Abstract
There has been an increase in wellness programming within police agencies across the U.S. We examined factors contributing to and inhibiting use of within-department and external mental wellness programming using a sequential mixed methods design within a large Mid-Atlantic U.S. metropolitan police department. Sworn and civilian policing personnel completed surveys (n = 297) and interviews (n = 26). Regression models and chi-square tests were run on survey data, and open coding was used to analyze qualitative interview data. Results from triangulation of data demonstrated departmental mistrust and confidentiality in service usage were barriers to services. Additionally, the pervasiveness of stigma within the department and the field of policing at large was emphasized. Health insurance was key to accessing mental health services when people reached a point of extreme stress. In response, within-agency messaging about confidentiality of services and options for external mental health services should be prioritized in police agencies. Furthermore, police agencies looking to promote mental health could start by offering health insurance plans that include coverage of mental health services.
Need for Wellness Services Among Police
It is well understood that policing is a stressful occupation, made particularly more so in the recent climate of the COVID-19 pandemic, the nationwide calls for reform, and the recruitment and retention crisis being faced by departments/agencies across the United States (Laufs & Waseem, 2020; Stogner et al., 2020). Moreover, the well-being of individual policing personnel directly impacts (and can cause harm to) their colleagues, their families, and the communities in which they are embedded (Blumberg et al., 2022; Laufs & Waseem, 2020; McCarty et al., 2019). Occupational and organizational stressors experienced by sworn and civilian personnel working in policing are associated with increased symptomatology of post-traumatic stress disorder (PTSD) and anxiety, and suicidal ideation (McCarty & Skogan, 2013; Violanti et al., 2019). For example, 14% of policing personnel meet criteria for PTSD and 10% for generalized anxiety disorder (Syed et al., 2020). For comparison purposes, 5% of individuals have PTSD and 3% have generalized anxiety disorder within the general population (APA, 2013). In turn, poor mental wellness in policing personnel can lead to a variety of negative physical or behavioral wellness outcomes, including cardiac-focused health concerns, alcohol and/or other substance use disorders, and musculoskeletal issues related to wearing heavy gear (Maguire et al., 2020). Therefore, it is in a police agency’s best interest to promote opportunities to improve the mental and physical wellness of sworn and civilian professionals (Spence et al., 2019). The current study examined rates of (and factors inhibiting and promoting) wellness resource usage for sworn and civilian policing personnel using a mixed methods approach.
Wellness Resources in Police Agencies
Interventions designed to target wellness among police personnel typically focus on the most frequently presenting mental and physical health concerns within this population (Maguire et al., 2020; McCarty & Skogan, 2013; Violanti et al., 2019). Responsive interventions have focused on a variety of treatments, such as skills and resiliency training, dietary changes, or weight training (Maguire et al., 2020). Many police wellness studies suffer from a number of issues that complicate evaluations of the systematic effectiveness of such programs. These include varied treatments and foci, operationalizations of wellness, and policing populations involved (Maguire et al., 2020). To date, there have been two large-scale systematic reviews of interventions for psychological distress and stress management among sworn policing personnel and recruits that were unable to conclude whether any of the departmental interventions had a significant impact (Patterson et al., 2014; Peñalba et al., 2008).
While there has been a substantial increase in wellness resource provision for police in the United States in recent years (Drew & Martin, 2023), many agencies still offer no form of wellness programming (Taylor et al., 2022). Recent studies have incorporated large, nationally representative samples of police agencies, highlighting the increased recognition and response to the need for such services in police agencies. Yet, there remains a paucity of information on wellness program effectiveness (Drew & Martin, 2023), and on factors promoting and inhibiting implementation and use of police wellness programming.
Types of Wellness Resources in Policing
There are a number of formal (which can be mandated or voluntary) and informal wellness resources and services offered to law enforcement personnel. Recent research has found that nearly one-quarter of agencies provide comprehensive wellness programming, including physical, nutritional, and substance use and mental health services (Taylor et al., 2022). Bonner and Crowe (2022) found that the majority of such programs focus on stress reduction and communication skills, but rates of program use remains largely unknown.
The most common types of formal wellness services offered in policing agencies are employee assistance programs or counseling services (53%; (Taylor et al., 2022)). More informally, departments may recommend or at times mandate resources such as police-specific counseling connection services (e.g., Cop2Cop program – Copple et al., 2019), peer support groups, chaplain programs, internally hosted workshops on mental wellness, and wellness check-ups (Crowe et al., 2022; Padilla, 2023). Beyond what is already offered, data indicate that policing personnel are most interested in their respective departments offering two forms of wellness programming (Crowe et al., 2022); namely, officer wellness initiatives and counseling. And while data demonstrate promising steps toward promoting a culture of mental health in policing, studies to date have centered around the needs of sworn policing personnel, despite research demonstrating the toll of working as a civilian employee within police agencies (Jeanguenat & Dror, 2018; McKay-Davis et al., 2020).
Use of Wellness Resources by Ethnoracial and Gender Identity, and Rank/Role
Existing research surrounding wellness resource utilization has predominantly focused on department-level aggregates, rather than individual-level social identifiers that may influence mental health help-seeking behaviors. Lane et al. (2022) found that characteristics such as gender, age, and self-reported resiliency had no impact on whether sworn policing personnel would seek out services. Further, characteristics such as self-reporting a mental health diagnosis, having at least 11 years of service as a sworn member of the department, and engaging in previous mental health courses were significant predictors of seeking out such services. Yet, in a qualitative study focusing on women working in policing as sworn personnel, Treece (2023) identified that issues related to mental health resource availability and perceived inequalities in treatment led to an aversion in help-seeking behavior.
Despite the fairly extensive literature on the impact of job stress on sworn policing personnel, there is a dearth of research on the impact of job stress on non-sworn civilian personnel, much of which centers around the experiences of police dispatchers. This population presents with elevated mental health needs (Lentz et al., 2020), as it is largely impacted by their relative proximity to trauma (over the phone with citizens and officers; Klimley et al., 2018), an ‘us-versus-them' dynamic between sworn and civilian personnel (Orosco & Gaub, 2022), and many of the same stressors that afflict sworn personnel (McCarty & Skogan, 2013). Non-sworn personnel are not consistently provided with the mental health resources that are afforded to their sworn personnel counterparts (Martin et al., 2021).
