Examining the Psychophysiological Efficacy of CBT Treatment for First Responders Diagnosed With PTSD: An Understudied Topic

Abstract

First responders are often exposed to multiple potentially traumatic incidents over the course of their career. However, scientific research showed that first responders are more resilient compared with the general population. In addition, experience of life-threatening situations and acute stress may lead first responders to the development of posttraumatic stress disorder (PTSD) or posttraumatic stress symptoms. Current clinical research and practice has developed evidence-based treatments shown to be effective in helping first responders ameliorate their PTSD symptoms and perform their duties effectively. Literature showed that cognitive–behavioral therapy (CBT) entails multiple evidence-based techniques that lead those suffering from PTSD toward symptom improvement and trauma recovery. The current article aims to (a) provide readers with rigorous information about stress and trauma experienced by first responders, (b) present PTSD symptomatology as well as risk and protective PTSD factors prevalent among first responders, (c) provide information about the psychophysiology of PTSD, and (d) explore the efficacy of CBT treatment for first responders diagnosed with PTSD. The author highlights the necessity for psychophysiological measurement of CBT treatment efficacy for first responders diagnosed with PTSD; also, potential gaps in the current scientific literature regarding this issue are highlighted. Recommendations for future research and clinical practice are discussed so that health professionals and researchers continue to serve those who serve our communities.

Introduction

In addition to the ever-present threat of external traumatic events and violence on the street, there is a secondary, less recognized psychological threat, and invisible assassin, that can be just as deadly for peace officers; traumatic stress. (Capt. Greg Davis, Los Angeles, posttraumatic stress disorder [PTSD] survivor)

The Unique Job of First Responders: Oscillating Between Life Threat and Ethics of Care

Most people, if asked about the actual work involved in being a police officer, firefighter, or an emergency medical services (EMS) worker, would probably suggest that police work mainly focuses on crime investigations, patrol, and arrest of criminals; that a firefighter’s work is primarily related to extinguishing fires; and that the EMS worker’s job is aimed at providing first aid services. Nevertheless, the reality of what first responders’ work entails is more complex than many people may presume. Undeniably, police officers are often crime fighters and, as such, they are sworn and mandated to respond to virulent crimes (i.e., terrorism attacks, murders) and arrest the criminal(s) (Haugen, Evces, & Weiss, 2012). Similarly, firefighters are mandated to respond, among other things, to residential and commercial fires, explosions, spills, and large-scale natural disasters (Del Ben, Scotti, Chen, & Fortson, 2006). Analogously, EMS workers are trained to respond to a variety of emergency situations, medical crises, and community disasters, to name but a few of the critical situations in which they may find themselves (Corneil, Beaton, Murphy, Johnson, & Pike, 1999; Van der Ploeg & Kleber, 2003). Apart from the importance of their own bodily survival on the street, the value of “heroism” in the first responders’ subcultures is salient, because its members are expected to approach situations and be prepared to sacrifice their lives where average individuals would have escaped (Lucas & Kline, 2008). For instance, during the 9/11 terrorist attacks, firefighters and police officers, risking their own lives, entered in and stayed in the ready-to-collapse buildings to save civilians who were otherwise unable to escape; they remained in the buildings saving civilians until the buildings collapsed on them (Dwyer & O’Donnell, 2005).

Notwithstanding, the other side of the coin reveals that first responders often support victims of crimes (i.e., abused children, battered women) as well as victims of natural disasters and accidents, being more often among the first responders present at the crime scene (Andersen, Papazoglou, Arnetz, & Collins, 2015; May & Wisco, 2016). For instance, when the mass school shooting occurred in Newtown, Connecticut, first responders were the first present at the scene (Draznin, 2013). As a result, they were the ones holding the wounded children and providing them with first aid as well as psychological support. What many may—consciously or unconsciously—ignore, is that first responders are exposed to a plethora of life-threatening and potentially traumatic situations—over the course of their careers. Therefore, what makes first responders’ work unique is that they are expected to diligently maintain a dual role, oscillating between “critical incident responder” and “social service worker” (Manzella & Papazoglou, 2014). Some police psychologists and scholars have argued that first responders may encounter—not surprisingly—hundreds of potentially traumatic events during their careers (Rudofossi, 2009).

