“Playing the system”: Structural factors potentiating mental health stigma,challenging awareness,and creating barriers to care for Canadian public safety personnel

Abstract

There are growing concerns about the impact of public safety work on the mental health of public safety personnel; as such, we explored systemic and individual factors that might dissuade public safety personnel from seeking care. Public safety personnel barriers to care-seeking include the stigma associated with mental disorders and frequent reports of insufficient access to care. To better understand barriers to care-seeking, we thematically analyzed the optional open-ended final comments provided by over 828 Canadian public safety personnel as part of a larger online survey designed to assess the prevalence of mental disorders among public safety personnel. Our results indicated that systematic processes may have (1) shaped public safety personnel decisions for care-seeking, (2) influenced how care-seekers were viewed by their colleagues, and (3) encouraged under-awareness of personal mental health needs. We described how public safety personnel who do seek care may be viewed by others; in particular, we identified widespread participant suspicion that coworkers who took the time to address their mental health needs were “abusing the system.” We explored what constitutes “abusing the system” and how organizational structures—systematic processes within different public safety organizations—might facilitate such notions of abuse. We found that understaffing may increase scrutiny of injured public safety personnel by those left to manage the additional burden; in addition, cynicism and unacknowledged structural stigma may emerge, preventing the other public safety personnel from identifying their mental health needs and seeking help. Finally, we discuss how system-level stigma can be potentiated by fiscal constraints when public safety personnel take any leave of absence, inadvertently contributing to an organizational culture wherein help-seeking for employment-related mental health concerns becomes unacceptable. Implications for public safety personnel training and future research needs are discussed.

Keywords

care-seeking mental health and disorders public safety personnel stigma system-level stigma trauma

Introduction

The category of public safety personnel (PSP) includes, but is not limited to, call center operators, correctional workers (i.e., institutional, community, and administrative roles), dispatchers, firefighters, paramedics, and police officers (Oliphant, 2016). In Canada, the 2016 Standing Committee on Public Safety and National Security report concluded there was insufficient empirically valid research available to inform decision-making regarding the mental health of Canadian PSP (Oliphant, 2016). That conclusion was drawn from various limitations of prior research, such as small sample sizes, exclusively quantitative data, or singularly clinical samples. The report also indicated that PSP mental health was further complicated by reports of stigma and associated discrimination.

Internationally, PSP are regularly exposed to potentially traumatic events as part of their employment (American Psychiatric Association (APA), 2013; Galatzer-Levy et al., 2011 Jonsson et al., 2003; Komarovskaya et al., 2011; Skogstad et al., 2016; Van Der Ploeg and Kleber, 2003). The ways in which diverse PSP are exposed to trauma varies by occupation, where some groups experience trauma directly in person (e.g., police), while others experience trauma more vicariously, such as dispatchers hearing the event or administrators reviewing the associated documentation (Adams et al., 2015). PSP also have different levels of information regarding resolutions of the trauma (e.g., some do not know outcomes of events while others do), which can differentially impact their well-being (e.g., not knowing what happened may be particularly problematic; Carleton, 2016). Exposure to traumatic events has been associated with several mental health concerns, including posttraumatic stress disorder (PTSD; APA, 2013) and major depressive disorder (Bonde et al., 2016), among others (Fetzner et al., 2011; Sareen et al., 2007).¹ Prevalence estimates for such concerns among PSP have been diverse, both nationally (e.g., Asmundson and Stapleton, 2008; Corneil et al., 1999; Haugen et al., 2012; Horswill et al., 2015; Oliphant, 2016) and internationally (Berger et al., 2012; Faust and Ven, 2014; Haugen et al., 2012; Neria et al., 2011; Oliphant, 2016; Stanley et al., 2016). In a recent study, researchers addressed some of the previous limitations underpinning the range in prevalence estimates using a large Canadian sample of PSP who responded to several well-validated self-report measures (Carleton et al., 2018). The study results provided important information regarding PSP experiences with mental health symptoms and indicated a substantial proportion of PSP (44.5%) screened positive for one or more current mental disorders. There remains, however, a paucity of published research describing the complex experiences of PSP regarding mental health. In this study, we use additional information provided by respondents in the recent Canada-wide study, allowing for analyses of the complex ways in which stigma manifests for PSP and influences their care-seeking behaviors. Specifically, we sought to interpret how personal, structural, public, and system-level processes impact views of and decisions about care-seeking for mental health. We also strive to first hear the words of PSP and then bring their voices central to view as we contextualize proposed reasoning for, as well as solutions to, the barriers to care-seeking among themselves and colleagues, and to reveal the role of system-level processes in perpetuating under-awareness of personal mental health needs among PSP.