Given the effects of ethnoracial and gender identity, as well as rank/role on mental health service usage, it stands to reason that there may be individualistic needs within any given agency, and leaders should take these needs into account when promoting mental health services. Still, research examining the connection between these social identities and what this means for engagement, access, effectiveness of wellness interventions is limited at best.
Factors Promoting Mental Health Services Usage Among Police
Leadership plays a critical role in creating an organizational climate that is receptive to and accepting of mental health services. Indeed, the structure of policing as an institution tends toward a transactional leadership model, characterized by the use of rewards for following procedures or rules established by the leader (Aymerich et al., 2021). Yet, a growing body of evidence suggests that traditional theories of leadership do not adequately capture the skills required of leaders who are most impactful on staff wellness, and suggests health leadership approaches might better promote a culture of wellness and health (Santa Maria et al., 2019). Moreover, there is increasing recognition that abandoning heroic perceptions of leaders could promote a policing culture of wellness that will benefit policing personnel and community members alike (Schweiger et al., 2020).
Research has further demonstrated a recognized need for a shift in policing culture at the agency level specific to supporting mental health and reducing stigma associated with mental health care seeking (Crowe et al., 2022). Where the traditional machismo culture of policing may often act as a barrier to wellness services engagement, agencies can foster a supportive environment conducive to and accepting of the use of mental health services (Cohen et al., 2019; Crowe, 2022). Certainly, the leadership of the organization plays a critical role in this shift, but so too do policing personnel at all levels, particularly new recruits starting at the Academy. Indeed, some departments have excelled at fostering this type of culture, and legislation in some states is beginning to create the resources to support this culture (e.g., Arizona House Bill 2502 (2018), “the Craig Tiger Act”; the Law Enforcement Mental Health and Wellness Act). Beyond larger aggregate examples of cultural acceptance of engagement in mental health services, some research indicates that police officers themselves may be shifting away from a “suck it up” mentality toward a “taking a knee” approach (Cohen et al., 2019; Padilla, 2023).
Barriers to Mental Health Services Usage Among Police
There are many barriers when it comes to police personnel seeking out and using mental health services (Burke, 2019; Fox et al., 2012), predominately relating to stigma. Stigma broadly paints a negative picture of the need for and engagement in mental health services. Similar to stigma among members of the broader community, stigma specific to policing personnel is perpetuated by individuals, peers, and the general public at large (Drew & Martin, 2021; Papazouglou et al., 2021; Soomro & Yanos, 2019). Particularly within the policing profession, the ‘cult of masculinity’ (Silvestri, 2017) and machismo culture deeply value physical and mental toughness (Soomro & Yanos, 2019). Not surprisingly, the literature consistently identifies stigma as a common barrier among policing personnel, with more targeted concerns about being viewed as weak by colleagues or superiors and job termination (Craddock & Telesco, 2022; Drew & Martin, 2021; Padilla, 2023). Yet, due to repeated exposure to operational and organizational stressors during the course of one’s day-to-day duties, it is imperative that police recognize the need for wellness services and feel supported in seeking and receiving them. It is also critical to note that many officers who feel their situations are particularly dire or severe may seek out mental health services regardless of the pervasiveness of stigma in their department or society at large (Drew & Martin, 2023; Jetelina et al., 2020).
Additional barriers to engaging in mental health services can be related to police agencies or offered resources. For example, policing personnel may be hesitant to use such services due to a perceived lack of confidentiality (e.g., Stinchcomb, 2004). Officers interested in mental health services must first learn what services are available and how to access services (Padilla, 2023). Further, many mental health services offered by agencies may be inadequate (Fox et al., 2012). Regardless, identification of facilitators and barriers to mental health care seeking are critical to improving access and use of such services.
Current Study
Recent research on wellness programming provided by police agencies has focused largely on understanding what features of wellness programming are included and whether agencies are providing programming at all. To date, there remains a gap in our understanding about the rates of usage of wellness programs, particularly concerning what types of services are used. Research has also been limited methodologically, primarily focusing on using quantitative methods to understand: wellness needs, police agency offerings related to wellness needs, only including sworn policing personnel, and demonstrated barriers to use of resources. In the current sequential mixed methods study, we examined self-reported usage of wellness programming within a single police agency and answered five questions specifically. Of note, we examined the potential influence of participant ethnoracial and gender identity, and policing role in our quantitative (but not in our qualitative) analyses. Our five research questions were:
What physical health- and mental health-centered wellness resources are policing personnel using of those provided within and external to a police department?
What factors (i.e., demographic characteristics, rank/role) are associated with use of department wellness programming?
What are the associations between demographic characteristics, mental health problems, perceptions of mental health service use, stigma, and organizational stressors and counseling and agency-offered counseling?
What are the barriers to not using mental health resources through department wellness programming? Are ethnoracial or gender identity associated with these barriers?
Using qualitative interview data, what do policing personnel describe as factors promoting and inhibiting their mental health services use?
Methods
Wellness Program Overview
The police agency examined as part of this study (a metropolitan police department) maintains a comprehensive set of wellness tools designed to both prevent and actively remedy wellness problems when they occur. Some critical aspects of the program are described below. These tools are organized and promoted by their ‘Wellness Program’ [renamed to maintain agency anonymity]. For the active management of wellness problems, whether personal or work-related, the agency employs two separate channels of intervention (1) formal, triggered by policy violations or concerning behavior as observed by supervisors, and (2) informal, initiated at the suggestion of a supervisor or peer or the affected employee themselves.
Concerning agency-offered counseling, the agency documents all interactions between its officer wellness section and employees in distress, no matter the channel employed. It has developed an “after-action report” which memorializes the reason for a visit from the peer support team, the topics discussed during the visit, and any resources which may have been recommended during the interaction. External counseling is not typically documented by the agency, but documentation can occur for cases where the employee was referred by the agency (especially if services were mandated like substance use treatment). Select additional details about agency-provided services are noted below.
Early Intervention
A unit of sworn officers on the wellness team was created to monitor policing personnel who display potentially problematic behaviors that could (if unaddressed) result in disciplinary action, termination, and/or a personal crisis. Officers self-identified or referred who are at-risk for substance use disorders and mental health problems are provided services as needed, taking a non-punitive approach. Officers and not penalized for missing work during the treatment period.