Psychological Trauma Among First Responders

Psychological trauma refers to any sudden, uncontrollable, and disruptive incident that negatively affects one’s physical, emotional, behavioral, and cognitive processes, and consequently, that may beget various forms of psychopathology (i.e., posttraumatic stress reaction, major depression; Van der Kolk, 2003). The origin of the term trauma can be traced back to the Greek word “τραύμα” or “τραυματίζω” which literally means “to wound” (Oxford English Online Dictionary, 2015). In the area of psychological trauma, the etymology of the verb “to wound” insinuates the “psychological wounds” that may emanate from exposure to any traumatic incident. Psychological research of the impact of trauma on police officers has shown that the experience of trauma may be debilitating for first responders’ physical (i.e., high blood pressure, cardiovascular diseases) and psychological health (i.e., anxiety disorder, depression) over the course of their careers (Miller, 2000; Stephens, Long, & Miller, 1997; Violanti et al., 2006). Furthermore, exposure to traumatic incidents may aversely affect first responders’ behavior (i.e., impatience, anger outbursts), cognitive processes (i.e., memory, information processing), and emotional reactivity to daily life (i.e., sadness, feeling like a failure; Andersen et al., 2015). As aforementioned, trauma experience by first responders is cumulative, long term, and complex (Papazoglou, 2013, 2016). The complexity of first responders’ trauma refers to the fact that first responders may experience trauma directly (i.e., loss of a partner) or indirectly (i.e., by asking a victim of abuse to describe what happened; May & Wisco, 2016). Among first responders, trauma is often experienced through some or all the human senses. For instance, a life-threatening situation (i.e., shooting) experienced by a police officer in the line of duty, may involve the following senses: sight (officer was at the incident), sound (officer listened to the sounds of shots being fired), smell (officer smelt the smoke of the firing bullet), and touch (officer held the weapon during the incident). It is possible that either direct or indirect exposure to potentially traumatic incidents may lead first responders to the experience of many incapacitating mental and physical health-related conditions (Marmar et al., 2006; May & Wisco, 2016; Pietrzak et al., 2014). Furthermore, exposure to potentially traumatic incidents may lead to the onset of PTSD (Donnelly, 2011; May & Wisco, 2016).

In the scholarly literature, it is appeared that trauma experienced between first responders and military personnel has certain commonalities as well as distinctions. Both first responders and military personnel are exposed to numerous potentially traumatic incidents during their career on the grounds that they often respond to violent incidents, and are even prepared to sacrifice their own lives for social welfare and freedom. Furthermore, both military personnel and first responders may vicariously experience trauma and loss when, for instance, their comrades (or colleagues) are wounded or even die; also, they may often support civilians who have been wounded or lost family members and friends by deplorable actions (e.g., terrorist attacks, crimes; Walker, McKune, Ferguson, Pyne, & Rattray, 2016). Nevertheless, there are some distinct differences between military and first responders’ trauma. Military personnel may be exposed to horrific incidents in the combat zone; however, exposure to such incidents is expected to end upon completion of deployment and return to their home country. However, first responders serve for almost three decades, and exposure to potentially traumatic incidents (even though as intense as in the combat zone) may occur any time until retirement (Papazoglou, 2013, 2016). In addition, experience of death, killings, and violent situations is more prominent and frequent among military personnel who are deployed in the combat zone (Litz et al., 2009; Shay, 2014). In contrast, first responders are mandated to maintain peace and order in the communities they serve and may often experience satisfaction in the line of duty by supporting traumatized individuals (e.g., victims of crimes; Andersen & Papazoglou, 2015; Figley, 1995, 2002).

The Enemy Within the “Fortress”: PTSD Among First Responders

PTSD Diagnosis and Symptomatology

The scientific literature emphasizes the complex nature of PTSD among first responders following exposure to traumatic incidents (Donnelly, 2011; Fushimi, 2012; MacDonald, Colotla, Flamer, & Karlinsky, 2003; Skogstad et al., 2013). The complexity of PTSD among first responders derives from the fact that first responders may experience multiple traumatic incidents over the course of their careers (Papazoglou, 2013, 2016; Papazoglou & Andersen, 2014). These incidents may vary in terms of their intensity, frequency, and level of life threat that may entail against first responders. For instance, Special Weapons and Tactics (SWAT) officers may be exposed to hundreds of potentially life-threatening situations over the course of their career. Also, an officer who serves in a child exploitation unit is probably exposed to a plethora of cases of abused children over a calendar year. The author posits that what renders first responders’ trauma idiosyncratic compared with the general public who may or may not experience trauma is the exposure to a myriad of life-threatening situations that may be present (e.g., violent criminal shoots a cop) or eminent (e.g., officers respond to a domestic violence call). However, researchers found that increased number of deployment tours of military personnel in the combat zone is related to higher risk of PTSD development because exposure to potentially traumatic incidents is accumulated over multiple deployments (Conard & Sauls, 2014; Reger, Gahm, Swanson, & Duma, 2009). The American Psychiatric Association (APA; 1980) defined trauma as a horrific event that is beyond the scope of the normal human experience. More specifically, a person experiencing trauma is likely to perceive the incident as life threatening, leading to the experience of helplessness, fear, horror, or disgust. However, one needs to consider certain parameters to define an event as traumatic (Greenwald, 2007; Weathers, Marx, Friedman, & Schnurr, 2014). The severity and personal impact of the event appear to be the most important factors in the consideration of an event as traumatic. For instance, during the Holocaust, millions of people were killed (severity of event) and many survivors lost their family members and their friends (personal impact of the event). Other parameters may also be related to the proximity of the experience and the after-event impact (Greenwald, 2007; Weathers et al., 2014). For instance, a family may have experienced a natural catastrophe (i.e., earthquake) and, as a result of the natural catastrophe, find themselves homeless (after-event impact). In addition, first responders may experience trauma directly or indirectly. In the first case, an officer, for instance, may experience a life-threatening situation (e.g., shooting) in the line of duty. In the second case, first responders may experience trauma indirectly when, for instance, they respond to critical incidents and they support traumatized individuals. This type of indirect traumatization among frontline professionals has received considerable attention in research. To this end, Figley (1995, 2002) has coined the term “compassion fatigue” to put emphasis on the indirect trauma experienced by caregiving professionals who often support traumatized individuals (e.g., victims of crimes, survivors of natural disasters) in the line of duty. A concise description of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) diagnostic criteria for PTSD is as follows: (a) experience of the stressor (e.g., direct or indirect exposure), (b) intrusive symptoms (e.g., intense or prolonged distress), (c) avoidance (e.g., trauma-related external reminders), (d) negative alterations in cognition and mood (e.g., persistent distorted blame of self or others), and (e) alterations in arousal and reactivity (e.g., hypervigilance, sleep disturbance). These symptoms need to have persisted for more than a month to qualify as diagnostic criteria for PTSD.

