (clinical) of the American Board of Professional Psychology. He is an associate editor of the APA journal Psychological Services. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to W. Brad Johnson, Department of Leadership, Ethics & Law, U.S. Naval Academy, Luce Hall, 7B, Annapolis, MD 21402. E-mail: johnsonb@usna.edu

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Psychologists are ethically obligated to ensure their own competence to practice in specific domains of professional psychology. Because practitioner health is considered essential for rendering effective services and for protecting clients, psychologists who suffer personal problems and conflicts are obligated to refrain from professional work if their competence is likely to be hampered (American Psychological Association [APA], 2002). When psychologists practice in extremis, that is, at the point of death (Kolditz, 2007, p. 160), in dangerous or life-threatening contexts, the probability of distress and diminished competence increases. For instance, most military psychologists currently face frequent extended deployments to combat zones, either embedded with active combat units or stationed in isolated duty stations caring for severely traumatized populations (Johnson & Kennedy, 2010). Like all military personnel, deployed psychologists are considerably more likely than others in the population to suffer mood, anxiety, trauma, substance, and relational disturbances (Hoge, Auchterlonie, & Miliken, 2006). Further, military psychologists are often quite junior and inexperienced, the very psychologists most vulnerable to work-related distress (Shapiro, Brown, & Biegel, 2007). In this Focus on Ethics, we consider the significant risks to competence accrued when psychologists engage in in extremis practice, that is, practice in settings where exposure to trauma both personally and vicariouslyis high. Although our contribution emphasizes military practice, we recognize that psychologists working in law enforcement, prisons, and disaster relief contexts, among others, often face similar concerns; we believe that this discussion is relevant to those groups as well. We illustrate professional competence problems using two real first-person narratives provided by a military psychologist during his deployment to Iraq and shortly following his return. We propose that psychologists working in extremis may be poorly suited to effectively evaluate their own competence; we suggest that the community of psychologists must shoulder more of the burden for insuring colleague competence during and following deployments.

provision of substandard care, is often a subtle process; extremely distressed psychologists are poorly suited to the ethical task of monitoring their own competence.

Consistent Stress Heightens the Risk of Specific Competence Problems

Various surveys of practicing psychologists paint a sobering picture of psychologist distress. For instance, more than half of psychologists in one survey had experienced at least one episode of clinical depression, and a quarter reported suicidal feelings during that episode (Pope & Tabachnick, 1994). Other surveys indicate that between one half and one third of all practicing psychologists experience extreme emotional exhaustion, sleep problems, and mood or anxiety disturbances (Guy, Poelstra, & Stark, 1989; Mahoney, 1997; Sherman & Thelen, 1998). Perhaps most sobering is survey evidence that many psychologistsnearly 60% in one national surveyadmit seeing clients when too distressed to do so ethically and effectively (Guy et al., 1989; Pope, Tabachnick, & Keith-Spiegel, 1987). When a psychologist must function in an environment characterized by consistent and overwhelming stressan in extremis settingthe risk of specific forms of competence problems increase. First, military psychologists run the risk of direct exposure to traumatic events and subsequent trauma-related disturbances. Second, competence problems may emerge when a psychologist develops symptoms of traumatic stress as a consequence of working with traumatized individuals. Regehr, Goldberg, and Hughes (2002) describe vicarious traumatization this way: Through the process of hearing the graphic details of other peoples horrifying experiences, the [psychologist] can begin to experience symptoms that include intrusive imagery, generalized fears, sleep disturbances, a changed world view and affective arousal (p. 505). Third, psychologists working with seriously wounded or traumatized persons for an extended period, perhaps with little previous professional experience, are at greater risk of compassion fatigue, an emotional exhaustion syndrome resulting from excessive demands on ones own resources in empathizing with clients who are in serious pain (Figley, 2002). Compassion fatigue is synonymous with burnout (Koocher & Keith-Spiegel, 1998). A corollary of compassion fatigue is a syndrome we call empathy failure (Post, 1980). Empathy failure occurs when a previously emotionally competent psychologist begins to process client experiences and feelings on a purely cognitive level, perhaps no longer capable of emotional processing and mirroring. Empathy failure is not easy for the distressed psychologist to discern.

Problems of Professional Competence

Professional competence refers to a psychologists ability to carry out certain tasks appropriately and effectively (Elman & Forrest, 2007; Johnson et al., 2008). At times, problems of professional competence (Elman & Forrest, 2007) may be linked to foundational deficits in character (i.e., integrity, prudence, caring) or psychological fitness (e.g., personality adjustment, psychological health; Johnson & Campbell, 2002). These preexisting problems make achieving competence difficult or impossible and are statistically predictive of professional infractions and disciplinary action postlicensure (Papadakis et al., 2005). More often, problems of professional competence relate to decrements in ones previous level of professional functioning as a result of distress. Barnett, Baker, Elman, and Schoener (2007) defined distress as a subjective emotional state or reaction experienced by an individual in response to ongoing stressors, challenges, conflicts, and demands (p. 603). Although most psychologists experience distress at one time or another, it is essential to note that distress does not always result in impaired competence (Barnett & Hillard, 2001; Elman & Forrest, 2007). We are concerned that diminished occupational functioning, including the

Military Deployment as an in Extremis Practice Environment

Today, between 400 and 500 military psychologists serve on active duty. A junior psychologist entering the military is nearly guaranteed to deploy to a combat zone, and multiple deployments in a short period of time are increasingly common (Johnson & Kennedy, 2010). In addition to the dangers of a combat theater, military psychologists are often exposed to severely injured service members and a constant stream of traumatic stories from their clients. Not surprisingly, military psychologists have begun to describe poignant struggles with posttraumatic stress disorder

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(Kraft, 2007). As an illustration of the toll of in extremis work, the following narrative samples were provided by a military psychologist during and immediately following his deployment to Iraq.

Deployment
This afternoon, as my patient sat before me describing his difficult emotions and concerns, my brain went into lockdown. I stared at his face, saw his lips move, and heard his voice, but my ability to process information was lost. Instead, my mind was hijacked by a stream of disturbing images from my own experiences in Iraq: a young marine burning alive in his armored vehicle, the guard outside our dining facility who had her head taken off by a rocket-propelled grenade, one of my long-term clients literally blown to pieces by an IED shortly before he was to return home. Flooded by a sudden onset of these memories, I briefly lost all awareness of the marine sitting in front of me. When my patient said, Sir, are you okay? I stared back blankly, feeling nothing. For the first time in seven months, I had nothing to offer, not compassion, not hope, not encouragement; some invisible boundary had been crossed and I was no longer able to relate to anyone elses sadness or process any more tragedy.

those with whom they interact professionally. Training to become a professional psychologist requires the development of a professional identity that includes a well-honed sensitivity to the best interests and protection of ones clients (Barnett & Johnson, 2008; Glickauf-Hughes, 1994). But can the psychologist himself or herself reasonably be expected to adequately discern and address these problems?