Stigma

Stigma can leave PSP feeling discredited or discreditable for a variety of reasons (see Goffman, 1963). Consistent with Goffman’s notion of a discreditable stigma (e.g., tied to an invisible attribute), PSP may face mental health issues only to be dissuaded from care-seeking due to fears that disclosure may render them “discreditable” by their peers. The stigma and lost credibility may include the individual being designated as lazy, weak, deceitful, and not suited for the job in the first place (Goffman, 1963), all of which may prevent PSP from self-care or taking time off work (Karaffa and Koch, 2015; Lyons et al., 2017). Accordingly, understanding the sources of stigma regarding mental health and/or care-seeking appears invaluable.

Underpinning the influence of “stigma” is an ideology that develops based on the “questionable trait” under consideration (Goffman, 1963). The concept of “stigma,” seminally described as a discrediting attribute where “a special kind of relationship between attribute and stereotype [exists] …” (Goffman, 1963: 4), has permeated scholarship on mental health and intervention seeking behaviors for decades. The application of a discrediting stigma may be evoked by an individual attribute, with the broader stigma ideology informed by prejudice and stereotypes that shape the lens through which a stigmatized person is viewed. A stigmatized person, once identified, can be actively discredited by others, resulting in negative evaluations including being perceived as less deserving than peers or even dangerous (Goffman, 1963); indeed, a stigmatized person’s entire social identity can be readily devalued (Clow and Ricciardelli, 2014; Crocker et al., 1998; Goffman, 1963; Jones et al., 1984; Major and O’Brien, 2005; Markowitz, 2005; Scheff, 1966) such that they become acceptable targets of a stigma ideology that supports devaluation and encourages problematic assumptions about their identity (Goffman, 1963). The devalued social identity is often focused on a single stigmatized attribute (e.g., a mental health diagnosis) thought to define the person. The attribute becomes synonymous with their status, constrains the perceptions of others, including interpretations of their actions and words, and defines the stigmatized person’s social experiences (Goffman, 1963; Markowitz, 2005). Viewing an individual based on who he or she is believed or assumed to be, rather than who he or she is, gives credence to the “virtual social identity” rather than the “actual social identity” (Goffman, 1963: 4). The virtual social identity is grounded in assumptions rather than fact and comprises the expected characteristics tied to any member of a social group. A virtual social identity represents the interplay between stereotypes, prejudice, and the potential for discrimination, often exclusively focusing on a single attribute, therein ignoring the more complex “actual social identity” (Goffman, 1963).

The pervasive stigma around mental health makes persons with mental disorders less likely to access care (Clement et al., 2015; Corrigan et al., 2014 Karaffa and Koch, 2015) and increases their risk for being given a problematic virtual social identity (e.g., perceived as dangerousness or unreliable; Crisp et al., 2000; Hinshaw and Stier, 2008; Lyons et al., 2017; Penn and Martin, 1998). Essentially, persons identified as having a mental disorder are often considered deviant, which Goffman (1963) defines as “any individual member that does not adhere to the norms” (p. 141). Mental disorders may be considered particularly deviant because each can be less visible than physical health concerns, making the presence or absence of a disorder more difficult to assert, which creates uncertainty regarding the potential vulnerability such deviance imposes on colleagues or dependents (e.g., the notion that mental disorders may compromise one’s ability to perform his or her occupational responsibilities particularly under pressure; Crisp et al., 2000; Hinshaw and Stier, 2008). For example, treatment-seeking veterans with combat-related PTSD self-reported being stereotyped by others as “dangerous/violent,” “crazy,” “cold-hearted,” “unreliable,” “unstable,” “unfit to raise your kids,” “pissed off at the world,” and as personally responsible for developing PTSD (Mittal et al., 2013: 86–90).