It is estimated that the prevalence of PTSD among the general population is 1.5% to 5.5% (Frans, Rimmö, Åberg, & Fredrikson, 2005; Helzer, Robins, & McEvoy, 1987). Unlike the general population, the prevalence of PTSD among first responders is reported as follows: 7% to 19% among police officers (Haugen et al., 2012), 14.6% among EMS workers (Streb, Haller, & Michael, 2014), and 6.5% to 37% among firefighters (Del Ben et al., 2006). It should be noted that the these numbers are not conclusive but rather suggestive, considering that different researchers estimated different PTSD prevalence rates among first responders; however, their estimated PTSD prevalence rates for first responders approximate the above-mentioned PTSD prevalence rates’ ranges. For instance, Skogstad and colleagues contended that PTSD prevalence among police officers is less than 10% as opposed to a rate of 20% among firefighters and EMS workers. In her article published in the issue on “Diagnostic Cracks” in the journal of the National Center for PTSD, Schnurr (2014) emphasized that although many clients appear to have multiple PTSD-related symptoms, clinicians are yet unable to diagnose them with PTSD on the grounds that these clients lack the required symptoms to satisfy the diagnostic criteria for a full PTSD diagnosis. Considering the abovementioned issue, Schnurr (2014) pointed out the catalytic role of “partial,” “subthreshold,” or “subsyndromal” PTSD in helping in the diagnosis and treatment of individuals with PTSD-related symptoms who did not meet all the PTSD diagnostic criteria.

The Relationship Between PTSD, Suicide Risk, and Alcohol Consumption

Apart from the psychiatric diagnostic criteria, research showed that PTSD has a profound impact on first responders’ psychosocial and professional lives. Specifically, in their systematic review of the literature, Stergiopoulos, Cimo, Cheng, Bonato, and Dewa (2011) found that work-related PTSD resulted in increased sick leave and had further malicious effects on workers’ productivity, leading in many cases to burnout and even unemployment (Van der Ploeg & Kleber, 2003). In addition, there is a myriad of studies in the scientific literature that emphasize on the relationship between PTSD, alcohol consumption, and suicide risk among first responders (e.g., Chopko, Palmieri, & Facemire, 2014; Debell et al., 2014; Stanley, Hom, & Joiner, 2016). In their study with police officers (n = 1,734) in Finland, Leino, Eskelinen, Summala, and Virtanen (2012) inferred that increased alcohol consumption, psychological distress, and fear for future retraumatization were prevalent among those who experienced work-related violence and injury. Furthermore, Violanti and his colleagues (2011) found that significantly more male officers compared with female officers were more at risk of higher levels of hazardous alcohol use. Researchers in this study highlighted the officers’ hazardous alcohol use was not related to police work stress per se; however, it was found to be significantly related to officers’ personal life stressors (e.g., divorce, separation) and believed that personal and family life stressors are related to police work-related stressors’ impact on officers’ personal and family lives. Even though some studies showed that police officers’ alcohol consumption is not significantly higher than that of the general population (Lindsay, Taylor, & Shelley, 2008; Weir, Stewart, & Morris, 2012), other studies found that exposure to critical incidents is associated with increased PTSD symptomatology as well as alcohol consumption among police officers (Ménard & Arter, 2013). To this end, many researchers emphasized on the strong association between PTSD and increased alcohol consumption (Chopko, Palmieri, & Adams, 2013). Moreover, PTSD symptomatology was found to mediate the relationship between alcohol dependence and suicide risk among firefighters (C. E. Martin et al., 2017). In his research with a U.S. national police sample, Violanti, Robinson, and Shen (2013) concluded that police officers indicated significantly higher suicide risk compared with the general population. In addition, in another empirical study with police officers (n = 934), Violanti (2004) found that the combined impact of PTSD and increased alcohol use appeared to increase the odds of suicide ideation approximately 10 times. In addition, Violanti’s (2010) findings in this area of research revealed that police suicides outnumbered police homicides by 2.36 times. Analogous findings in research with firefighters revealed the association between PTSD and suicide risk (Henderson, Van Hasselt, LeDuc, & Couwels, 2016).