Why Psychologists Often Fail To Address Problems of Professional Competence

Even in more mundane practice circumstances, psychologists who begin to experience problems of professional competence may fail to take the steps necessary to limit their practices, get needed consultation, or seek personal treatment. Reasons for this failure may include both individual and systemic factors. Individual factors include inadequately developed or compromised selfawareness (Barnett & Hillard, 2001). But even self-aware practitioners are often not effective when it comes to accurately assessing their own level of competence (Davis et al., 2006). Psychologists may also suffer shame and fear rejection from colleagues when they recognize their own impairment (Counselman & Alonso, 1993; OConnor, 2001). Still other psychologists may deny human limitations and use narcissistic defenses to maintain the illusion of imperviousness to even extreme distress and trauma (Glickauf-Hughes, 1994). To make matters worse, research evidence suggests that colleagues are reluctant to step in when a psychologist suffers competence problems (Bernard, Murphy, & Little, 1987). Common reasons for this reticence include a wish to respect the colleagues privacy, autonomy, and professional judgment; discomfort with confrontation; worry that one has insufficient evidence to support competence concerns; fear that the intervention will harm the collegial relationship; lack of clarity regarding ones ethical obligations to intervene; and even fear that ones reputation will be harmed in the larger community of psychologists (Johnson et al., 2008). In military contexts, peers may also worry about the career implications for the psychologist who may be temporarily placed in a nondeployable limited-duty status.

Post-Deployment
Months after my return to the states, I was back at work in a busy outpatient clinic. Dragging myself to work each day, I was aware of an emotional hardening that allowed me to maintain distance from my patients and their problems. I was vaguely disturbed by this, occasionally concerned that I could no longer relate as the compassionate and committed clinician Id been at the outset of my career, but I knew that I needed these rigid boundaries and emotional detachment for my own survival. Most worrisome were strong feelings of anger that would bubble up during sessions with patients who became emotional or showed weakness. I was especially irritable with younger patients who had never served in combat; I felt that they had not earned the right to complain. I could not muster the empathy required to help me see past their maladaptive coping and discern what they needed from me.

Distress, Competence, and the APA Ethics Code

Psychologists provide services only within the boundaries of their established competence (APA, 2002). When psychologists encounter personal problems and conflicts, Standard 2.06 of the APA code offers the following guidance: (a) Psychologists refrain from initiating any activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner. (b) When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their workrelated duties (APA, 2002, p. 1064). Standard 2.06, designed to support principle A (Beneficence and Nonmaleficence), and Standard 3.04 of the Ethics Code, Avoiding Harm, together enjoin psychologists to actively prevent harm to

In in Extremis Practice, Competence Is a Community Obligation

Although ethical psychologists must recognize their own limitations and weaknesses, and refrain from practicing when too distressed to do so effectively (APA, 2002), severely distressed clinicians are often the last ones to accomplish this effectively (Davis et al., 2006). We propose that psychologist communities must begin to own greater ethical responsibility for routinely assessing colleague competence. This is particularly true in professional communities such as military psychology in which combat-zone deployment and other in extremis experiences are the norm rather than the exception (Johnson & Kennedy, 2010). As Elman and Forrest suggested, it may take a village to accurately and effectively ensure ongoing competence in in extremis jobs (Johnson et al., 2008). We conclude this article with several succinct recommendations for leaders of the military psychologist community:

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1.

Help military psychologists to appreciate the fluid, context-driven, and variable nature of professional competence (Barnett & Hillard, 2001). Encourage all psychologists to see themselves as vulnerable to distress, impairment, and reduced competence (Barnett, Baker, Elman, & Schoener, 2007; Johnson et al., 2008). Emphasize self-awareness, self-care, and the utter normalcy of periods of diminished competence. Train military psychologists to be deliberately self-assessing, open to peers, and vigilant to signs of personal and professional dysfunction (Elman & Forrest, 2007). Desensitize military psychologists to the anxiety and stigma that may be provoked by acknowledging personal distress (Kraft, 2007). Expose junior military psychologists to senior role models in the community with prior deployment experience; these role models give permission for help-seeking when competence ebbs (Kraft, 2007). Develop a comprehensive program for both supporting and monitoring the health and competence of deployed military psychologists, both in theater and following their return to this country. Because many psychologists struggle with the transition from wartime triage to relatively mundane outpatient clinic work (Kraft, 2007; Johnson & Kennedy, 2010), reintegration programs should be established. Create what we call support constellations for military psychologists that combine numerous modalities for collegial support and competence maintenance, such as peer-to-peer consultation matches, support groups, semi-annual continuing education meetings, online peer networking, and opportunities to solicit peer assessments of ones competence (OConnor, 2001). Ongoing peer support and consultation must become a norm in in extremis settings. Work to instill a norm of colleague assistance and intervention within the community of military psychologists such that Standard 2.06 of the APA Ethics Code is interpreted as a communal ethical obligation, not merely the responsibility of the psychologist who may be suffering competence problems (Barnett, Doll, Younggren, & Rubin, 2007). Actively destigmatize deployment-related problems of professional competence. Periods of limited duty or a nondeployable status for the purpose of self-care and treatment should not lead to adverse career consequences.

2.

3.

4.

5.

6.

7.

Four noted scholars in the area of professional competence have been invited to offer commentaries on this contribution and to reflect on the ethical implications of ensuring competence during in extremis work in unique settings. Our concerns about military psychologists will certainly resonate with psychologist leaders in prisons, police psychology, and disaster relief.