Critical Incident Response
Members of the wellness programming team respond to all police-involved shooting incidents to provide officers support. Sworn and civilian wellness program staff go to the scene to provide peer support. Supervisors within the wellness program follow-up with the involved member at least once, and multiple times as needed.
Wellness Crisis Hotline
The agency has a crisis management hotline and app through which policing personnel can seek services for themselves or refer a colleague. The hotline operates 24/7 and connects personnel with a sworn wellness program team member to connect to mental health services.
General Agency Mental Health Programming
While employees in the agency have multiple health insurance options that make mental health services accessible and affordable through external providers, the police department provides all employees free and confidential services for individual and family counseling. Lastly, both sworn and civilian personnel in the agency have been trained as peer support specialists to provide services like mental health first aid and resource referral. Personnel who complete the training are added to a list that is internally circulated throughout the agency.
Study Design
A mixed methods design was used, consisting of a questionnaire study (n = 297) and a sequential individual interview study (n = 26) with volunteer respondents who had completed the survey to enrich findings from the questionnaire. We implemented a sequential quantitative and qualitative study design to first gain a general idea about use of physical and mental health services through a larger quantitative sample, and second further explore results within individual interviews. We received institutional review board approval from the first author’s affiliated university and our study was approved by our partner police agency. We describe the methods and results of Part 1 and of Part 2 separately below followed by a general discussion.
Part 1 – Survey
Participants and Procedures
Demographic Characteristics and Descriptive Characteristics for Key Study Variables From Police Participants (N = 297).
Note. * = p < .050; ** = p < .010; *** = p < .001. Race–Other = Asian American (n = 5), Biracial (n = 4), Hawaiian Native/Pacific Islander (n = 2), Multiracial (n = 1), Native North American (n = 2), and unspecified (n = 19).
Recruitment materials were distributed internally by the partnering police agency’s health and wellness department through email and an app used agency-wide to communicate about training and policy updates. Recruitment materials included a study description and a direct link to the online survey and clarified that this study was not being conducted by the police agency. For more detailed information on survey items, please see Supplemental Appendix A.
Measures
Demographic Information
As noted above, ethnoracial identity, gender identity, age, and rank/role were included on the study survey. Ethnoracial identity was measured as two separate constructs – race and ethnicity. Race included Black, Asian American, biracial or multiracial, Hawaiian Native/Pacific Islander, Native North American, and White. Ethnicity included two categories: Latine/Hispanic or non-Latine/non-Hispanic. Gender identity included woman, man,and no-binary/transgender/other. Policing rank/role included patrol officer, detective, supervisor (sergeant/lieutenant), captain, commander, or civilian.
Mental and Physical Health
We assessed for the presence of mental (i.e., Depression, Anxiety) and physical (Sleep Problems, Health Problems) health problems using a modified (cut) version of the Physical Health Questionnaire (Schat et al., 2005) and the Patient Health Questionnaire-4 (Kroenke et al., 2009). This included 8 Likert-style scale (0 = not at all to 4 = every day) items. All subscales demonstrated adequate internal reliability (α = .72-.84).
Workplace-Related Traumatic Stress
A truncated version of the Trauma Screening Questionnaire (Brewin et al., 2002) was used to measure common reactions to a traumatic event within policing. This included 6 items, with response options being yes/no. In the current study, this measure demonstrated adequate internal reliability (α = .85).
Alcohol Use
We used the Alcohol Use Disorders Identification Test (Bush et al., 1998). This is a brief screener (ten items) for alcohol use problems (α = .81).
Openness to Counseling
To measure whether participants were amenable to counseling, the Intentions to Seeking Counseling Inventory was modified to include language specific to policing (Cepeda-Benito & Short, 1998; Hammer & Spiker, 2018). This included five items specific to reasons someone might be willing to seek out mental health care (0 = not at all to 3 = definitely). Internal reliability was high (α = .96).
Stigma for Seeking Help
The Perceptions of Stigmatization by Others for Seeking Help (PSOSH Scale) was used to measure stigma specific to seeking mental health services (Vogel et al., 2017, 2019). This is a 5-item Likert scale questionnaire (1 = not at all to 5 = a great deal). Internal reliability was adequate in the current study (α = .94).
Stress Specific to Policing
The Organizational Police Stress Questionnaire (McCreary & Thompson, 2019) was used to measure workplace stress specific to policing. This is a 20-item scale using Likert scale items (1 = no stress at all to 7 = a lot of stress). The scale demonstrated adequate internal reliability in the current study (α = .84).
Use of Mental and Physical Wellness Services
Use of mental wellness services in the past year (psychological and psychiatric) were assessed through three questions. One question asked whether participants used mental health resources offered by their police agency. The second asked whether participants use mental health resources outside of their police agency. Another separate question asked about the use of department-offered physical wellness programming. Analyses examined both use of any mental or physical wellness services and each type of service usage reported separately. Participants were asked whether physical and mental health resources provided by the police agency met their needs, and whether a supervisor had encouraged them to use resources. Response options were yes/no.
Barriers to Mental Health Service Use
Participants who denied using mental health wellness resources were asked why not. Response options were provided, and they could select multiple options and write in another response. We did content analysis of written responses and categorized responses as: (1) no time, (2) available services are not desirable, (3) services are difficult to access, and (4) mistrust in the police department.
Data Analysis
Chi-Square Tests for Independence were run to examine whether physical and mental health resource use, satisfaction, and encouragement were observed at different rates by race, ethnicity, gender, and role. Logistic regressions were carried out to test for factors associated with use of specific mental health support services (i.e., agency counseling services, any counseling services). Lastly, independent samples t-tests were run in subsamples of participants with any clinical symptoms of PTSD, depression, anxiety, and alcohol use problems to examine associations with use of mental health services and agency-offered services.
Survey Results
Use of Physical and Mental Health Resources
Police Agency-Offered Physical and Mental Health Resource Use, Satisfaction, and Encouragement by Race (N = 297).
Note. For additional analyses based on demographic characteristics, please see the Results section. Other = participants identified as Asian American, Biracial or Multiracial, Hawaiian Native/Pacific Islander, Native North American, and who selected ‘other’ but did not expand on their identification in writing.