A person identified with a mental disorder and reduced to a virtual social identity can then be readily reconceptualized “from a whole and usual person to a tainted, discounted one” (Goffman, 1963: 25). The virtual social identity becomes compatible with contemporary concepts of “public stigma,” defined by Corrigan and Rüsch (2002) as how “the public reacts to a group based on stigma about that group” (p. 316). Public stigma is compounded with both structural stigma and self-stigma. Structural stigma involves “societal-level conditions, cultural norms, and institutional practices that constrain the opportunities, resources, and well-being for stigmatized populations” (Hatzenbuehler and Link, 2014: 2, emphasis ours). Structural stigma can be inherent to institutional or system-level processes that allow associated persons to be identified and stigmatized (Lyons et al., 2017; Ricciardelli and Moir, 2013); for example, engaging in programming designed to reduce symptoms of a mental disorder systematically indicates to any observers that participants have mental disorders. Self-stigma is the process through which “individuals [turn] against themselves because they are members of a stigmatized group” (Corrigan and Rüsch, 2002: 316). Self-stigma reflects a stigmatized person internalizing character attributions made by others (i.e., the virtual social identity), which can become a self-fulfilling prophecy that leads a person to revise their actual social identity to conform with expectations (see Merton, 1948, notion of a self-fulfilling prophecy); for example, regularly telling a person that a mental disorder makes them unreliable can lead to reduced effort placed on reliability which can then, paradoxically, reduce reliability.

Mental disorders have been associated with intersecting and multidimensional forms of stigma that can severely devalue and discredit those affected (Crisp et al., 2000; Hinshaw and Stier, 2008; Mittal et al., 2013; Penn and Martin, 1998). There is growing evidence that PSP may have significant challenges with mental disorders (Carleton et al., 2018; Ricciardelli et al., 2018), making fallout from any associated stigma potentially pervasive, potentiating substantial personal, social, community, and economic harm; however, the published literature on PSP and mental health stigma remains scarce. This study was designed to provide preliminary information on perceptions of mental health stigma among PSP as described by participants in their own words. Although the sample is Canadian, PSP roles are ubiquitous in most human cultures. As such, our study is relevant and applicable across countries, building on international discourse that engages the problems tied to responding to trauma, of any kind, which are universally experienced.

Method

Available in English and French, an online survey with quantitative and qualitative components was available for PSP to access from 1 September 2016 to 31 January 2017 (Carleton et al., 2018). The survey was approved by the University of Regina Institutional Research Ethics Board (#2016-107). Recruitment was conducted through diverse media efforts and organized by the Public Safety Steering Committee (PSSC) representatives of the Canadian Institute for Public Safety Research and Treatment (CIPSRT), which included leaders from diverse public safety organizations in Canada (e.g., Canadian Association of Chiefs of Police (CACP), Canadian Association of Fire Chiefs (CAFC), Correctional Service of Canada (CSC), and Paramedic Association of Canada (PAC)). The Canadian Minister of Public Safety and Emergency Preparedness was featured in an information video about the survey, and emails were sent to participants via their organizational list serves, through which they were directed to the online survey only after consenting to participate. Invitations to participate were also posted in social media and organizational websites, as well as distributed by unions and advocacy organizations. As such, we cannot say for certain how large the sampling frame is; however, we do know that raw data were collected for 9260 participants.

The self-report measures generated substantial quantitative data, some of which has been reported by Carleton et al. (2018); however, participants also had four opportunities to respond to open-ended items, therein producing substantial amounts of unique qualitative data. This study is focused specifically on responses to the open-ended item: “If you have any additional information you would like to provide or additional feedback, please feel free to do so below.”

Sample

A total of 828 participants responded to this item, of whom 556 were males and 269 were females. There were three participants who did not report their sex (Table 1).

Table 1.

Participant region of employment.

Region	Total
*Western	433
Ontario	244
Quebec	48
**Atlantic/Eastern	97
Outside of Canada	3

Western = 4; MB = 23; BC = 140; AB = 154; SK = 112.

Eastern = 2; NB = 24; NL = 15; NS = 44; NT = 4; NU = 1; PEI = 4; YK = 3.

In the previously published quantitative analyses (Carleton et al., 2018), the sample was assessed for representativeness based on sex, age, and provincial region comparisons made to extant Statistics Canada PSP data from the 2011 National Household Survey and the National Occupational Classification (Statistics Canada, 2011). The resulting comparisons indicated that the sample sex distribution was representative for firefighters, municipal/provincial police, paramedics, and Royal Canadian Mounted Police (RCMP); the age distribution was representative for municipal/provincial police, paramedics, and RCMP; and the provincial distribution was representative for correctional officers, firefighters, municipal/provincial police, and RCMP. As such, the sample is believed to be broadly representative (Table 2).