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060 1073. Barnett, J. E., Baker, E. K., Elman, N. S., & Schoener, G. R. (2007). In pursuit of wellness: The self-care imperative. Professional Psychology: Research and Practice, 38, 603 612. Barnett, J. E., Doll, B., Younggren, J. N., & Rubin, N. J. (2007). Clinical competence for practicing psychologists: Clearly a work in progress. Professional Psychology: Research and Practice, 38, 510 517. Barnett, J. E., & Hillard, D. (2001). Psychologist distress and impairment: The availability, nature, and use of colleague assistance programs for psychologists. Professional Psychology: Research and Practice, 32, 205210. Barnett, J. E., & Johnson, W. B. (2008). Ethics desk reference for psychologists. Washington, DC: American Psychological Association. Bernard, J. L., Murphy, M., & Little, M. (1987). The failure of clinical psychologists to apply understood ethical principles. Professional Psychology: Research and Practice, 18, 489 491. Counselman, E. F., & Alonso, A. (1993). The ill therapist: Therapists reactions to personal illness and its impact on psychotherapy. American Journal of Psychotherapy, 47, 591 602. Davis, D. A., Mazmanian, P. E., Fordis, M., Harrison, R. V., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence. Journal of the American Medical Association, 296, 1094 1102. Elman, N. S., & Forrest, L. (2007). From trainee impairment to professional competence problems: Seeking new terminology that facilitates effective action. Professional Psychology: Research and Practice, 38, 501509. Figley, C. R. (2002). Compassion fatigue and the psychotherapists chronic lack of self care. Journal of Clinical Psychology, 58, 14331441. Glickauf-Hughes, C. (1994). Character resistances in psychotherapy supervision. Psychotherapy, 31, 58 66. Guy, J. D., Poelstra, P. L., & Stark, M. J. (1989). Personal distress and therapeutic effectiveness: National survey of psychologists practicing psychotherapy. Professional Psychology: Research and Practice, 20, 48 50. Hoge, C. W., Auchterlonie, J. L., & Miliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 10231032. Johnson, W. B., & Campbell, C. D. (2002). Character and fitness requirements for professional psychologists: Are there any? Professional Psychology: Research and Practice, 33, 46 53. Johnson, W. B., Elman, N. S., Forrest, L., Robiner, W. N., Rodolfa, E., & Schaffer, J. B. (2008). Addressing professional competence problems in trainees: Some ethical considerations. Professional Psychology: Research and Practice, 39, 589 599. Johnson, W. B., & Kennedy, C. H. (2010). Preparing psychologists for high risk jobs: Key ethical considerations for military clinical supervisors. Professional Psychology: Research and Practice, 41, 298 304. Kolditz, T. A. (2007). Leading as if your life depended on it. In D. Crandall (Ed.), Leadership lessons from West Point (pp. 160 187). New York, NY: Wiley. Koocher, G. P., & Keith-Spiegel (1998). Ethics in psychology: Professional standards and cases (2nd ed.). New York, NY: Oxford University Press. Kraft, H. S. (2007). Rule number two: Lessons I learned in a combat hospital. New York, NY: Little Brown. Mahoney, M. J. (1997). Psychotherapists personal problems and self-care patterns. Professional Psychology: Research and Practice, 28, 14 16. OConnor, M. F. (2001). On the etiology and effective management of professional distress and impairment among psychologists. Professional Psychology: Research and Practice, 32, 345350.

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Papadakis, M. A., Teherani, A., Banach, M. A., Knettler, T. R., Rattner, S. L., Stern, . . . Hodgson, C. S. (2005). Disciplinary action by medical boards and prior behavior in medical school. New England Journal of Medicine, 353, 26732682. Pope, K. S., & Tabachnick, B. G. (1994). Therapists as patients: A national survey of psychologists experiences, problems, and beliefs. Professional Psychology: Research and Practice, 25, 247258. Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, 42, 9931006. Post, S. L. (1980). Origins, elements, and functions of therapeutic empathy. The International Journal of Psychoanalysis, 61, 277293. Regehr, C., Goldberg, G., & Hughes, J. (2002). Exposure to human tragedy, empathy, and trauma in ambulance paramedics. American Journal of Orthopsychiatry, 72, 505513. Shapiro, S. L., Brown, K. W., & Biegel, G. M. (2007). Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology, 1, 105115. Sherman, M. D., & Thelen, M. H. (1998). Distress and professional impairment among psychologists in clinical practice. Professional Psychology: Research and Practice, 29, 79 85.

Disaster Mental Health: Practicing in Extremis

Glenn R. Sullivan and Bruce Bongar
We are pleased to offer a brief commentary on the ethical ramifications of in extremis practice (Johnson & Johnson, this issue) as it pertains to the realm of disaster mental health (DMH). The authors raise several critical issues regarding professional competence that resonate well beyond military psychology. We thank the authors for their thought-provoking article and for the opportunity to comment. Military psychologists face an extraordinarily difficult task: helping combat troops marshal their personal resources in order to manage intense fear, helplessness, and horror within a context in which similar or worsetraumas might strike at any moment. In contrast, most of the patients treated by DMH providers expect some respite from the recent threat (except after acts of human malevolence, e.g., terrorism campaigns or shooting rampages; (Sullivan & Bongar, 2007). While the military psychologist is threatened by roadside bombs and rockets, the disaster mental health specialist can also be directly exposed to physical harm from a variety of sources (e.g., earthquake aftershocks, infectious disease, and marauding looters). Both the military psychologist and the DMH provider experience continuous exposure to both direct (e.g., witnessing sick or injured children) and vicarious (e.g., listening to victims recount their losses) trauma. Both psychological specialties operate under increased risk of compassion fatigue and (adopting Johnson and Johnsons phrase) empathy failure. It seems to us that in extremis practice could be alternatively defined as any set of circumstances that will unavoidably result in diminished professional competenceif experienced for a sufficient duration or in sufficient intensity. In that light, the provision of mental health services in the aftermath of a natural disaster, terror attack, or other catastrophe may well be comparable to the delivery of psychological services to military personnel during deployment. Further, both roles share an important feature with combat service itself: Given sufficient intensity or duration of