Race, Ethnicity, Gender, and Role, and Use of Physical and Mental Health Resources
Participants’ demographic characteristics significantly distinguished use of physical and mental health resources within the police agency. Table 2 provides an overview of overall use, satisfaction with, and encouragement to use police agency-offered physical and mental health resources. It also presents detailed information specific to race. Overall, ethnoracial identity significantly impacted all responses apart from satisfaction with agency-provided mental health resources. Identifying as a woman (30.6%; man 16.8%) was significantly associated with more use of agency-offered mental health resources, χ 2 (1) = 4.9, p = .027, CI = 2.2 [1.1, 4.4]. Women (36.7%) were significantly more likely than men (20.2%) to be encouraged by a supervisor to use agency-offered mental health resources, χ 2 (1) = 6.2, p = .013, CI = 2.3 [1.2,4.5].
Ethnicity was only significantly associated with use of police agency-offered physical health resources. Latine/Hispanic policing personnel (27.6%) were significantly more likely to use physical health resources than Non-Latine/non-Hispanic personnel (11.8%), χ2(1) = 5.6, p = .019, CI = 2.9 [1.2, 7.1]. Role was also only significantly associated with differences in use of police agency-offered mental health services. More specifically, civilian employees (42.3%) were significantly more likely to use these resources compared with detectives (13.4%), χ 2 (1) = 10.2, p = .001, CI = 4.7 [1.7, 12.9]; patrol officers (17.0%), χ 2 (1) = 7.7, p = .006, CI = 3.6 [1.4, 9.1]; and supervisors (20.0%), χ 2 (1) = 4.6, p = .032, CI = 2.9 [1.1, 8.0].
Factors Associated with Use of Mental Health Services
Factors Associated With Police Use of Specific Mental Health Services provided by Agency.
Note. * = p < .050; ** = p < .010; *** = p < .001. Referent groups were oldest age cohort and White race. ‘Other’ race included participants who identified as Asian American, Hawaiian/Pacific Islander, multiracial, Native North American, and unspecified ‘other’.
The regression model specific to use of agency-offered mental health services was significant (χ 2 (18) = 47.8, p < .001). ‘Other’ race (i.e., Asian, Hawaiian/Pacific Islander, Biracial or Multiracial, Native North American, unspecified ‘other’) relative to White race and symptoms of anxiety (β = .56 (SE = .17), p < .001) were significantly associated with more use of agency-offered mental health programming. Factors associated with significantly lower rates of agency-offered program use included physical health concerns (β = −.26(SE = .11), p = .025) and greater exposure to workplace stressors (β = −.10 (SE = .04), p = .011).
Use of Services by Clinical Symptom Presentation
We ran a series of independent samples t-tests to assess the effects of clinical mental health symptoms and mental health service use. Participating officers were significantly more likely to endorse using counseling services if they had higher levels of clinical symptoms of PTSD (p < .001) and alcohol use problems (p = .003). Nearly mirroring these findings, participants were also significantly more likely to endorse using agency-offered counseling if they had more clinical symptoms of PTSD (p = .015), generalized anxiety (p = .030), and alcohol use problems (p = .003). Depression was not significantly associated with any counseling service use.
Barriers to Mental Health Service Use
We also asked participating police personnel who were not using mental health wellness resources provided by the police department why they were not using such resources. Many participants (54.5%) reported they simply did not need mental health services. Some had concerns about disciplinary repercussions (9.5%), others felt a need to protect their reputation (9.8%), and others worried that such service use would go into their employee file (7.5%).
Twenty-four participants typed in responses about other barriers. Many of these responses (44%) included having “no time” or being “too busy.” Nearly one-quarter (24%) included statements about how services are not desirable (e.g., “Doesn’t meet needs - not real help”) and 8% wrote about services being difficult to access (e.g., “no in-person available”). Twenty percent of participants wrote about mistrust in the police department being a major barrier for them. For example, someone wrote, “Do not trust the department will not find out and use against me.”
We observed no differences in barriers by ethnoracial identity or rank/role, but gender was significantly associated with several barriers. First, woman were significantly more likely to report using other mental health services compared with men, (χ 2 (1) = 23.9, p < .001, OR = 8.76 [3.38, 22.69]). Second, women were significantly less likely than men to say they did not need counseling, (χ 2 (1) = 23.6, p < .001, OR = .15 [.07, .35]). And lastly, within coded written responses under the other reasons for not using mental health services category, women were significantly more likely to say they were already using mental health services, (χ 2 (1) = 12.7, p < .001, OR = 8.86 [2.47, 31.79]), and no women said they felt no need, (χ 2 (1) = 5.1, p = .045, OR = .76 [.34, .91]).
Part 2 – Individual Interviews
Participants and Procedures
A subsample of 26 civilian (n = 7) and sworn (n = 19) departmentally representative (by rank, role, and demographic characteristics) policing personnel volunteered for qualitative interviews. Sixteen participants identified as men, nine participants as women, and one participant as transgender. Ethnoracial identity was noted by participants as: White (n = 14), Black (n = 5), Latine (n = 2), Biracial (n = 3), and Asian (n = 2).
Recruitment materials were distributed through the survey. We embedded a question at the end of the survey asking people to volunteer for an interview by sharing their email or phone number. We also made interview recruitment materials available via email and the training and policy app, but only had participants express interest through the survey. Our team reached out to all interested parties for interviews; we were unable to connect with some interested parties for different reasons including lost interest, typos in contact information, and non-responses.
Semi-structured interviews asking about wellness and mental health service availability, direct (or learned about) experiences, and recommendations were led by two White women (Lead 1: cisgender White woman, heterosexual, divorced and remarried, no previous policing experience, master’s degrees in public health and forensics studies; Lead 2: genderqueer White woman, bisexual, married, previous experience leading therapy with current police officers and adolescents in the juvenile legal system, doctoral degree in clinical psychology with a forensic focus, licensed psychologist). Interviews were conducted on the phone or on Zoom based on participant preference outside of work hours; conversations lasted 60 minutes–130 minutes (most were about 90 minutes in duration).