Table 2.

Occupation of PSP.

PSP occupational group	Total
Call center dispatch/operator	26
Canadian Border Services	10
Other (coast guard, coroner, nursing, administrative, USJE)	12
Correctional work, administrative	21
Correctional work, operational	92
Pre-medicine (paramedic, EMR, EMT)	146
Firefighter	103
Other fire (fire/paramedic, volunteer, search and rescue)	25
Municipal police	142
Provincial police	30
RCMP	208
Other police (transit, special constable)	5

EMR: emergency medical responder; EMT: emergency medical technician; RCMP: Royal Canadian Mounted Police; USJE: Union of Safety and Justice Employees.

Analysis

The qualitative data are embedded within a wide range of demographic and quantitative data; accordingly, to thematically analyze the comments of participants by gender and occupation, the dataset was first transferred to an Excel spreadsheet file and then imported into NVivo. The process involved using NVivo’s “Autocode” function, where each individual study participant was transformed into a unique “case” with their set of “Attributes.” The Autocode function coded all qualitative responses gained from each respondent as separate “Nodes”, which function as categories used to organize material based on commonalities. Within these nodes, “Child Nodes” can be created to represent more specific subcategories within broader categories. NVivo’s “Attributes” function served to keep track of the demographic information embedded in each respondent’s case.

Upon importing the dataset into NVivo, qualitative coding processes from a semi-grounded approach (Glaser and Strauss, 1967) were employed. Responses were coded by category; for example, all responses to the “social support, family support, and self-care” question were coded together. A unique coding scheme was developed for each question’s body of responses. To begin, the coder would read the first 100 responses in the category they were coding. Themes were cataloged as they became apparent to the coder, and, upon completion of reading the first 100 responses, these themes were organized into a preliminary coding scheme. As the coder proceeded to qualitatively code the responses, new themes that emerged were noted. Once a sufficient number of new themes had emerged, the coding scheme was amended to reflect these new themes, and the responses that had previously been coded were re-coded according to the updated coding scheme. The described process, referred to as “axial coding” (Saldaña, 2015), allowed the coder to disaggregate, amalgamate, and reclassify some nodes, ultimately producing a cohesive categorization of the topics the comments discuss. The comments were repeatedly re-read and the coding schemes were axially coded until the scheme represented an exhaustive list of themes and all of the information within each category was coded. Inter-coded dialogue, including refinement, occurred during the analysis. Where appropriate, participant responses were edited for very minor typographic errors.

The participant sample was diverse, with breadth and depth among PSP who reasonably reflect the substantial diversity in Canada; as such, we suggest that the results likely have applicability and relevance for understanding the needs of PSP organizations beyond Canada, but that suggestion will remain to be tested with subsequent research.

Results

PSP indicated that system-level processes, underpinned with stigma directed toward persons with mental disorders, may be shaping care-seeking decisions, influencing how colleagues view care-seekers and reducing awareness of mental health needs. We explored what constitutes “abusing the system,” what such abuse means, looks like, and where the stigmatizing notion comes from. Next, we shed light on how organizational structures—system-level processes within different public safety organizations—may create and reinforce notions of abusing the system, particularly in occupations where the positions of employees on leave may not get backfilled (e.g., RCMP, see Ricciardelli, 2018). A sense of cynicism appears to emerge alongside a cyclical relationship that creates an unacknowledged structural stigma that can prevent PSP from identifying their mental health needs and thus seeking help. In all cases, the sample variability allowed us to identify qualities and effects of structural stigma from multiple perspectives.