traumatic exposure, any person can suffer significant psychological harm and performance impairmentregardless of training, experience, or personal characteristics. No one can reasonably expect to be unchanged or unaffected by such work. However, we strongly urge that practitioners not confuse work that might be difficult for them to perform with work that would be ethically inappropriate for them to perform. To our knowledge, there are no empirical studies identifying personal characteristics that would peremptorily disqualify an otherwise competent psychologist from performing disaster mental health work, including past personal traumatic life events. For example, Jayasinghe et al. (2006) found that male Vietnam veterans providing disaster relief at Ground Zero in lower Manhattan did not differ from a notrauma control group on clinician-rated posttraumatic stress symptom severity. Regression analyses identifying personal variables that contribute to increased risk of negative outcomes such as posttraumatic stress disorder (PTSD) in combat veterans (e.g., childhood abuse; Bremner, Southwick, Johnson, Yehuda, & Charney, 1993) have helped us to appreciate the complex etiology of this disorder. However, any screening process based on such findings would yield unacceptably high rates of false positives (i.e., personnel identified as at high risk for psychiatric breakdown who subsequently perform adequately under extreme conditions; Rona, Hyams, & Wessley, 2005). We suspect that regression studies on the risk factors for compassion fatigue or even trauma-related professional incompetence could result in psychologists needlessly selfselecting themselves out of the pool of potential disaster responders because they have, for example, personal trauma histories. It is possible that more patient harm could result from high-quality mental health providers finding reasons not to deliver necessary services under unpleasant or dangerous conditions than from practitioners experiencing temporarily diminished professional competence. We agree wholeheartedly with Johnson and Johnson (this issue) that in extremis practice is best conducted in a consultative context, throughout which the practitioner has the benefits and safeguards of collegial observation and support. We have strenuously emphasized the importance of consultation in a variety of emergency and crisis contexts (see Bongar, Brown, Beutler, Breckenridge, & Zimbardo, 2007). Rona, Hooper, and Wessley (2009) recently presented evidence that group cohesion significantly influences mental health outcomes among British military personnel. We believe that such group cohesion may also be protective among mental health practitioners. For example, among New York City social workers delivering mental health services in the wake of 9/11, having a supportive work environment was negatively correlated to both secondary traumatization and job burnout (Boscarino, Figley, & Adams, 2004). Johnson and Johnsons proposed support constellations appear to address the reality that in extremis practice cannot be effectively managed as a solo practitioner. We fully support the authors recommendation for continued support of practitioners (reintegration). McCaslin et al. (2005) found that 9/11 Red Cross workers who experienced negative life events (e.g. divorce, job loss) in the year following their service in the disaster zone were at far greater risk for negative mental health outcomes; in fact, the absence of such negative life events seemed to serve as an extraordinary protective factor. We do caution, however, that only em-

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pirical studies can determine the form that any contemporaneous and postevent group support procedures or interventions should take. Our profession should bear in mind the lessons of Critical Incident Stress Debriefing (CISD), which proved to be worse than no treatment at all (e.g., Litz, Gray, Bryant, & Adler, 2002; McNally, Bryant, & Ehlers, 2003). Would-be disaster mental health psychologists must obtain relevant and sufficient training, experience, or education prior to engaging in this challenging, yet rewarding, work. Regardless of quality of preparation or personal strengths, all mental health professionals are vulnerable to distress, and excessive distress could impair professional competence. However, we must take care not to indulge in a variation of what Meehl (1973) called the spun-glass theory of the mind (p. 252). Is professional competence really such a delicate, fragile accomplishment that listening empathically to stories of loss and pain, while living temporarily in conditions familiar to most of the worlds citizens, could easily render us ineffective or even harmful to our patients? Our patients are far more resilient than we tend to give them credit for being and so are we. Experiencing distress while performing the functions of a psychologist does not necessarily indicate professional incompetence. It would be very unusual not to experience some level of reactive stress when working in such challenging environments. However, it is unclear if even transitory dissociation during a psychotherapy session signals professional impairment or whether it is a normal reaction to abnormal circumstances (or, perhaps, the consequence of sleep deprivation). Many psychotherapists suffered nightmares while treating Holocaust survivors; those who did not were more likely to be colluding with their patients avoidance (some patients were in treatment for decades without the war being mentioned in session). We need to determine (a) the actual base rates of temporary professional incompetence associated with in extremis practice, and (b) whether negative patient outcomes are associated with such impairment. At our current state of knowledge, we do not actually know if patients are more or less likely to recover when treated by psychotherapists with high or low levels of compassion fatigue (or emotional hardening). Finally, we address the notion of communal ethical obligations as suggested by Johnson and Johnson. Under the American Psychological Association (2002) Ethics Code, psychologists are already expected to informally address (and somehow resolve) the ethical violations of their colleagues (Section 1.04) and, should that informal intervention fail, to report the ethical violation to some appropriate authority (Section 1.05). The obligation to intervene with a distressed colleague is established in the Ethics Code. However, the duty to monitor the professional activities and distress levels of ones professional colleagues is not. We wonder if this omission might foster a look the other way attitude among psychologists. It is certainly true that neither of us know of any ethics case that involves a psychologist suffering sanctions for failure to intervene with a distressed colleague. On the other hand, the Ethics Code clearly obliges psychologistsupervisors to take reasonable steps to ensure that their employees and supervisees perform their work competently (Section 2.05, p. 1064). In in extremis settings, the provision of additional support, consultation, and supervision seems to be a step that is both reasonable and necessary. In addition to carefully monitoring case loads and performing case reviews, the in extremis supervisor

should monitor the physical well-being of employees (e.g., nutrition, hydration, quantity and quality of sleep) and be alert to the signs of compassion fatigue. The early intervention of the psychologist-supervisor is particularly important in these settings because lack of insight is a critical feature of compassion fatigue (Johnson & Johnson, this issue). Psychologists operating in extreme environments may be less aware of emerging personal problems that might impair their ability to perform their work duties competently (Section 2.06). But what of a team of four psychologists working side-by-side in a disaster zone? In our example, all are independent practitioners volunteering their time and expertisethere is no supervisor. The Ethics Code obliges them to have acquired competence in disaster mental health (Sections 2.01) and to ensure that their own personal problems do not interfere with their ability to deliver services adequately (Sections 2.06). However, should one of their colleagues begin to show early signs of emotional hardening or compassion fatigue, it seems that the Ethics Code does not demand that they intervene, at least not until they believe that there may have been an ethical violation by another psychologist (Section 1.04, p. 1063). We are enjoined as individuals to practice self-care in order to prevent ethical violations in the form of diminished professional competence (Section 2.06). In its present form, the Ethics Code appears silent regarding our responsibilities to prevent similar problems in our colleagues.