Measures/Study-Relevant Interview Questions
Officers and civilian police personnel who completed interviews were asked about their perceptions of services provided by their police agency. For example, “Are you familiar with the [Wellness] Program? Of the resources available to you through the [Department Wellness] Program, which have you used?” They were also asked about recommendations to improve physical and mental wellness within their agency (e.g., “What can help professionals who are having difficulties with the stress of working at the [Department]/in policing?”). Our research team audio recorded interviews, and then transcribed them using Rev. Interviewers took field notes, which guided our discussions during research team meetings as we worked to achieve data saturation.
Data Analysis
Transcripts from interviews were reviewed for content specific to factors promoting and inhibiting use of mental health care services among policing personnel. The use of open coding allowed for the identification of naturally emerging themes for inductive category development (Saldana, 2020). A codebook was created to identify and define themes, and several examples of each theme were included. We separately coded the same transcripts (N = 2) until we reached an interrater reliability above a conservative cutoff of .85 (Miles & Huberman, 1994). Once we had achieved sufficient reliability, we independently coded remaining transcripts, and reviewed each other’s codes for consistency. Any discrepancies were discussed. During interviews, three overarching categories of responses emerged: factors promoting mental health services use, descriptions of stigma in policing, and other barriers to mental health services use. Multiple subthemes were noted within each parent code. Transcripts were uploaded to Dedoose software and coded by the two study interviewers.
Interview Results
Factors Promoting Mental Health Services Use
Individual interviews with participants revealed unique factors that contributed to use of mental health services beyond those that were included on our study survey. Most participants who used services or knew someone who had used services said that they were self-referred due to sudden increases in stress. A White female civilian employee also described how one personal experience led to her seeking services. She said, “I got divorced two years ago… I needed to talk to somebody. And I was able to reach out to send an email to the wellness program. [Wellness program staff] called me right away.” Some sworn personnel sought out mental health services independent of the department. For example, a White male detective spoke about a difficult experience in policing that prompted his journey into counseling: “I've had a friend actually commit suicide in the department... To this day, it bothers me that he did that. I don't know why he did it, but I always feel like, ‘why didn't you come talk to me?… we were here for you. We loved you. We didn't want you to leave us.’ But like I said, it was all in his mindset. He knew what he wanted. He was fighting a battle that we didn't know about.”
And while the program had resources available, this individual sought out external services, evidencing the strength of a police agency providing internal and external mental health options.
Some respondents described being mandated by the police agency or encouraged by people outside of the agency to meet with a clinician. A Latina detective reported only using mandatory mental health services encouraged by the police department saying, “The only time that I needed was when it was my police-involved shooting.” A White male patrol officer described how his significant other encouraged him to go to couples counseling, and also noted the usefulness of the services: “Years ago, I saw somebody because I was drinking a lot and I mostly did it because… my fiancé wanted me to go, that kind of thing. But it was good. And, [the city] paid for it… [It was like] Let's have a third person in the room for some of the things that we had going on at the time. So, I think it was good to use. If anybody asked me, I would tell them to use it.”
Importance of Good Health Insurance
Good health insurance made services a realistic possibility for many interviewed personnel. Insurance also made wellness resources affordable beyond typical counseling and psychiatric care. People described massages, yoga, and other group-based wellness programming being covered by their healthcare plan. A White male detective described his good coverage supporting external mental health services access, saying: “for my police-involved shooting, I… [met with] a psychiatrist…I felt so safe in there for some reason, and I did it for a whole year…. And the services usually are free anyways, so I always tell them it's better to do it. It's covered, and whatever is not covered is covered by our insurance. It's just a $5 copay…”
A White male civilian employee described how his family members were able to benefit from their healthcare coverage, as well: “And [services are] available to our family too... My oldest son was going through depression. And so I reached out to [the Wellness team] and I said, ‘Is there anything that I can do for my son? Do you offer any support for that?’ They're [like], ‘Absolutely. It's covered 100%. You get ten free visits’. And so I was able to get my son connected with somebody to talk to. And they did a really great job of calling and checking up on you after the fact, ‘How are you doing? Are you seeing that doctor? Do you need any more help from us?’ So yeah, [civilian employees] are able to take full advantage of it just like the sworn members are.”
Despite health insurance covering many services, some employees still faced barriers to care in getting their insurance accepted. A White male forensic scientist described the importance of employee insurance while also naming some limitations he had encountered that could serve as a barrier to others seeking mental health care: “I have really good health insurance through the [city]. But, unfortunately, when it comes to mental health, healthcare insurance doesn't want to pay, or keep up with payments with a lot of mental health professionals…And two, once you find one with an appropriate specialty, you have to find one that's willing to take your insurance.”
Descriptions of Stigma in Policing
It was common for participants to directly name or imply that stigma influenced their own and their colleagues’ decisions about whether to pursue mental health services. Responses highlighted complexities in how policing personnel view mental health and factors driving and maintaining stigma, including societal factors. A White male Lieutenant indirectly recognized their own internalized stigma of help seeking in policing saying, “I haven’t been brave enough to ask [for therapy]”. This brief statement represents the power of stigma in help seeking for police and further demonstrates that stigma is pervasive including among those in command roles within a police department. And if those in command are unwilling to seek services, their stigma could limit the likelihood of accurately recognizing the need for therapy in their subordinates. Such stigmatized views could also increase the threshold for counseling recommendations.
There was also mention of the department not addressing internalized stigma that was perhaps deepening peoples’ concerns about repercussions. In fact, this issue came up during an interview with a Black male Sergeant, who spoke about stigma they noticed while interacting with a coworker who expressed concerns about internal workplace problems specific to working in a profession with an authorized firearm. They said, “I actually suggested to a buddy of mine who was going through some challenges that he go and speak to someone, and his comment was, ‘Now you’re trying to take my gun away from me’… What he was implying was that I was trying to get him suspended for stress related issues and so on and so forth. And what I was trying to suggest to him is that he unpack some things… And he said, ‘Hey, but I’m talking to you.’ I said, ‘No, don’t put that on me.’ Because I know…a professional is going to unpack that and going to help you in ways that you couldn’t imagine.”