“Abusing the system”: suspicion and cynicism

First and foremost, mental injuries were considered to be real and prevalent problems among participating PSP—there was evidence of a genuine concern (1) for people who have, or might be more likely to experience, a mental injury; (2) for people who have experienced or will experience trauma; and (3) about meeting the mental health needs of all such persons. There was also concern that diagnostic status could be “abused,” therein reducing the treatment and resources available for “legitimate” mental injuries. In this context, the prevalent theme that some individuals insincerely reported the source of their stressors, attributing personal sources of stress to their work experience, or simply “taking advantage” of the provisions available for those experiencing work-related difficulties, emerged. The stigma was not attributed to the mental disorder; instead, the stigma was cast on the process of care-seeking and on the causal mechanism of injury, complicating notions of when help-seeking may be considered socially acceptable. The theme was pervasive among participants and PSP categories. For example, a male RCMP officer explained his concerns regarding which experiences merited time away from work:

I feel there are many RCMP “playing” the system … the Canadian tax payer should not be covering this unless there is a documented disability. All front line officers suffer mental anguish from experiences seen on the job, why are some persons getting paid for this and others are not? (Male, RCMP, participant 9055)

In the above excerpt, the officer takes issue with individuals claiming disability pensions or benefits (particularly when earning an income) and invocates a discourse of “fairness” to articulate his displeasure with people being compensated for what he views as “seen on the job” (i.e., part of the job). His words echo those from others, revealing the stigma tied to mental injuries and to the idea of requiring supports for psychological distress. The stigma appears to diversely manifest across participants who tend to associate negative traits (e.g., laziness and weakness) or a less-than-desirable virtual social identity with persons claiming mental injuries or a need for help coping with their occupational demands on duty. Persons with mental injuries are viewed, by some, as “milking the system” and burdening their colleagues, their organizations, and tax payers.

Such concerns appeared across PSP groups, reinforcing the attachment of stigma to mental disorders. Additional examples of stigma include concerns that people would use a mental disorder to extend their “vacation” time, as explained by a male firefighter from BC:

My one worry about the recent focus and awareness about mental illness and PTSD in the work place is the new “back injury” hard to prove [if] the person is hurt or not but [they can] miss a lot of time from work. I honestly see and know people who will and do use mental illness/PTSD as a way to get more time off from work. Sadly, I think it will be greatly abused, but I also think it will help those who are legitimately suffering. Would be nice if people were honest and didn’t abuse a great tool, but sadly this is not the world we live. (Male, Firefighter, participant 2959)

In a similar context, a male employee with Correctional Services Canada (participant 1579) wrote, “it can be disheartening when some take advantage of claiming mental health issues where none exist.” The implicit risk raised is that those who seek assistance for mental health considerations may be stigmatized as bearing devalued traits; furthermore, these participants’ words suggest that a structural stigma is inherent to the very processes designed to provide aid or intervention for those in need.

Beyond “milking” the system, selected participants suggested that some of their coworkers avoided taking responsibility for their personal actions and attribute personal stressors to their occupational experiences. For example, participant 9055 continued,

Members who have stress in life because of their own actions (cheat on your wife), buy a car or house that you cannot afford etc … please don’t consider this work stress … this is entitlement stress and should not be considered part of the job.

The concern about the source of stress (e.g., work vs life) was evinced across PSP categories. For example, a female paramedic (participant 6339) noted that

throughout the evaluations of individuals [for PTSD] we do need to separate out what is home and life stress vs true PTSD. As mentioned before I believe that true PTSD is getting watered down and it is a disrespect to the people who really have the condition.

The paramedic’s words reveal an assertion that work stress should be distinguished from personal stress and that personal stressors should not become the problem of colleagues who are grappling with “genuine” difficulties related to their work. This implies a nearly impossible capacity to delineate work and personal “difficulties” as well as the fact that work stresses can transcend into home life and vice versa. Overall, there were undertones of a directed bitterness around seeming injustices or dishonesties expressed by PSP, suggesting a pervasive perception that not all mental health needs were genuine or the responsibility of the organization; accordingly, the theme “abusing the system” emerged as prominent.

Systematic (institutional) stigma and perceptions of abuse

Across all groups, but particularly among police officers, participants reported experiencing system-level or structural stigma (Hatzenbuehler and Link, 2014) that they felt shaped the way mental disorders, specifically PTSD, were viewed within their organizations. The structural stigma appeared to shape how PSP who expressed experiencing mental injury were perceived—even reinforcing the notion that some PSP “play the system.” Structural stigma may originate from budget constraints that leave employees distressed when someone takes a leave of any sort. Structural stigma may also be bolstered by insufficient mental health awareness and education, leaving persons unprepared to work with colleagues who have mental health needs. The variability of our sample allowed us to identify qualities of structural stigma and implications therein from multiple perspectives.