References
American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060 1073. Bongar, B., Brown, L. M., Beutler, L. E., Breckenridge, J. N., & Zimbardo, P. G. (Eds.). (2007). Psychology of terrorism. New York, NY: Oxford University Press. Boscarino, J. A., Figley, C. R., & Adams, R. E. (2004). Compassion fatigue following the September 11 terrorist attacks: A study of secondary trauma among New York City social workers. International Journal of Emergency Mental Health, 6, 57 66. Bremner, J. D., Southwick, S. M., Johnson, D. R., Yehuda, R., & Charney, D. S. (1993). Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. American Journal of Psychiatry, 150, 235239. Jayasinghe, N., Jedel, S., Leck, P., Difede, J., Klausner, E., & Spielman, L. (2006). Are male disaster workers with Vietnam military service at greater risk for PTSD than peers without combat history? Journal of Nervous and Mental Disease, 194, 859 863. Litz, B., Gray, M., Bryant, R., & Adler, A. (2002). Early intervention for trauma: Current status and future directions. Clinical Psychology: Research and Practice, 9, 112134. McCaslin, S. E., Jacobs, G. A., Meyer, D. L., Johnson-Jimenez, E., Metzler, T. J., & Marmar, C. R. (2005). How does negative life change following disaster response impact distress among Red Cross responders? Professional Psychology: Research and Practice, 36, 246 253. McNally, R., Bryant, R., & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4, 4579. Meehl, P. E. (1973). Why I do not attend case conferences. In Psychodiagnosis: Selected papers (pp. 225302). Minneapolis. MN: University of Minnesota Press. Rona, R. J., Hooper, R., & Wessley, S. (2009). The contribution of prior psychological symptoms and combat exposure to post Iraq deployment mental health in the UK military. Journal of Traumatic Stress, 22, 1119.

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Rona, R. J., Hyams, K. C., & Wessley, S. (2005). Screening for psychological illness in military personnel. Journal of the American Medical Association, 293, 12571260. Sullivan, G. R., & Bongar, B. (2007). Psychological consequences of actual or threatened CBRNE terrorism. In B. Bongar, L. M. Brown, L. E. Beutler, J. N. Breckenridge, & P. G. Zimbardo (Eds.), Psychology of terrorism (pp. 153163). New York, NY: Oxford University Press.

Policing the Police Psychologist: Ensuring Health and Competence

Laurence Miller
Like siblings separated at birth and discovering later in life that they both work for the same company, military psychology and police psychology have each independently addressed the cognitive, perceptual, emotional, and behavioral aspects of men and women performing extreme service in defense of their communitieswhether this be a specific neighborhood or the nation as a wholeall the while not realizing, until recently, their common origin in the behavioral science of high performance under what Johnson and Johnson (this issue) describe as in extremis conditions (Miller, 2008a, in pressb). In fact, many law enforcement officers have had military experience, and many military service members utilize tactics and strategies derived from patrol and special unit policing to carry out their assigned duties (International Association of Chiefs of Police, 2009; Miller, 2008a). The present commentary seeks to highlight the commonalities between military psychology and police psychology in order to encourage further productive cross-collaboration.

outside consultant basis to one or several local and regional agencies as part of their more general clinical and forensic psychology practices. A few are also actively involved in training and education through courses, seminars, and publications. Like police psychology, military psychology has become a burgeoning field (Freeman, Moore, & Freeman, 2009; Kennedy & Zillmer, 2006; Miller, in press-b), including subspecialties (Kennedy & Moore, 2010), and the need for psychologists, both active service military and civilian, to deal with returning veterans in the current Iraq and Afghanistan theaters is almost certain to grow in the coming years. And like their military counterparts, police psychologists need to be aware of, and be able to effectively respond to, the professional and personal challenges that may impair their ability to be effective in this crucial area of mental health practice.

Police Psychology and Military Psychology: Similarities and Differences

There are a number of similarities and differences between the work of psychologists with law enforcement officers and with military service members. Both deal with members of an elite, mission-focused, hierarchically organized, warrior class, whose members value courage, intragroup loyalty, and no-excuses excellence, where failure is not an option and weakness is a source of shame. Both police officers and soldiers are trained to kill when necessary and to deal with the reality of death. In the processes, they are exposed to the very real possibility of their own death or injury, or that of their comrades. Both groups may become traumatized by what happens to them as well as by what they may happen to do. Both groups are at risk for posttraumatic stress disorder (PTSD), depression, suicidality, substance abuse, physical disability, brain injury, and family problems related to their service. Both groups may be extremely reluctant to seek psychological help, equating it with capitulation and folding under pressure. There are differences, however. The main one is that while most cops get to go home after their shifts, soldiers may be deployed for months at a time, often half a world away. Another difference is that while police officers may have to fire their weapon in the line of duty, killing another person in these circumstances is generally regarded as a last resort and the overall emphasis in law enforcement is on maintaining order without the use of deadly force. Military service members, however, know that they are trained precisely to kill the enemy and may have to do so on a regular and sustained basis.

The Field of Police Psychology

Police psychology is the application of behavioral science and mental health principles to the concerns and activities of law enforcement officers, their families, and the community. Police psychologists perform a wide variety of functions that can be divided into several broad categories. Clinical and mental health services include critical-incident stress debriefing, officer-involved shooting intervention, individual and family psychotherapy, and individual and departmental stress management. Operational assistance services include hostage and crisis negotiation; interview and interrogation; investigation and criminal profiling; undercover, antiterrorism, and other special unit assignments; and crime victim services. Administrative and training services include evaluation and fitness-for-duty; internal investigation and discipline; community policing and officer-citizen contact; leadership and management consultation; and law enforcement education and training (Blau, 1994; Kunke & Scrivner, 1995; Miller, 2006; Russell & Beigel, 1990; Toch, 2002). At the present time, there is no officially board-certified specialty of police psychology, and pathways into this subspecialty include clinical psychology, forensic psychology, law enforcement, and criminal justice (Blau, 1994; Freeman, Miller, Freeman, & Moore, in press; Kunke & Scrivner, 1995; Miller, 2006; Rodgers, 2006; Russell & Beigel, 1990). While there are a number of full-time police psychologists, most of whom work for large municipal police departments or for state or federal law enforcement agencies, many others offer police psychology services on an

Police and Military Psychology: Clinician Roles and Stresses

These differences also apply to the psychologists role. At least during active service, and often postdeployment as well, military service members and veterans are likely to be treated by psychologists who are themselves military officers, either deployed to the front lines, on a military base, or at a VA facility. In theater, military psychologists have to wrestle not just with the stresses and strains of vicarious traumatization and compassion fatigue (see below) accruing from treating their soldier-patients, but also with their own separation from loved ones and the very real prospect of becoming casualties themselves. Except for the rare extended