PTSD: Risk and Protective Factors

Scientific research has extensively explored factors that play a salient role in leading first responders to PTSD or preventing them from the onset of it (i.e., Kehl, Knuth, Hulse, & Schmidt, 2015; MacDonald et al., 2003). Kehl and colleagues (2015) argued that risk factors for PTSD are distinguished in two categories: objective factors (i.e., tension of incident, fatalities) and subjective ones (i.e., perceived life threats, peritraumatic distress). Furthermore, researchers have attempted to distinguish predictors of PTSD by establishing three categories: pretraumatic, peritraumatic, and posttraumatic (Marchand, Nadeau, Beaulieu-Prevost, Boyer, & Martin, 2015). However, it seems that the aforementioned factors often overlap within the abovementioned categories. For instance, prior psychopathology (i.e., depressive symptoms), poor communication among peers, and poor emotional coping strategies, may be pre- and posttraumatic risk factors for PTSD (Armstrong, Shakespeare-Finch, & Shochet, 2014; Asmundson & Stapleton, 2008; Marchand et al., 2015). In their systematic review of the literature (n = 4,301 articles), Skogstad and colleagues concluded that first responders often experience work-related PTSD, and they further found that mental health problems prior to traumatic incident exposure as well as lack of social support are factors that may increase the risk of PTSD. What is noteworthy is that lack of social support and poor communication within the organization relative to the traumatic experience were argued by many researchers as risk factors associated with the onset of PTSD among first responders (Armstrong et al., 2014; Stephens & Long, 2000; Van der Ploeg & Kleber, 2003). Nonetheless, what seems to be effective (protective factor) in terms of social support and communication, specifically, is humor and nonjudgmental and empathic listening between first responders and their supervisors (M. Martin, Marchand, Boyer, & Martin, 2009; Stephens & Long, 2000) as well as emotional expression between first responders and their family members (Evans, Pistrang, & Billings, 2013). Furthermore, lack of resources (i.e., psychological services) and the peritraumatic sense of uncontrollability and unpredictability were also found to be risk factors that may lead to the onset of PTSD among first responders (Armstrong et al., 2014; Regambal et al., 2015). In addition, peritraumatic dissociation (e.g., emotional numbness, derealization, depersonalization, lack of awareness in one’s surroundings) has been found to be one of the risk factors that may trigger PTSD symptoms (M. Martin et al., 2009).

From the organizational perspective, elevated organizational and operational stress among first responders may trigger or deteriorate the PTSD symptoms (Armstrong et al., 2014; Kehl et al., 2015). Conversely, low levels of operational and organizational stress and a strong sense of confidence in their cognitive processing of a traumatic incident as challenging (vs. threatening) were found to be protective factors against the onset of PTSD among first responders (Armstrong et al., 2014; Streb et al., 2014). In their study on firefighters (n = 397), Pinto and colleagues found that perceived threats relative to the critical incident significantly predicted PTSD symptomatology. Moreover, the intensity of the traumatic incident and prior psychopathology (i.e., anxiety or depressive symptoms) and/or previous exposure to a traumatic incident seem to be integral in the later onset of PTSD (Armstrong et al., 2014; Asmundson & Stapleton, 2008; Luce, Firth-Cozens, Midgley, & Burges, 2002). More specifically, in their phenomenological study with EMS workers (n = 77) and firefighters (n = 103), de Soir and colleagues (2012) noted that the death of a colleague, the involvement of a family member or friend in the incident, and the pain and screaming of burned victims were major characteristics of a traumatic incident that profoundly affected both EMS personnel and firefighters.

PTSD and Psychophysiology: Heart Rate (HR) Reactivity

A synthetic approach of the voluminous research work in the psychophysiology of PTSD has indicated the close relationship between PTSD and HR. In their theoretical analysis of heart–brain interactions and psychophysiological coherence, McCraty, Atkinson, Lipsenthal, and Arguelles (2009) pointed out that the natural fluctuations in HR (“so-called heart rate variability [HRV]”) emanate from the heart–brain interactions as well as the interplay of the sympathetic and the parasympathetic branches of the autonomic nervous system (ANS). Therefore, any fluctuation in psychological processes—as occurs in negative emotions such as sadness—was found to be directly associated with changes in HR reactivity because the human body tends to maintain or restore a harmonious state (Buckley, Holohan, Greif, Bedard, & Suvak, 2004; McCraty et al., 2009; Norte et al., 2013). Analogously, dysregulation of the ANS—increased sympathetic and decreased parasympathetic activity—resulting from a traumatic experience is often caused by depressed—or maladaptive—HRV, indicating trauma survivors’ reduced capacity to regulate PTSD symptomatology (i.e., emotional arousal, hypervigilance, stress; Tan et al., 2009). It is argued that PTSD is akin to survivor’s inability to restore the aforementioned harmony due to the intense psychophysiological reactivity to the traumatic experience; hence, survivors of trauma diagnosed with PTSD manifest an elevated HR when examined in their resting baseline levels, compared with non-PTSD–diagnosed individuals (Buckley et al., 2004; Norte et al., 2013).

Nevertheless, although research findings in measuring the psychophysiology of PTSD showed that HRV was less adaptable among veterans diagnosed with PTSD, HRV was increased and PTSD symptoms reduced at the end of the PTSD biofeedback treatment (Tan, Dao, Farmer, Sutherland, & Gevirtz, 2011; Tan et al., 2009). Analogously, in their study with individuals (n = 19) with PTSD diagnosis, Norte and colleagues (2013) found that individuals diagnosed with PTSD experienced persistently elevated HR and lowered HRV during and after the reexperiencing of the traumatic incident (researchers employed traumatic incident cues). In similar ways, observational studies with veterans diagnosed with PTSD indicated the relationship between PTSD and elevated baseline resting HR (found 6.63 increased beats per minute—BPM; Buckley et al., 2004) as well as depressed HRV (Tan et al., 2009). What is also noteworthy is that individuals exposed to a traumatic event had elevated HR (greater than one standard deviation above the age and sex mean) 24 hr following exposure to trauma, and were significantly more likely to experience PTSD symptoms in the aftermath (6 months) of their traumatic experience (De Young, Kenardy, & Spence, 2007).