Budget constraints and employer needs clearly contributed to structural stigma. For example, a challenging economic context became evident when participants reported experiencing stress tied to the seemingly cyclical challenges posed by the need to backfill the positions of employees on leave. In the words of one male municipal police officer (participant 1461),

Part of the issue surrounding the mental health crisis is the systematic stress placed on individuals. Supervisors who are stressed and not seeking help are creating stress in subordinates and co-workers and the cycle continues. We need to take the fear away from coming forward and understand that there is only so much trauma the human brain can deal with. Because of cutbacks and staff shortages, not only do officers look negatively about the stigma of mental health but also repercussions of “leaving the team short.”

As this officer’s words highlight, structural stigma can increase the stress felt by PSP across all ranks. Colleagues of a person on leave are left with additional work demands. Supervisors who need to fill staff positions have minimal or no resources with which to do so, which results in fatalistic attitudes and evidence the pervasive structural stigma. PSP underscore perceptions of insufficient resources that result in the person on leave whose spot required filling being scrutinized about the legitimacy of the claims, which propagates notions that people are “taking advantage of the diagnosis.” To further exemplify this, a male RCMP officer (participant 3643) explains,

It is difficult in the RCMP to seek mental health assistance as there is still a stigma in relation to staff that go off work due [to] mental health issues. Many think they are just getting a free pay cheque. Unfortunately there are a few that do this and it ruins it for those with mental health issues that actually need to be away from the work place. I know this sounds contradictory but in my role as a supervisor I know of members that told their peers that if they didn’t get their way they would just see a doctor and go off on stress leave or if they had performance issues and the issues were addressed they would just get a doctor’s note and go off work. This has an impact on the staff that are legitimately sick and need time to recover as they tend to be painted with the same brush.

A second male RCMP officer (participant 3694) reinforced concerns about system abuse, evidencing the system-level stigma underpinning care-seeking or intervention-targeting practices in stating

There remains a very real sentiment that senior managers in the RCMP will punish or look unfavorably upon those that come forward with Mental Health issues or concerns. Part of this stems from a minority of RM’s taking advantage of the system and thus putting increased pressure on their colleagues with respect to workload etc …

The officer’s words underscore the degree to which a claimant can be questioned; however, not mentioned is the very real possibility that, for some PSP, poor performance reflects a hidden mental injury that may be the causal factor. The second officer reports pervasive fears that PSP expect to be negatively evaluated in performance reviews if they come forward with mental health concerns. Fears of negative evaluation were echoed by many participants, who clearly stated they “wouldn’t dare tell anyone” because they feared they would be discriminated against because of their mental injury, something they had reportedly witnessed happen to others:

Unfortunately too many people use stress leave when they are angry or upset at bosses/company. It hurts the people who really need it because they feel that is what they are doing as well. I put off getting help because I was afraid that people would think that I was abusing the system. (Male, RCMP, participant 3613)

This officer’s words exemplify the insufficient success of contemporary efforts to change the institutional cultures (e.g., Civilian Review and Complaints Commission for the RCMP, 2017; Oliphant, 2016) that facilitate mental health stigma; instead, the emphasis has shifted to people who might “abuse” or “take advantage of” the system, compromising persons who truly need help, and forcing PSP to suffer in silence. Systemic pressures surrounding ongoing short-staffing or resources, compounded by an institutional culture perceived as intransigent, may lead people who do come forward with mental health concerns to be viewed negatively. Those who did come forward, then, remain at “fault” for “abusing” the system, creating a variant of victim-blaming.

The pressures caused by employees who take leave undermines their colleagues’ capacity to be fully understanding and compassionate. Those who remain at work, instead, are left trying to manage the stresses of coping with the workload increases caused by the person on leave without replacement. The frustration caused by questioning the legitimacy of mental injuries leaves some individuals feeling that current organizational mental health policies may be only “smoke screens.” Participant 1099, a male RCMP officer, reports that “daily there are stigmas of stress leaves; and marginalization of those who are on leave for Mental Health issues.” Such marginalization can be disguised by notions that certain PSP are “not suited” to the occupation—a theme across occupations that in some cases was expressed very directly: “I just want to say one thing about PTSD. When you apply for a job, you should have knowledge of the stuff you might/will see in your job. If that stuff bothers you, DO NOT APPLY!!!!!” (male, firefighter, participant 6011). The firefighter expresses his dissatisfaction with some of his colleagues’ perceived inadequate capacities to deal with trauma, inadequacies he believes were individual characteristics that preceded their employment.