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on-scene critical incident call-out or crisis negotiation scenario, most police psychologists see their officer-patients from the comfort of an office and, even if called to a crisis scene, their own physical safety is almost never in question. Nevertheless, there are stresses and strains that affect police psychologists that are similar to those affecting military psychologists, as described by Johnson and Johnson (this issue). Some of these are generic stressors that can affect members of any professional helping group, while others are more specific to psychologists working with law enforcement officers (Miller, 1995, 1998a, 1998b, 1998c, 2006, 2007, in press[a]). Compounding the situation is the fact that many police psychologists may also work with crime victims or other trauma survivors and/or serve as members of crisis intervention teams (Miller, 1998b, 1999, 2008b), which can multiply the stresses of helping. Like their military counterparts, police psychologists can succumb to compassion fatigue (Figley, 1995), losing interest in cases they are working on, and begin to hear every officers problems as an echoing sequence of yadda-yadda-yaddas. Some of this may be due to empathic overengagement and overidentification with the traumatic narratives they hear on a regular basis, leading to hypersensitization and avoidance, a process called vicarious traumatization (McCann & Pearlman, 1990; Pearlman & MacIan, 1995). The psychologist may find herself relieved when patients cancel sessions (Moon, 1999). He may walk around in dread of that next cell phone call alerting him to an on-scene critical incident call-out (Talbot et al., 1995). The stress effects may spill over into the psychologists family life as he or she becomes more withdrawn and emotionally unavailable (Cerney, 1995). Other psychologists may become trauma junkies, increasingly reinforced by the lurid thrill of working with such dramatic cases but in the process sacrificing their clinical objectivity and effectiveness (Yassen, 1995). Eventually, even these psychologists may fizzle into a state of burnout (Ackerly, Burnell, Holder, & Kurdek, 1988; Talbot et al., 1995). Military psychologists who work on base or are deployed to theater are typically positioned within a hierarchical, evaluative system, often in close quarters and with frequent contacts with other personnel, so that their day-to-day behavior is regularly observed by a variety of people. Theoretically, at least, this should make signs of professional deterioration and personal distress easier to spot, leading to a recommendation or strict orderfor clinical or supervisory intervention, or at least some R and R. Ironically, the more freelance nature of most police psychology work makes it less likely that anyone will readily identify the red flags signaling compassion fatigue or burnout, and there is usually no one who is in an official position to order the psychologist to get help, except in the minority of cases where the psychologist is a full-time employee of a large police agency.

regular patient schedule, and to seek guidance and supervision from colleagues where appropriate. For full-time employed police psychologists, this may mean knowing when to use allotted vacation time and when to ask for additional time off when necessary. Face it: We are often in the position of informing a police commander that one of his/her officers needs time off to psychologically regroup after a critical incident or following a cumulative set of professional and/or work stressors. But there may be no one to tell us we need a break or a consultation but ourselves or our colleagues. Continued education and training, interaction and crossfertilization with peers, interdisciplinary collaboration, access to competent supervision, periodic diversion into pleasant activities, reinforcement of a sense of mission and purpose, and a willingness to access help for ourselves when necessary can protect against premature burnout and contribute to our effectiveness as police psychologists and mental health professionals in general. As with crisis responders in all fields, we serve others best when we properly serve ourselves.

References
Ackerly, G. D., Burnell, J., Holder, D. C., & Kurdek, L. A. (1988). Burnout among licensed psychologists. Professional Psychology: Research & Practice, 19, 624 631. Blau, T. H. (1994). Psychological services for law enforcement. New York, NY: Wiley. Cerney, M. S. (1995). Treating the heroic treaters. An overview. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 131149). New York: Brunner/Mazel. Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In Figley, C. R. (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 120). New York, NY: Brunner/Mazel. Freeman, S., Miller, L., Freeman, A., & Moore, B. (Eds.). (in press). Living and surviving in harms way: A psychological treatment handbook for working with law enforcement officers. New York, NY: Routledge. Freeman, S. M., Moore, B. A., & Freeman, A. (Eds.). (2009). Living and surviving in harms way: A psychological treatment handbook for preand post-deployment of military personnel. New York, NY: Routledge. Hibler, N. S., & Kurke, M. I. (1995). Ensuring personal reliability through selection and training. In M. I. Kurke & E. M. Scrivner (Eds.), Police psychology into the 21st century (pp. 169 188). Hillsdale, NJ: Erlbaum. International Association of Chiefs of Police. (2009). Employing returning combat veterans as law enforcement officers: Supporting the integration or reintegration of military personnel into federal, state, local, and tribal law enforcement. Alexandria, VA: Author. Kennedy, C. H., & Moore, J. L. (Eds.). (2010). Military neuropsychology. New York, NY: Springer. Kennedy, C. H., & Zillmer, E. A. (Eds.). (2006). Military psychology: Clinical and operational applications. New York, NY: Guilford. McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor: Theory, therapy, and transformation. New York, NY: Brunner/Mazel. Miller, L. (1995). Tough guys: Psychotherapeutic strategies with law enforcement and emergency services personnel. Psychotherapy, 32, 592 600. Miller, L. (1998a). Our own medicine: Traumatized psychotherapists and the stresses of doing therapy. Psychotherapy, 35, 137146. Miller, L. (1998b). Psychotherapy of crime victims: Treating the aftermath of interpersonal violence. Psychotherapy, 35, 336 345.

Police Psychology: Ethical and Professional Self-Management

Hence, perhaps more so than with our military counterparts, we police psychologists have to police ourselves, and we have to be forthright in sensitively confronting our professional colleagues who seem to be flagging under the stress of their high-intensity work. In most cases, this simply means learning to titrate the amount of heavy-duty trauma work we do in proportion to our

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Miller, L. (1998c). Shocks to the system: Psychotherapy of traumatic disability syndromes. New York, NY: Norton. Miller, L. (1999). Posttraumatic stress disorder in child victims of violent crime: Making the case for psychological injury. Victim Advocate, 1, 6 10. Miller, L. (2006). Practical police psychology: Stress management and crisis intervention for law enforcement. Springfield, IL: Charles C Thomas. Miller, L. (2007). Crisis intervention strategies for treating law enforcement and mental health professionals. In F. M. Dattilio & A. Freeman (Eds.), Cognitive-behavioral strategies in crisis intervention (3rd ed., pp. 93121). New York, NY: Guilford. Miller, L. (2008a). Military psychology and police psychology: Mutual contributions to crisis intervention and stress management. International Journal of Emergency Mental Health, 10, 9 26. Miller, L. (2008b). Counseling crime victims: Practical strategies for mental health professionals. New York: Springer. Miller, L. (in press[a]). Cops in trouble: Helping officers cope with investigation, prosecution, or litigation. In J. Kitaeff & K. Cather (Eds.), Handbook of police psychology. New York, NY: Psychology Press. Miller, L. (in press[b]). Psychotherapy of military veterans: Restrengthening the wounded warrior. Springfield, IL: Charles C Thomas. Moon, E. (1999, February). How to handle the high cost of caring. Professional Counselor, 18 22. Pearlman, L. A., & MacIan, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice, 26, 558 565. Rodgers, B. A. (2006). Psychological aspects of police work: An officers guide to street psychology. Springfield, IL: Charles C Thomas. Russell, H. E., & Beigel, A. (1990). Understanding human behavior for effective police work (3rd ed.). New York, NY: Basic Books. Talbot, A., Dutton, M., & Dunn, P. (1995). Debriefing the debriefers: An intervention strategy to assist psychologists after a crisis. In G. S. Everly & J. M. Lating (Eds.), Psychotraumatology: Key papers and core concepts in posttraumatic stress (pp. 281298). New York: Plenum. Toch, H. (2002). Stress in policing. Washington, DC: American Psychological Association. Yassen, J. (1995). Preventing secondary traumatic stress disorder. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 178 208). New York: Brunner/Mazel.