Based on the previously discussed findings relative to the direct association between PTSD and HR reactivity, many researchers have suggested that HR reactivity be employed as a way to predict the onset of PTSD following exposure to a traumatic incident (De Young et al., 2007; Keane, Long, Schmidt, Mincemoyer, & Garner, 1998; Kendall et al., 1998), as well as to measure the reduction of PTSD symptomatology following PTSD treatment (Rothbaum, Ruef, Litz, Han, & Hodges, 2003; Tan et al., 2011). Furthermore, the employment of physiological measures in addition to the extant psychological scales may endorse accuracy and reliability in the assessment of PTSD among first responders (Orr & Roth, 2000). Analytically, Bauer and colleagues (2013) employed physiological measures (HR, skin conductance, and electromyogram) and contrasted them with the Clinician-Administered PTSD Scale (CAPS) in assessing a group of participants (n = 46) diagnosed with PTSD at the beginning of treatment and 6 months posttreatment. Their results indicated a significant association between physiological measures and CAPS.

PTSD and Psychophysiology: Cortisol Hormone

Research indicated that hypothalamus–pituitary–adrenal (HPA) axis dysregulation—hence cortisol secretion abnormality—is associated with numerous psychological disorders (Johnson, Kamilaris, Chrousos, & Gold, 1992; Tsigos & Chrousos, 1996). Furthermore, chronic fatigue syndrome, PTSD, and depressive symptomatology were found to be related to cortisol level dysregulation (Morgan et al., 2000; Tsigos & Chrousos, 1996); that is, cortisol dysregulation is indicative of what McEwen (2000) referred to as “allostatic load,” a condition that manifests as a maladaptive response to trauma exposure. In this direction, other research findings suggested that cortisol secretion abnormality is also associated with immune system dysregulation, which increases the risk of a number of diseases (i.e., vulnerability to influenza virus and infectious illnesses; Padgett & Glaser, 2003; Wirth et al., 2011). In their systematic review article, Chida and Steptoe (2009) found that the cortisol awakening response (CAR) phenomenon was positively associated with job stress and general life stress. Therefore, individuals occupied in highly stressful professions (i.e., elite athletes, soldiers; Morgan et al., 2001; Skoluda, Dettenborn, Stalder, & Kirschbaum, 2012) and specific population groups who experience extreme stress and trauma (i.e., veterans; Baker et al., 2005) have elevated CAR values compared with the general population. Various stressors over one’s daily life may induce elevated cortisol levels (Chida and Steptoe, 2009; Dickerson & Kemeny, 2004), that is, stress reactivity cortisol levels. Analytically, when an individual perceives a stressor—either physical or psychological—the hypothalamus produces the corticotrophin-releasing hormone (CRH), which then leads to the synthesis of the adrenocorticotrophic hormone (ACTH) by the pituitary gland, which, in turn, stimulates the adrenal cortex to release cortisol (Shalev et al., 2009).

Research with PTSD-diagnosed individuals inferred that cortisol dysregulation and PTSD are closely associated (Dekel, Ein-Dor, Gordon, Rosen, & Bonanno, 2013; McFarlane, Barton, Yehuda, & Wittert, 2011; Weems & Carrion, 2007); specifically, PTSD-diagnosed individuals manifested suppressed diurnal cortisol levels (Yehuda, Halligan, Golier, Grossman, & Bierer, 2004). The inexorable relationship between cortisol dysregulation and PTSD is emphasized by Yehuda and Golier (2009) who argued that

it is often stated that cortisol-related alternations in PTSD are “controversial.” It is perhaps more accurate to conclude that such alterations have not always been detected; perhaps reflecting that cortisol levels are dynamic and subject to a large degree of measurement error and individual variation. (p. 1113)

Observational studies with first responders (Witteveen et al., 2010) and veterans (Lauc et al., 2004) diagnosed with PTSD showed that both first responders and veterans who participated in the studies had “flat-like” diurnal cortisol patterns compared with the regular ones. Analogously, Neylan and colleagues (2005) studied police officers (n = 30) exposed to a traumatic incident, and their findings showed the significant relationship between elevated CAR and PTSD. Conversely, in their study with police officers (n = 100) diagnosed with PTSD (mild, moderate, and severe type of PTSD), Violanti and colleagues (2007) contended that an association between PTSD and cortisol dysregulation existed among their study participants. They also found that officers diagnosed with severe PTSD symptomatology manifested elevated CAR. Their findings come in contradiction with other studies in this area; however, Violanti and colleagues (2007) interpreted their findings on the grounds that police trauma—as opposed to other traumatized groups previously studied—is multifaceted, chronic, and complex; yet, research knowledge of the biological impact of trauma or threat on police officers is still limited. However, it is argued that HPA axis dysregulation—prior to trauma exposure—seems to be a predictor in the pathogenesis of PTSD following traumatic experience (Inslicht et al., 2011; Pineles et al., 2013). Longitudinal studies with police officers demonstrated that short-term afternoon or night shift employment is associated with lower CAR (Wirth et al., 2011); in addition, lower CAR before exposure to a potentially traumatic incident was associated with posttrauma negative moods, anxiety symptoms, and physiological reactivity (HR and skin conductance) among police officers and firefighters (Pineles et al., 2013). Randomized clinical trials (RCTs) with individuals diagnosed with PTSD—and also with those who manifested lower cortisol levels before treatment—indicated that PTSD psychotherapy treatment (brief eclectic) was effective in increasing cortisol levels among those who received the treatment (Olff, de Vries, Güzelcan, Assies, & Gersons, 2007). Analogous outcomes (RCT) were found with mindfulness-based treatment delivered to veterans diagnosed with PTSD compared with those who participated in the control group (Bergen-Cico, Possemato, & Pigeon, 2014). However, Gerardi, Rothbaum, Astin, and Kelley (2010) reported that prolonged exposure therapy or eye movement desensitization and reprocessing (EMDR) treatment significantly reduced elevated cortisol levels among rape victims diagnosed with PTSD. The aforementioned research findings indicate the effectiveness of PTSD evidence-based treatment in significantly reducing HPA (and cortisol) dysregulation.