In other cases, PSPs expressed their concerns indirectly. Comments focused on their own abilities and comparatively suggested that some of their colleagues fall short in their capacities:

As a first responder we are exposed to many terrifying situations which the average person will never see in their lifetime, it is part of the job and I knew this coming into it. I would never have joined if I was not prepared to deal with this. (Female, municipal police, participant 2372)

This officer clarifies that she felt aware of and prepared for the trauma she would witness when she entered the occupational field and expects the same of her colleagues; she implies anything less would be unacceptable and should not then affect her or her occupational responsibilities. Similarly, several PSP argued that their colleagues need to take responsibility for their own individual occupation-related capacities, to be accountable for, rather than try to divert attention away from, their suggested low occupational fit. For example, a male paramedic (participant 5453) explained that

… this job isn’t for everyone. Support the people who do the job and help those who are no longer able to or who were never appropriate for the job in the first place to transition to other work. Stop with the excuses … Call “Bullshit” when it’s appropriate. Drop the politically correct language, stop worrying about every minor hurt feeling that some innocent comment causes. HARDEN THE FUCK UP. Teach employees to deal with reality, stop whining, life is short, play hard, protect your family, spend time with your kids, THE WORLD IS NOT YOUR SAFE SPACE. GROW UP. MAKE A DIFFERENCE. EMBRACE THE SUCK.

Salient here is the idea that colleagues should be expected to “harden,” as well as to better understand the realistic expectations of their occupational capacity. PSP careers are not easy, the incidents they respond to may not be manageable, and the outcome for the “client” will not always be positive: “Although the whole issue of mental health is definitely valid I also feel that some of it is generated by the misperception that First Responders are ‘heroes’” (male, paramedic, participant 6910). Aligning job expectations with experience (i.e., helping to make job expectation more realistic) may also change the organizational culture, facilitating PSP acknowledging changes in their overall well-being—without feeling anyone has failed to live up to their occupational calling or was never really suited to the occupation. In this sense, if career expectations aligned with actual on duty experiences, PSP may feel more comfortable recognizing and addressing mental health concerns. A latent consequence of such a process may also be reduced potential for self-stigmatization and the associated impact on sense of self and self-worth.

Individuals experiencing mental health concerns who choose not to seek help may also negatively affect their coworkers’ perception of safety and support. For example, a male paramedic (participant 8647) from British Columbia voiced his apprehensions about being partnered with a coworker with a documented occupational stress injury:

In the Emergency Services we rely A LOT on our partners, as the decisions that we make are literally life or death in a lot of situations. Working with somebody who, due to a mental health condition, cannot be relied upon to be at 100% capacity when under a lot of stress only places more stress on the other partner. I have been in that situation, when “shit hits the fan” as we call it and both myself and my partner had to be “switched on” at 200% capacity to multitask while triaging a bunch of people and making critical decisions including resource needs, treatment, and evacuation, and I was left to fend for myself as my partner was overcome with fear and anxiety due to a previous similar experience and was essentially instantly disabled on the spot. I feel a huge amount of compassion because that is something that she acquired because of our work and her occupational exposures, I want to work with somebody I can trust to be there 100% of the time, because the only thing worse than having to deal with these situations is having to do it without any back-up or help.

The paramedic’s experience outlines the depth of complexities tied to PSP mental health concerns. On one hand, if time away from work is taken to address a mental injury, resentment may build among coworkers who are left feeling overburdened and under-supported (e.g., a variant in institutional stigma). On the other hand, if someone with mental injury is dissuaded from addressing such concerns—given the myriad of deterrents that seem to exist within public safety professions—that person may be compromised at a critical moment, jeopardizing their mental health and that of their coworkers. Perceptions of insufficient suitability for PSP work may stem, in part, from attempts to reconcile the diverse and sometimes conflicting mental health beliefs held by some PSP; however, career unsuitability did not appear consistently attributed to a discourse of self-responsibilization and PSP did not typically engage in dedicated “victim-blaming” practices. Only a small degree of self-responsibilization was tied to PSP preparations for what their careers entail. Instead, participants argued that organizations failed to prepare public safety candidates for the realities of their occupational endeavors—they attributed responsibility, at least in part, to organizational structures, including those that shape hiring practices.