Is All Psychological Practice in Extremis?

Morgan T. Sammons
Johnson and Johnson (this issue) outline the stresses that may be associated with the practice of psychology in operational settings and produce a set of recommendations that are aimed at assisting psychologists returning from theatres of operation. They produce a vignette that describes the response of a psychologist whose experiences in the deployed environment created emotional responses that affected her or his ability to conduct psychotherapy. Johnson and Johnson enumerate a list of seven recommendations for leaders of the military psychological community. All of these are sound, and psychologists who work in institutional settings such as the military would be wise to be mindful of the potential hazards associated with providing psychological services in difficult situations (I note parenthetically that while Johnson and Johnson are correct that all military active duty clinical psychologists must be licensed, but often do not practice in the state granting licensure, they are not relieved of the burden of conforming to

ethical standards and the laws of the jurisdiction in which they are licensed. All active duty psychologists are also individually credentialed by a military treatment facility that utilizes a peer review process to ensure that their work falls within acceptable standards of care). Before large-scale interventions for psychologists are adopted, however, we should address several points. First is the issue of occupationally related impairment in general. We have little data to suggest that occupational stressors represent a major cause of diminished performance among psychologists. Even if we accept the hypothesis that occupational stressors are causal of impairment, we have little evidence that military psychologists are differentially prone towards the development of such impairment compared with psychologists in other settings. Also, it should be pointed out that Johnson and Johnsons recommendations are not specific to military psychologists (save for those dealing with psychologists returning from theaters of operation). Psychologists in any organizational setting would be wise to take heed of them. Thus, it might be wise to refer to all psychological practice as in extremis. Regarding the issue of occupationally mediated impairment in general, evidence is lacking that this is an issue for most psychologists. In the studies cited by Johnson and Johnson, personal, not occupational, stressors accounted for the majority of impairment. The Pope, Tabachnick, and Keith-Spiegel (1987) survey addressed questionable ethical practices that psychologists might be involved in. One of 83 survey questions referred to working when too distressed to be effective. While 59.6%1 endorsed this question in the affirmative, only 0.6% of respondents endorsed this at the fairly often or very often level. Likewise, in the Guy, Poelstra, and Stark (1989) survey, while 74.3% reported experiencing personal distress in the past 3 years, only 4.6% agreed that the distress was serious enough to result in inadequate patient care (p. 49). In the very few other surveys extant of impaired psychologists, alcohol or substance abuse, and not occupational stress, was the principal source of impairment (Pooler, Sheheen, & Davidson, 2009). In none of these studies does the number of impaired providers approach those reported by Pope, Tabachnick, and Keith-Spiegel (1987), who relied solely on an individual, subjective assessment of impairment in conducting their research. It would be surprising for a number of reasons, then, if over 60% of military psychologists admitted to working when too distressed to be effective, and it would be equally surprising if such a percentage were found by more objective means to be impaired. Further, in both the studies mentioned by Johnson and Johnson, a significant majority of practitioners both recognized that their effectiveness was impaired and took remedial steps. This is not to imply that psychologists are immune to such stressors or that they at least occasionally allow such stressors to affect the quality of their practice. But it is important not to overstate the problem.
1 In reporting the Pope et al. (1987) data, Guy et al. (1989) appear to have made an error in addition. Per the data in Table 3 of the index article by Pope et al. (1987), to the stem question of working when too distressed to be effective, 38.8% responded never, 48.5% responded rarely, 10.5% responded sometimes, 0.4% responded fairly often, 0.2% responded very often, and 5.3% responded not applicable, for a total of 59.6%, not 62.2%, giving any response in the positive direction.

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To my knowledge, there are no systematic surveys of vicarious traumatization or similar constructs among military mental health providers who have served in theaters of operation. In fact, systematic assessments of vicarious traumatization or related constructs among healthcare providers in any setting are few (SabinFarrell & Turpin, 2003). As those authors remarked, the ability to distinguish between vicarious traumatization and other forms of occupational stress remains constrained, and numerous conceptual and methodological problems persist in the literature. Boscarino, Figley, and Adams (2004) have provided perhaps the only systematic survey of vicarious traumatization in mental health practitioners who have been exposed to a significant stressor. This was a study of 236 New York City social workers who either had some involvement in the aftermath of the World Trade Center attacks in 2001 or who provided counseling to those affected by the attacks. The authors separated respondents into two groups: those who were more directly involved in recovery efforts (supporting rescue efforts or providing shelter) and those who were indirectly involved (providing counseling services to those affected by the disaster). They then extrapolated scores on a scale of secondary traumatization to a scale suggesting a risk of developing significant signs of such stress. They found that 52% of the social workers who reported high levels of involvement in the recovery efforts were deemed to have the potential to exhibit effects of secondary traumatization, as opposed to only 25% of those with low recovery involvement. Similarly, 35% of those who were highly involved in providing counseling services to affected persons were judged to have the potential to exhibit secondary traumatization, versus 25% of those with low levels of counseling involvement. Thus, a potential relationship between exposure to traumatic events or working with patients so exposed and the development of secondary traumatization symptoms is suggested by this study. Two important questions, however, remain unanswered. First, we do not know if the presence of potential symptoms of secondary traumatization results in significant impairment in therapists. Second, it is of interest that in the Boscarino et al. (2004) study, at least 25% of all respondents, even those with low levels of involvement in disaster services, reported potential symptoms of secondary traumatization, suggesting external factors other than therapeutic work affected expression of these symptoms. To answer the question of potential secondary traumatization in military psychologists, we must make inferences based on surveys of returning service members in general, as there are not any surveys specifically of military psychologists returning from theaters of operations. In making such inferences, we must be careful to note that most of these survey data have been collected on enlisted personnel as opposed to officers, most of who are younger and far more likely to be directly involved in combat operations than military psychologists. Psychologists, like other staff officers, are not assigned to combat roles, and therefore their level of direct exposure to combat trauma is less than that of those whose assignments places them directly into combat. This is not to say that psychologists deployed to theater are not exposed to stresses associated with combatpsychological consultation may take place in the context of the field hospital, where psychologists are exposed to incoming wounded and dead (sometimes directly, when they assist in mass-casualty events). Also, any military member in a theater of operations is exposed to the routine threats attendant to