Cognitive–Behavioral Therapy (CBT): An Overview

CBT was developed as a psychotherapeutic approach in the late 1950s by Albert Ellis, who developed the rational-emotive therapy (RET), and Aaron Beck, who developed cognitive therapy (CT; Corey, 2008). Ellis argued that the philosophic origins of RET can be traced back to the writings of Stoic philosophers and, more specifically, the work of Epictetus and Marcus Aurelius who believed that individuals are not disturbed by events per se but by the way they view the events around them (Corey, 2008). Based on the previously mentioned assumptions of CBT, clients are encouraged to identify, dispute, and constructively change any thoughts, beliefs, assumptions, and emotions that seem to cause distress in their lives (Rector, 2010). Such distorted assumptions or core beliefs may be related—but not limited—to all-or-nothing thinking (e.g., if she calls me she loves me or if she does not she hates me), overgeneralization (e.g., the world is against me), and catastrophizing (e.g., there is no future for me). The major role of the CBT therapist is to help her or his client target and evaluate the distorted automatic thoughts or core beliefs related to certain incidents (Rector, 2010). As Ellis (1994) argued, human beings are often trapped in the horrific context of the irrational “shoulds” and “musts” (“Must-arbation”), and the therapist’s role is to dispute the client’s irrational beliefs and help them transform irrational beliefs into rational ones. Taking into consideration that distorted beliefs about specific situations are associated with (negative) emotions and behavioral patterns, any positive change of the distorted beliefs may lead to positive emotional and adaptive behavioral patterns within a subjectively “problematic” situation for the client (Corey, 2008). Therefore, CBT sets a goal-oriented, teleological, problem-focused, well-structured—in the here and now—approach, which also focuses on therapeutic alliance and rapport between the CBT therapist and the client (Rector, 2010).

CBT: An Evidence-Based PTSD Treatment

A simple search on Google Scholar about the CBT treatment for PTSD leads to more than 18,800 results for published articles, training materials, and commentaries related to the topic. In PTSD treatment, CBT has been identified as one of the most effective approaches (Koucky, Dickstein, & Chard, 2013) and is argued by many to complement pharmacotherapy for PTSD symptomatology reduction (Ramirez-Basco, Glickman, Weatherford, & Ryser, 2000). In their systematic review of the literature on the efficacy of the CBT treatment for PTSD, Harvey, Bryant, and Tarrier (2003) found that CBT proved to be effective in helping individuals who had survived traumatic situations (assault, terrorism, traffic accidents, refugees, child abuse) as well as in helping survivors struggling with multiple PTSD symptoms: improved social adjustment, decreased catastrophic cognitions, reduced avoidance, better quality of sleep, decreased muscle tension, and decreased hypersensitivity. Trauma-focused CBT (or CBT-PTSD) can be alternatively delivered in the form of web-based therapy and/or telemedicine to clients residing in remote areas with limited access to a CBT therapist (Foa, Gillihan, & Bryant, 2013). Analogously, research has showed that returning veterans were amenable to PTSD treatment and achieved PTSD symptoms’ reduction after the delivery of a brief CBT intervention (one session) via telephone (Stecker, McHugo, Xie, Whyman, & Jones, 2014). Another study examined the effectiveness of CBT group therapy (6 weeks) in helping military personnel (n = 496) suffering from PTSD; the study outcomes demonstrated that PTSD symptomatology reduction was effective during follow-up assessments (3, 6, and 12 months postintake; Khoo, Dent, & Oei, 2011). The trauma-focused CBT approach has been effectively applied to different victims/survivors of trauma, such as rape survivors (Jaycox, Zoellner, & Foa, 2002), New York City Transit employees (Lowinger & Rombom, 2012), psychotic patients who have experienced PTSD (Callcott, Standart, & Turkington, 2004; Ehlers, 2004), interpersonal violence trauma survivors (Iverson et al., 2011), and survivors of the 2005 London bombings (Wilson, d’Ardenne, Scott, Fine, & Priebe, 2012). From an international perspective, Kagoo, Suh, and Naidoo (2004) reported that all their participants considered CBT as an appropriate treatment for their traumatized clients in their training work with South African trauma therapists.