This Black male Sergeant further described how stigma has been present in policing over time but has changed, and also talked about racial identity and mental health stigma. He discussed how general stigma is problematic in policing and also named how his intersectional identity as a Black man working in policing has shaped his stigmatized views of mental health: “Growing up as African American male in [redacted], I think that there was a stigma associated with mental health. And up until a few years ago, even in the department, we referred to folks as, ‘Mental case,’ ‘Crazy.’ It wasn't until recent years that we started using the phrase ‘Behavioral health.’ And that's more accurate, because it can hit anyone. Anyone across all demographics. So, I definitely think that has affected how we look at people's mental health.”
During an interview with a Black female forensic scientist, she mentioned how stigma and concerns about associated workplace repercussions such as lowing one’s firearm can hold people back in seeking mental health services, particularly in policing. She said: “People are reluctant to talk to the therapist, even though it's confidential. We're in a society that people need their jobs… if they have a problem or if something may be hindering them from doing their job... They're going to be scared to talk to somebody because even though that therapist still has the right that if that person's going to hurt somebody or theirself [sic] because most [police] have a gun, [the therapist] has to tell somebody…I'm seeing the department not help people. So, people may be reluctant.”
Another salient note about stigma in policing was made by a White male detective who spoke about police as first responders. He described how police can experience an internalized pressure to not live up to societal expectations that they will suffer from mental health problems, saying, “…the stereotype, officers are afraid to seek services because of stereotyping… or they just think, no, it’s not an issue at all. [Mental] wellness and the stress is not a problem.”
A Black female civilian employee described some of the efforts of the police department’s wellness program. She also recognized that while wellness resources are available both through the police department’s Wellness Program and through external providers, stigma holds people back from mental health services use, saying: “The information is there. [The Wellness Program] sends multiple emails probably every couple of days about health and wellness. ‘Here. Call these. Call peer support’… and things of that nature. But I also think that sometime, people don't think they need help.”
In another interview, the importance of tone in communications from the department’s wellness unit was emphasized. A White female civilian employee suggested the police department’s Wellness team focus on being more genuine and transparent in their own experiences with mental health support, given how pervasive stigma is in policing. “I think the biggest thing with [our department] is they send out these emails and it says, ‘We care about your mental health, and we know that this job can be stressful, and PTSD is a real thing. Please reach out to [our office] if you need help.’ And there's just still such a stigma. And again, it comes across like, ‘We were told we had to send this, so we sent it.’ That's how it feels.”
Stigma About Mental Health Among Civilians versus Sworn Personnel
Differences between civilian and sworn personnel about perceptions of stigma were described during interviews. There appeared to be a general consensus between the two groups that sworn personnel are more apt to experience stigma and have their behavior dictated by stigma. The following quotes from women were selected because women were the most likely to voice recognition that stigma appears to be more impactful on sworn policing personnel. “When we [peer specialists] go to support the officers and civilians, I believe that they're glad to get the support, but a lot of [male] officers are like, they don't need it… like, ‘Okay. All right. I'm good.’… [I'm like,] ‘you're good right now, but when you go home and you're trying to go to sleep and it hits you, what you saw today, you may not feel that way.’” [Black female forensic scientist]
In addition to recognizing the impact of stigma on decisions to seek mental health services, the detective described additional barriers to help-seeking.
Other Barriers to Mental Health Services Use
In addition to (and in tandem with) stigma, multiple other barriers were experienced by personnel in seeking mental health services. First, there were periods of time where employees had difficulty connecting to the Wellness-sponsored hotline. Moreover, some personnel had problems connecting to therapists even if they were able to connect to the hotline. A White male detective spoke about this phenomenon, saying, “An officer told me that he was trying to… get through to [the wellness team]… it was an urgent situation or feeling that he can’t come to work, but he couldn’t get through…I tried calling four or five times. I couldn’t get through either.”
This detective went on to describe an example of difficulty connecting to therapists (particularly during the COVID-19 pandemic). He said: “When I was in patrol, there was an officer that he was going through a lot… from talking to him and listening and hearing him out, I felt that, whether he was going to do something dangerous to hurt himself or just that he had enough... Well, he already, he tried reaching out to [the wellness program]... they said that someone will reach out to him in a week or two, and that's not what he needed. He needed someone to talk to him that night or the next day.”
Both of these statements reflect a need for a reliable system for employees to use, particularly in times of emergency, and imply potentially dire consequences of an unreliable system.
Another barrier was a lack of clarity about repercussions associated with seeking services, as is exemplified by a statement from an Asian and White/biracial male patrol officer who shared: “I am not familiar with if I really needed to talk to them and I felt like I couldn't go to work because I was having issues from something that happened on my shift yesterday and I'm like, ‘I'm not okay,’ I'm not familiar with specifically how logistically it works. Would I be taking a pay cut for not going to work? How am I supported in that way, if at all?”
Lastly, multiple employees expressed a general level of mistrust in their department. “The director…was givin’ some context and some background information, obviously without revealing folks' names… I'm glad that it ended well for that person. Which for me though, I'm still a little hesitant…I always question the department's confidentiality. They say it, but I just question them. I'll always question them.” [Black male Sergeant] “…a lot of people believe that there's nothing confidential and it's all [our department] trying to get information about them. And they're afraid of [our department] and they're afraid of the leadership and they're afraid of command. They're afraid to touch anything… Those are the same officers stereotyping and all that stuff.” [White male detective]
These representative statements reflect an endemic concern impacting this and other police departments that you will be punished if you seek out mental health services. That these concerns remain in a department so dedicated to mental health and wellness highlights that more work is needed to reduce stigma associated with mental health services. Concerns also point to a need for police departments to ensure clearly stated and observable protections and support for police personnel who seek mental health services.
Triangulation of Mixed Methods Data
As a follow-up to RQ2 and RQ4, we used interview data to further examine how policing personnel describe factors promoting their mental health services use, and the barriers to seeking mental health services. First, we triangulated survey data and data from individual interviews on factors promoting mental heatlh service use. In addition to corroborating survey findings of anxiety and other health problems as contributing factors, qualitative data further identified other unique factors contributing to use of mental health services, such as immediate need, personal problems, and family member encouragement. In addition, participants described how critically influential their insurance plan was on service availability and usage.