that environment (IED blasts during transport, incoming mortar fire, and the like). With these constraints in mind, Booth-Kewley, Larson, HighfillMcRoy, Garland, and Gaskin (2010) found a rate of 17.1% of possible PTSD among Marines returning from Iraq and Afghanistan between 2002 and 2007 (recall that there are no Marine psychologists; Navy medical providers including clinical psychologists are honored with the privilege of providing health care services to the U.S. Marines). In examining the contribution of psychosocial factors to the development of possible PTSD, their multivariate analysis revealed deployment-related stressors to be more strongly associated with possible PTSD than any other variable. Inasmuch as returning mental health providers are subject to deployment related stressors, this may be a contributing factor to PTSD rates or similar types of distress among professionals. The types of deployment stressors identified by Booth-Kewley et al. (2010) as principally contributory to possible PTSD symptoms were problems back home, problems with supervisors, and lack of privacy, things that would affect deployed psychologists. Direct exposure to combat was the second strongest predictor of development of PTSD, however, and psychologists would not be expected to have such exposure. Fear et al. (2010) noted a much lower rate of PTSD in returning British troops of 4% (it is of interest that in general, rates of PTSD in non-U.S. troops tend to be much lower than that reported for American service members); however, approximately 20% of their respondents reported symptoms of other common mental disorders, and 13% gave answers suggestive of alcohol abuse. Alcohol misuse is a common cause of impairment among returning combatants. Psychologists are probably no more or less susceptible to alcohol abuse than other professionals, but this problem is already closely regulated by state boards and professional practice communities and should likely not be considered a factor unique to in extremis practice. We might conclude, then, that even with the understanding that deployed military psychologists (as well as those who work in other stressful environments) may be at differentially higher risk for impairment, we should not accept, without question, the assumption that exposure to potentially traumatizing events creates a higher risk for compassion fatigue, vicarious traumatization, or extreme distress among them. All psychological practice is associated with exposure to some degree of trauma or loss. Psychologists routinely deal with suicidal patients and with those who have experienced trauma and loss through the suicide of a loved one. The effects of violence and trauma on individual and family well-being are also unfortunate staples of what clinical psychologists do. Yet most psychologists with appropriate clinical training, supervision, and exposure learn to deal with these traumas with equanimity. Since exposure to trauma is a staple of much of clinical practice, it is perhaps better, as I previously suggested, to view much of psychological practice as in extremis practice. What protective factors assist military psychologists who practice in in extremis situations? First, it is undoubtedly true that military psychologists undergo a process of self-selection into military environments, and it is possible that this process of selfselection taps into a personal construct of hardiness that makes military psychologists more able to endure the stresses of deployment. Second, most are the beneficiaries of a yearlong predoctoral military internship (the most common mechanism of accessing psychologists into the active duty force), and such training gener-

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FOCUS ON ETHICS symptoms in Marines back from war. Journal of Traumatic Stress, 23, 69 77. Boscarino, J. A., Figley, C. R., & Adams, R. E. (2004). Compassion fatigue following the September 11 terrorist attacks: A study of secondary trauma among New York City social workers. International Journal of Emergency Mental Health, 6, 57 66. Fear, N. T., Jones, M., Murphy, D., Hull, L., Iverson, A. C., & Wessely, S. (2010). What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study. Lancet, 375, 17831797. Guy, J. D., Poelstra, P. L., & Stark, M. J. (1989). Personal distress and therapeutic effectiveness: National survey of psychologists practicing psychotherapy. Professional Psychology: Research and Practice, 20, 48 50. Pooler, D. K., Sheheen, F., & Davidson, J. (2009). Professional impairment: A history and one states response. Journal of Addictive Diseases, 28, 113123. Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, 42, 9931006. Sabin-Farrell, R., & Turpin, G. (2003). Vicarious traumatization: Implications for the mental health of health workers? Clinical Psychology Review, 23, 449 480.

ally includes exposure to operational psychology and an understanding of the stresses combatants face and their consequences. Knowledge, imaginal exposure to potentially trauma inducing stressors, in vivo exposure to returning combatants, and appropriate supervision and support are all important elements of military training. Some branches of the military, for example, the U.S. Navy, also now define operational psychology as a specialty area and provide specialty training for operational psychologists. Third, junior military psychologists are imbued in a culture that assists them in placing the problems facing military members in a unique perspective. Finally, military psychologists, while they may be assigned to independent duty stations where they are the only military psychologist, have the advantage of a large support network of fellow military psychologists with whom they can consult with ease. A number of protective mechanisms, then, are already in place for military psychologists. This does not deny that these can be augmented, and the recommendations provided by Johnson and Johnson are an excellent place to start. Providing mechanisms to clinicians that enable them to seek the advice and support of their peers is of undoubted value, regardless of setting. But the establishment of specific programs to support military psychologists is not without cost. Given the absence of evidence of a systemic problem, it is necessary to ask the question if extant mechanisms of support do not already accomplish what the recommended scheme intends to do.

References
Booth-Kewley, S., Larson, G. E., Highfill-McRoy, R. M., Garland, C. F., & Gaskin, T. A. (2010). Correlates of posttraumatic stress disorder

Received March 26, 2010 Revision received November 2, 2010 Accepted November 5, 2010

Correction to Johnson et al. (2011)

In the Focus on Ethics article in the February 2011 issue Psychology in Extremis: Preventing Problems of Professional Competence in Dangerous Practice Settings, by W. Brad Johnson, Shannon J. Johnson, Glenn R. Sullivan, Bruce Bongar, Laurence Miller, and Morgan T. Sammons (Journal of Professional Psychology: Research and Practice, Vol. 42, No. 1, pp. 94 104), the title and authors for the first section of the article, beginning of the first column on page 95, were inadvertently omitted. The section should have begun with the following: In Extremis Practice: Ensuring Competence During and After Deployment to a Combat Zone, by W. Brad Johnson and Shannon J. Johnson.