Sometimes law enforcement officers who are suffering from police stress avoid seeking counseling, often for good reason (see my article "The Ugly Shrink"). But sometimes stress builds up to a point where they have an episode either of depression or panic that is so disturbing or so blatant that they reluctantly see a therapist. Often spouses convince their partners to get help. Or perhaps they are ordered or strongly encouraged to do so by a commanding officer. "Strongly encouraged" usually has a threat implied, so it might as well be an order. These later cases are the worst because the element of confidentiality, so important to the therapy, can be compromised. It is vital that any officer discuss confidentiallity with his or her therapist and feel secure that treatment is confidential with the one exception that all therapists must take steps to protect their client's life or the lives or others. Trust and confidentiality always go together and are often issues when an officer is put on unpaid leave or given desk duty pending completion of therapy and getting a second opinion as to fitness for duty given by another clinician, usually a psychiatrist.

The treating psychotherapist should not be the one to do the fitness to return evaluation because this should be separate from treatment. Otherwise, let's face it, officers would be tempted to slant what they say and how much they reveal to get the best recommendation. Honesty is the core of therapy and therapy won't work if one has an ulterior motive for not being forthright with the therapist.

Not only is there a second clinician involved in many instances but a third comes into the picture if you need medication. You can have an excellent therapist who understands law enforcement, but if you need medication and your therapist isn't an M.D., (and most psychotherapists are either social workers or psychologists who can't prescribe medication) you may be involved with yet a third. There's a chance the psychiatrist you see won't be as understanding of police stress (and corrections stress) as your therapist is. He or she may focus in on problems with temper and mood swings for example, because of a bias against LEO's; when in fact the underlying problem is anxiety or depression. Some therapists think that because you have access to firearms you are more likely to use one inappropriately when in fact, because of your training, the oposite is true. If that happens an officer may be treated with a mood stabilizer like Depakote, Tegretol or lithium. The first two drugs are primarily used as anti-convulsants in epilepsy but also are helpful in calming down the part of the brain called the lymbic system, which is responsible for strong emotions. Lithium has long been used for what used to be called manic-depressive disorder, but is now called bipolar disorder. It is quite possible these medications are the right ones for an officer. But it is also possible that using an anti-depressant like Prozac, Zoloft or Paxil; or even St. Johns Wort, to help "tune up" the serotonin system is more appropriate.

Police stress, like any other kind of stress, can wreck havoc with the brain chemistry that allows serotonin, a naturally occuring chemical, to do it's work in keeping a person level. (See my article on St. John's Wort.) Anxiety and mild->moderate depression often go together. I see a lot of irritability as a primary symptom with male LEO's, and this frequently disappears with a combination of counseling and anti-depressant medication (I include St. John's Wort in this group).

Another problem I see occurs when an officer ends up for some reason or another in a psychiatric hospital. Even the best hospitals for LEO's are under constraints placed by insurance companies, and because the anti-depressant medications usually take from three to as long as five weeks to have their full effects, other medications which act more quickly are often prescribed so the officer can be discharged before the insurance runs out. Tranquilizers like Atavan and Klonopin (similar to Valium) are often used these days. They work very well, and quickly, with panic and anxiety, but are difficult to get off because there is a rebound effect. They also can be abused. Depakote and Tegretol work quickly too, and aren't considered drugs of abuse. Conservative psychiatrists sometimes choose them because they don't fully trust their patients: they work quickly and can't be abused.

Being in the hospital has one benefit, it gets an officer a brief vacation; unfortunately sometimes that's all a stay in the hospital provides. Unfortunately, a drawback to hospitalization is the stigma associated with having been in a psychiatric hospital which officers are sensitive to. I rarely recommend hospitalization unless an officer is actively suicidal, and even then would prefer to avoid it and schedule more outpatient appointments and phone contacts with me.

Once an officer is ready to return to active duty, the department often requires a recommendation from a psychiatrist. Some progressive departments will accept an evaluation from a social worker or psychologist who specializes in police counseling; but most officers aren't "lucky" enough to have this option. This may sound biased, but most psychiatrists these days specialize in psychopharmacology and meet with their patients for fifteen or twenty minutes, and don't do lot of ongoing psychotherapy or counseling.

The psyhiatrists who do evaluations for a municipality, state or department are probably highly ethical and objective; but you can never know how much they may be influenced by the people who sign their pay checks. This may work to an officers advantage if they want to return to work and the job wants them, since this saves the department money. It can work to an officers disadvantage if they are requesting disability or continued light duty, which will cost the department money.

My own belief is that the best way to conduct return to work evaluations is by having a fairly large group of therapists with an understanding of police stress to choose from, so no one therapist gets a large portion of his or her income from doing evaluations. Money corrupts, and a lot of money corrupts even more. If an officer truly shouldn't return to full duty, the therapist must be able to make this recommendation with all concerned trusting that it is in the best interest of both the officer and the department. There should be the slightest suspicious that the psychiatrist is "in management's pocket". There should also be a right of appeal to another therapist, ideally one that both parties agree on.

If you ever are in the position of being evaluated for fitness to return to full duty, it is hard to know what to expect. Sometimes you'll be given one or more psychological tests like the well known MMPI. This is a long true/false test, which despite what you are told, DOES have right and wrong answers. At least for you. Usually psychiatrists don't go in for psychological testing, though. They're more likely to interview you for up to two hours and ask many questions, inclduing ones which will determine what is called your "mental status". Mostly this is to ascertain how well you are grounded in reality. Some of the questions will sound obvious, but they aren't trick questions. For example, asking the day of the week tells them if you are oriented to time. They may ask you some general information, arithmetic and memory questions. They may ask you to explain the meaning of some simple sayings like "a stitch in time saves nine". They will without doubt ask whether you feel suicidal and homicidal. They should determine your mood and whether you have periods of anxiety, sleeplessness, disorientation, confusion, inability to tell what is real and what isn't. They will ask if you hear voices or see things that aren't there.

They will probably ask you questions to see if you're trying to deceive them by trying to come across as "too normal"? They should have your records, which will probably be fairly extensive if you were in the hospital and may be rather sketchy if they're from an outpatient therapist like me who doesn't want to put too much in writing for this very reason. But they will not expect you to be in 100% perfect shape, just being more or less back to how you were before should be enough to get a clean bill of health.

A really good interviewer won't even seem to be evaluating you, and may not ask any of these questions (except about feeling suicidal, that's a must). Your law enforcement experience should prepare you to deal with interogation through indirection, unless the shrink is highly skilled in the Columbo Technique. If you get a psychiatrist version of Columbo, there's nothing you can hide. (If you never saw Peter Falk as Lieutenant Columbo on t.v., you missed some great shows and I suggest you catch them in re-runs on A&E.)