In their RCT with adult female survivors of childhood sexual abuse (n = 74), McDonagh et al. (2005) randomized their participants in CBT, into present-centered therapy (PCT), and wait-listed (WL) condition. In their 6-month follow-up assessment with the CAPS, they found that 76.5% of the CBT group participants had no PTSD symptomatology and that the CBT group was superior to the WL group. In another RCT with patients who experienced PTSD due to severe motor vehicle crash, Wu, Li, and Cho (2014) randomized their participants (n = 60) in a CBT and self-help program (SHP) group. In a 6-month follow-up, they found that the patients from the CBT group had significantly decreased their anxiety symptoms, their depressive symptoms, their intrusive thoughts, and their hyperarousal compared with the SHP group patients. Similar results have been found with other RCTs with veterans who experienced military sexual trauma (CBT group vs. PCT group), showing the high effectiveness of CBT trauma-focused treatment compared with other treatments (Surís, Link-Malcolm, Chard, Ahn, & North, 2013). Furthermore, an RCT of CBT-PTSD treatment for severely mentally ill patients showed that the CBT group was more effective compared with the control group in CAPS score (PTSD symptomatology) and depressive symptoms reduction.

From an international perspective, an RCT for war-affected Congolese boys (n = 50) showed that the CBT group had a significant PTSD symptomatology reduction—compared with the control group—at the end of the treatment program (McMullen, O’Callaghan, Shannon, Black, & Eakin, 2013). In a very similar study with war-affected Congolese girls, researchers found significant reduction in trauma symptoms between the CBT and the WL group (O’Callaghan, McMullen, Shannon, Rafferty, & Black, 2013). Other RCT studies showed significant effectiveness of CBT-PTSD treatment with regard to the following minority groups: Cambodian refugees (Hinton, Hofmann, Pollack, & Otto, 2009), Latino women (Hinton, Hofmann, Rivera, Otto, & Pollack, 2011), Vietnamese refugees (Hinton et al., 2004), and Black females diagnosed with PTSD (Otto, 2000).

Discussion: What Is Missing?

In a study conducted by Becker et al. (2009) with first responders (n = 379) from a southern state of the United States, participants were asked to identify their preference for psychotherapeutic treatment in a potential situation from which they might experience PTSD. What is interesting is that almost 90% of the participants chose CBT as their first or second most preferred treatment compared with other offered treatments (e.g., pharmacological, brief eclectic, EMDR). Nevertheless, as Flannery (2015) argued, “research on the treatment interventions of first responders has been limited” (p. 261). Literature in the area of CBT-PTSD treatment for first responders is sparse; researchers have conducted case studies examining the effectiveness of CBT treatment in one police officer diagnosed with PTSD (Tolin & Foa, 1999) and chronic PTSD (Cornelius & Kenyon-Jump, 2007). What is noteworthy is that there are almost no RCTs of CBT treatments for PTSD among first responders and, hence, the effectiveness of CBT in reducing PTSD symptomatology among first responders is unknown (Harvey et al., 2003; Stergiopoulos et al., 2011). Indeed, in their systematic review of the literature, Haugen et al. (2012) attempted to identify RCTs for PTSD among first responders; researchers inferred that from the 845 peer-reviewed articles found, only two—equal to 0.002% of all the studies—were RCTs of PTSD treatment among first responders. Following the abovementioned systematic review, from those two RCTs found, the first (Gersons, Carlier, Lamberts, & van der Kolk, 2000) examined the effectiveness of brief eclectic therapy (EBT) delivered to police officers (n = 42) and the second one (Difede et al., 2007) explored the effectiveness of a 12-week CBT treatment program delivered to disaster workers who responded to the 9/11 terrorist attacks. To date, there are no RCTs to study the effectiveness of CBT-PTSD treatment for first responders using psychophysiological assessment. In this direction, Lindauer and colleagues (2006) have attempted to psychophysiologically assess the efficacy of script-driven imagery for individuals diagnosed with PTSD. However, a considerable limitation of their study is that police officer participants (n = 15) were only examined in the pretest phase because they all discontinued their research participation.