Additionally, we observed compelling ethnoracial and gender identity effects on the survey, yet there was only limited mention of gender and ethnoracial identity and stigma during interviews. As an example, one sergeant highlighting how deeply entrenched stigmatized views of mental health are in the Black community. He also talked about how there were parallels between the Black community and policing institutions concerning such stigma. Regarding role, civilian personnel felt that they may harbor lower rates of stigma, but at the same time felt that the department was less likely to understand the need for civilian mental health service and thus less likely to support them compared with sworn officers.
Triangulation of Barriers to Mental Health Care
Survey results indicated that (of those not engaged in mental health care), just over half of participants did not feel they needed services. Overlapping with previous research, interviews demonstrated how pervasive and powerful stigma is, even among those in supervisory positions. Moreover, the department needing to move more toward a culture of health was emphasized. Qualitative data further uncovered how logistics need to be improved to ensure people could connect to services, particularly for timely responses to mental health needs including mental health crises.
Of course, the unique concern about having one’s firearm removed was mentioned by several sworn policing personnel, and even civilian personnel noted this issue. This finding further clarified the result noted within survey responses that hinted at disciplinary repercussions and how using mental health services would be permanently documented in their file.
Discussion
Mental health is an important component of wellness and resilience among policing personnel. Just a few decades ago, mental health was not prioritized in police work, and has often been internally and publicly/generally stigmatized as a sign of weakness; that is, mental health issues are not aligned with certain stereotypical expectations and norms about and within the field of policing. Still, over the last few decades, the role of mental health in police wellness and overall performance has garnered significant attention and stimulated discussions about its promotion and how to provide effective mental health services to police officers (Crowe et al., 2022; Padilla, 2023). Mental health is becoming increasingly recognized as a high-priority topic in police agencies (Drew & Martin, 2023), thanks in large part to recent research findings, the development of innovative policy programs, and progressive leadership (Aymerich et al., 2021). Thus, the current study sought to explore the factors that contribute to or impede sworn and civilian policing personnel’s decision to seek out mental health services in a large metropolitan police department within the US.
Mental Health Service Use
Our findings revealed that approximately one-third of participants had accessed mental health services, either through their police agency or through an external provider. This number is encouraging, demonstrating an expanded reach of mental health services beyond what has been observed in nationally representative samples of police agencies (Drew & Martin, 2023; Taylor et al., 2022). One reason we may have observed higher rates than typically observed are that we included civilian personnel, who may be more likely to seek mental health resources, despite research suggesting they have limited access to internal services (Martin et al., 2021). And the partner police agency provided mental health services specific to these personnel. This assertion is supported by our finding that civilian employees were nearly five times more likely to use mental health resources compared with sworn personnel. Given the unique stressors of civilian personnel (Jeanguenat & Dror, 2018; McKay-Davis et al., 2020), ongoing and future efforts to promote a culture of wellness within police agencies must include these employees alongside the needs of sworn personnel.
Two-thirds of participants did not utilize mental health services; there are numerous potential explanations for this result (recognizing not everyone in the agency may require mental health services). For instance, our own findings and other research has consistently demonstrated both internalized and general stigma serve as a powerful force in reducing the likelihood that policing personnel will seek mental health services (Craddock & Telesco, 2022; Drew & Martin, 2021; Padilla, 2023). One important implication of our study for policy, future research, and clinical practice is that mental health services do not have to be restricted so that they are provided solely based on the treatment of symptoms or only provided within or external to a department. Rather, mental health services may be developed based on a preventative, wellness-based philosophy aimed at providing services to police personnel and their families, even when they are not experiencing any mental health concerns or outstanding issues. For example, many agencies have established preventative mental health check-in sessions run by experienced providers. These sessions are available to personnel throughout the agency, and officers are strongly encouraged or, in some agencies, mandated to participate and receive confidential feedback from the provider based on their discussion during their session. This approach would allow all police personnel (both civilians and sworn officers) to familiarize themselves with the role of mental health providers and the caring nature of mental health services, as well as to obtain guidance on how they can maintain their mental health and wellness in their professional and personal lives. And future research should further examine the factors associated with factors driving wellness service initiatives within the law enforcement agencies including promoting services within and external to agencies, as well as factors associated with use of different forms of services for sworn and civilian policing personnel.
Additionally, it appeared that some participants who were interviewed did not have clarity about the absolute confidentiality within the counseling relationship (other than duty to warn/protect), which points to the need for personnel to be educated on the matter. Indeed, prior research has demonstrated higher levels of stigma among people who seek mental health services external to their police agency (Drew & Martin, 2021). This in part highlights that external services are more confidential and thus might be a better fit for people reticent to seek care due to concern about agency responses. In response, mental health providers could come to agencies/make themselves more visible and known and simultaneously explain the conditions of privacy and confidentiality and their exceptions (e.g., imminent danger to oneself and/or others) when introducing available programming. Such an introduction to the providers and services might help officers in particular feel that if they come to a mental health session, they are sharing their concerns in a safe space without fear that their gun or badge will be revoked if they say something they ‘should not.’ Additionally, offering internal and external services could likely circumvent many barriers to mental health care seeking.
Some of the interviewed policing personnel described using services for one of two reasons: they were either required by the department to meet with someone after a police-involved shooting or were in a personal situation that was so distressing to them that they felt they had no other options. An alternative approach that could capitalize on personnel being willing to meet with mental health professionals when they are mandated to do so is to provide mental health services to all police personnel under the broader umbrella of police wellness, and maintain such services on a rolling basis. For such an initiative to succeed, the critical role of leadership cannot be under-emphasized (Aymerich et al., 2021; White & Robinson, 2014).
An essential factor that promoted use of services was access to health insurance that covered mental health services. Our partnering police agency prioritized this is an option for their employees, and it was clear the employees appreciated and have leveraged their insurance as an opportunity to better their mental health. While stigma is certainly the most salient barrier that comes to mind for researchers and individuals in the field of policing when they are interviewed (as was further demonstrated in our study), the importance of insurance in the United States in particular cannot be understated (Walker et al., 2015).