Nevertheless, some scholars and professionals may argue that police and military tasks are quite overlapping. For instance, in both fields, military personnel as well as first responders are mandated to respond to critical incident situations and most—if not all—of the times the danger against their own lives is omnipresent. Thereby, one may contend that the evidence-based outcomes of CBT-PTSD treatment among military soldiers and veterans may give us enough evidence that the effectiveness of CBT-PTSD treatment is also pervasive among first responders. At this point, the author posits that first responders’ work is unique and in many ways distinct from military mission. CBT-PTSD treatment may be effective for—most—first responders and, hence, after the successful completion of CBT-PTSD treatment, they may not experience any PTSD-related symptomatology. Nonetheless, the author contends that what distinguishes first responders from military personnel and other populations is that first responders may have significant elevated risk to relapse to PTSD after successful completion of CBT-PTSD treatment. The last assumption is emanated from the fact that first responders’ work is singular and distinct from that of military. After successful completion of CBT-PTSD treatment, first responders are expected to return to the line of duty and, hence, they are mandated to respond to critical incident situations. Undeniably, some of those critical incident situations are expected to be life-threatening ones. The challenging—and even iconoclastic for the traditional PTSD treatment traditions—query may be the following: Is CBT-PTSD treatment sufficient enough so that it effectively prevents PTSD relapse among first responders, who returned to the line of duty after successful completion of CBT-PTSD treatment? In addition, is PTSD psychosocial assessment a sufficient indicator of first responders’ readiness to return to the line of duty after completion of CBT-PTSD treatment? Currently, there is no evidence-based finding that would provide us with substantial answer to the previous questions. For instance, Longmore and Worrell (2007) highlighted the scarcity of data that cognitive change in CBT treatment is the one that leads to symptomatic improvement. This last challenging perspective (cognitive change during CBT treatment) may be even more pervasive among first responders because their cognitive functioning in the line of duty is incumbent to the rationale of being alert and well-prepared to respond. Literature showed that various populations (i.e., incarcerated women, veterans) who successfully completed CBT-PTSD treatment relapsed in a certain period of time after completion of treatment (Stecker et al., 2014; Zlotnick, Johnson, & Najavits, 2009). In their systematic review of the efficacy of prolonged exposure therapy among anxiety disorder–diagnosed clients, Craske and colleagues (2008) emphasized the salient role of measuring physiological reactivity as a way to assess efficacy of treatment outcomes. What is also essential is that Craske and colleagues (2008) contended that physiological measurement should not be restricted to one variable specifically (e.g., HR); instead, it should include more than one physiological reactivity variables (e.g., HRV, skin conductance, cortisol), so that researchers employ a more holistic approach in the way they measure the psychophysiological efficacy of prolonged exposure treatment in clients diagnosed with anxiety-related disorders. Consequently, it is paramount that we study the psychophysiology of those first responders who may not be treated successfully by CBT-PTSD treatment as well as those first responders who—even though completed CBT-PTSD treatment successfully—have relapsed to PTSD symptomatology after return to the line of duty.

Conclusion: Recommendations for Future Research

The introductory section illustrates the complexity and cumulative form of trauma experienced by first responders in the line of duty. As it was mentioned, trauma exposure may lead first responders to the onset of PTSD, among other severe mental and physical health issues. Nevertheless, police organizations invest millions of dollars to make sure that first responders receive the highest quality of training, advanced technological equipment, and other necessary means to efficiently maintain peace and order in the communities they serve (Andersen et al., 2015). However, first responders’ efficacy in the workplace may be thwarted by complex mental health issues, such as PTSD. To this end, many scholars have emphasized on the efficacy of trauma prevention and resilience promotion programs that may support first responders’ mental preparedness in the face of adversities (e.g., Andersen et al., 2015; Skeffington, Rees, Mazzucchelli, & Kane, 2016). That is, it is essential that most organizations invest on first responders’ training and equipment; however, author suggests that organizational investment with additional funds and resources for first responders’ mental preparedness (e.g., trauma preventative training) should also be prioritized as a way to equip first responders against the risk to develop PTSD and other comorbid disorders.

One of the challenges that should be highlighted is first responders’ reintegration back into the operational units after CBT-PTSD treatment completion. The author suggests that future research should also emphasize on first responders’ reintegration procedures and develop evidence-based practices that can facilitate first responders’ reintegration in their agencies. For instance, would a police detective be ready to return to his previous tasks right after successful completion of CBT-PTSD treatment? Perhaps, this kind of reintegration procedure needs to occur gradually until both health professionals and high-ranking managers feel confident that detective is fully prepared to return to the previous position. That is, mental health professionals (e.g., psychiatrists, psychologists, mental health counselors) are expected to work closely with agencies’ high-ranking managers to facilitate reintegration procedures (e.g., assessments on a systematic basis) through a multidisciplinary collaboration. The Israeli military has developed exemplary policy programs that assist soldiers who experience PTSD to attend adequate treatment programs and then return back to their service successfully (Cobb, 2013). Toward this direction, Israeli military has developed army-based psychoeducation programs to destigmatize the experience of PTSD in the military and also established “mental health gyms” that allow mental health professionals to be present in the military training arenas and units so that resilience promotion prioritized (Cobb, 2013). Furthermore, research with U.S. combat veterans indicated that awareness of PTSD-related early help seeking might prevent the incapacitating impact of PTSD on veterans’ health (Mittal et al., 2013). Such practices may be transferred and applied to first responders’ agencies. For instance, mental health professionals may train high-ranking managers as well as first responders to identify cues that indicate the presence of PTSD symptomatology. That way, help seeking can be better coordinated and CBT-PTSD treatment be more efficient if provided in early stages of PTSD development (Adler, Bliese, McGurk, Hoge, & Castro, 2009; Ehlers et al., 2003).

However, if first responders diagnosed with PTSD remain untreated, they will be unable to properly provide their services and the government’s expenditures for first responders’ preparedness and training will be in vain; that is, PTSD precludes them from properly providing their services. Even though CBT has been proved to be effective in treating PTSD, research—especially RCTs—in examining the efficacy of CBT in ameliorating PTSD symptomatology among first responders is sparse. The current article aimed to introduce an innovative idea: Specifically, it attempted to discuss a synthesis of psychological and physiological measures so that the CBT-PTSD effectiveness among first responders is examined and justified via empirical research. Finally, the author hopes that the present article will draw attention to the necessity of future empirical research in relation to psychophysiological improvement among first responders who receive CBT-PTSD treatment.