Ethnoracial and Gender Identity and Policing Rank/Role
Findings from our study also showed that Black and women/female police personnel were more likely to seek out mental health services. There may be multiple explanations for this finding. Concerning gender identity, our observation that female police personnel were more likely to seek mental health services aligns with prior findings that female police personnel are more likely to access help when needed, especially following critical situations, instead of trying to suppress their emotions (e.g., Korol et al., 2021). It may be that the way Black and female police personnel express mental health issues differ from the dominant cultural perspective (i.e., White male) and the dominant police culture concerning mental health services (Cohen et al., 2019; Crowe, 2022), thus allowing them to more easily identify issues that are problematic or that require mental health services (Drapeau et al., 2009; Wang et al., 2005). Second, it is possible that Black and female police personnel may be perceived as more vulnerable within their organizations because they often do not align with mainstream expectations of traditional policing. Thus, they may be more likely to be encouraged to seek out mental health counseling (Drapeau et al., 2009). Third, it may be that these demographic groups seek out mental health services as a result of being subjected to biased stereotypes, attitudes, and discrimination (Vargas et al., 2020; Williams & Etkins, 2021).
Of additional significance is the matter of whether and why stigma is either not as prevalent in groups of Black and female policing personnel. Similar to women civilians (Garb, 2021), policing personnel who identified as women, may be perceived as more in need of mental health services. Taken together with our finding that women were significantly more likely to be advised by their supervisors to seek mental health services, it may be that they are both perceived as having more mental health needs and encouraged more often to seek help. Thus, they may ultimately seek help more given environmental pressures. Or, alternatively, it may be that stigma is outweighed by the need felt by these individuals to access support. These issues may be further explored in future research to develop a clearer understanding of how they impact mental health.
Implications for Policing Leadership
Study findings indicated that barriers to mental health service access and use were pervasive across ranks and roles. Additionally, findings point to the need for leadership to work toward a culture of health. Our results also demonstrated significant barriers–and contributing factors–to mental health service use among police personnel that policing leadership could capitalize on.
The role of leadership is integral in promoting mental health use among policing personnel. Modeling person-first language that demonstrates accurate knowledge and support for mental health promotion work is one primary strategy that leadership must adopt (Wu et al., 2021). Moreover, to promote mental health prevention and intervention, police leaders need to maintain open channels of communication with their staff (Cohen et al., 2019). In the interest of promoting a culture of wellness and health, leadership also need to individually monitor–and promote supervisor awareness and monitoring–any noteworthy changes in behavior among personnel (Santa Maria et al., 2019). When concerns are identified, police leaders must communicate possible concerns with their staff and use empathic listening to demonstrate compassion and reduce stigma, which is so elevated within this population (Drew & Martin, 2021). Such an approach may even be more efficient when police leaders have knowledge about how personnel with different identifiers (e.g., ethnoracial and gender identity) experience mental health challenges (e.g., Bishopp et al., 2020; Korol et al., 2021; Padilla, 2020).
Naturally, policing administrators and commanders can also play a crucial role toward de-stigmatizing mental health seeking support by sworn (Schweiger et al., 2020) and civilian personnel alike. This philosophy can have more powerful outcomes when police leaders overtly share with their police personnel that they themselves sought mental health support (Crowe et al., 2022). Given how open to counseling so many participants appear to be, simplifying access to therapy is advised, with services provided on the clock, given that the policing profession is associated with significant mental health problems.
Limitations and Future Directions
This study had several limitations. First, the data were cross-sectional. Thus, we were unable to examine wellness programming outcomes or impact and were unable to look at stigma or wellness overtime. Second, our data were collected from a single police department in the United States. In addition, selection bias likely impacted our obtained sample, in part because we worked with the Police Department to recruit internally and partly due to the topic. It remains unclear whether our findings might generalize to those individuals in the department whose voices are not represented in this study or to other police departments at large. It is important to consider recruiting individuals from other police agencies representing more diverse experiences across the U.S. (and internationally) and to use different recruitment methods in follow up work.
Additionally, our study was unable to ascertain in which type of wellness programing survey respondents participated and did not measure whether counseling was mandated or voluntary. Our measure of wellness programming was quite broad. In future research, it would be helpful to collect data that would allow for testing of whether and how respondents were steered to formal versus volunteer programming. This could also highlight important realities for how these services are utilized by law enforcement personnel. We also measured use of wellness services using a series of dichotomous yes/no questions. The use of other methods of measurement in follow-up research including Likert scale response options could better capture more nuanced recommendation and referral pathways to wellness resources. Moreover, collecting data that might illuminate whether stigma and other barriers are different for internal versus external services could help promote service use among officers.
Another survey limitation was that we did not include a measure that allowed us to examine whether participating officers or civilians were mandated to access services. This is a very important consideration when drawing conclusions about access rates that should be integrated into follow-up studies. Lastly, we only heard from people receiving the services and did not interview providers or leadership on the wellness team. In future studies, it would be informative to highlight the voices of these individuals.
Conclusion
The role of leadership in promoting a culture of mental health within policing organizations is integral. Police agencies should establish all the necessary resources that personnel need to access mental health services, ensuring a private and confidential context. Hotlines, peer support networks, wellness units, available resources, and directories of external providers are just some of the resources that agencies can provide to help officers utilize mental health services. In the case of external providers, building on our study findings, insurance options should cover mental health needs of police personnel and their families. Moreover, from the day police recruits join the academy, they should be educated about the benefits of seeking mental health services, not only for treatment, but also for preventive purposes. Instilling these principles early in the careers of sworn policing personnel will help them integrate mental wellness into their identity, deconstructing old-fashioned and stigmatizing attitudes towards seeking mental health services. In addition, police leaders can collaborate with providers to deliver psychoeducation about the critical role of mental health services in optimizing police performance and wellness, and not just as a way of dealing with psychopathology. And civilian policing personnel should not be overlooked. Mental health in policing has made tremendous progress over the last few decades, but there is much more that remains to be accomplished.
Supplemental Material
Supplemental Material - Factors Promoting and Inhibiting Use of Wellness Resources Among Police: A Mixed Methods Study
Supplemental Material for Factors Promoting and Inhibiting Use of Wellness Resources Among Police: A Mixed Methods Study by Rebecca L. Fix, Konstantinos Papazoglou, Kathleen E. Padilla, and Daniel M. Blumberg in Police Quarterly.
Footnotes
Acknowledgments
The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIOSH. The authors extend their appreciation to the partnering police agency, key leadership, and study participants.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This manuscript was supported by the grant U19OH012297 from the National Institute on Occupational Safety and Health (NIOSH).
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