Discussion

Participating PSP described three care-seeking-related scenarios: (1) individuals need and seek help; (2) individuals do not need help, but still seek help, ultimately “playing the system”; and (3) individuals need, but do not seek, help due to fears of stigmatization. Each scenario comes with unique implications indicative of a changing “stigma” for the care-seeker and their coworkers—a stigma that may now be more systemic rather than directed at having a mental disorder more specifically. In the first scenario, for example, the stigma can be generated through the increased workload coworkers experience as an individual engages with health care. Over time, the care-seeking PSP may become the target of their coworkers’ resentment, despite wanting their PSP colleague to seek help, simply because of the workload they are left to manage. In the second scenario, perceptions of systemic abuse become even more complicated. Indications of high rates of mental disorders among PSP (e.g., Carleton, 2016; Carleton et al., 2018) suggest many may be engaging with scenario one, therein facilitating stigma and resentment, which leads to perceptions of abuse caused by overwhelming numbers. The exacerbation of stress due to resource constraints may then lead to more PSP mental health concerns that may not be specific to traumatic exposure (see Ricciardelli, 2018; Ricciardelli et al., 2018). In scenario three, the fallout from scenarios one and two creates a culture that reinforces stigma and disincentivizes care-seeking, both of which may ultimately lead to an incredibly complicated and vicious cycle of distress. Moreover, the potential for loss of status associated with mental health stigma is a particular concern among PSP, more so than among the general population (Crowe et al., 2015).

Problematically, the identification of the mental health challenges faced by PSP, coupled with insufficient resources, may be exacerbating the problem—an area requiring future research. Indeed, PSP may become less likely to disclose mental health concerns, to access evidence-based care in a timely fashion, and to support colleagues in need of care. Organizational policies regarding mental health care may need revision—and therein organizations may need additional resources—to minimize resentment of care-seeking PSP by minimizing the work role impact of their absence on colleagues (Duxbury and Higgins, 2013). In any case, reframing the responsibility for mental disorders among PSP to focus on the organization and systemic variables, rather than the individual seeking care, may broadly support improvements in their mental health.

There are international precedents for improving mental health within international armed forces, which have increasingly recognized the need for a culture change that promotes earlier identification of mental health needs and encourages help-seeking behaviors. In an US study, Wright et al. (2009) demonstrated that leadership within the organization, coupled with the perception of social support enacted through unit cohesion, reduced perceptions of stigma as well as barriers to care. In the United Kingdom, the anticipation of public stigma for seeking mental health services remains a considerable deterrent for serving members (Iversen et al., 2011). A comparative study across the United States, United Kingdom, Australia, New Zealand, and Canada affirmed that patterns of perceived stigma and barriers to care are similar across the armed forces members despite cultural differences (Gould et al., 2010).

A prevalent theme across participants and PSP groups in this study was the perception that selected individuals insincerely report stressors, attribute personal sources of stress to their work experience, or simply take “advantage” of the provisions available for those experiencing work-related difficulties. A sense of cynicism may emerge alongside a cyclical relationship that creates an unacknowledged structural stigma, potentially preventing PSP from identifying their mental health needs and seeking help. Budget constraints and employer needs may be contributing to structural stigma, particularly in policing organizations where the economics of policing are long noted to be unsupportable and escalating at formidable paces (see Griffiths, 2014).

Perceptions of systemic abuse raise important questions regarding whether (1) many PSP are actually reporting stressors insincerely or (2) their reporting reflects previously unrecognized high prevalence rates, thus creating perceptions of substantial systemic abuse. Participants reported recognizing mental health needs and that PSP mental health needs appear disproportionately higher than in other groups. This recognition suggests perceptions of systemic abuse may be precipitated by resentment among those asked to do more work with less resources while coworkers receive treatment. The resentment may be contributing to PSP non-disclosure regarding mental health concerns, with PSP compromising their own health to support team members out of a sense of commitment or a fear of reprisal; that said, the current results suggest the stigma may be much less related to mental disorders than to the current systemic attempts to manage mental disorders. Future researchers should continue efforts toward establishing defensible estimates of mental disorders among PSP, as well as ensuring those estimates are pervasively communicated. Future researchers should also specifically explore the varied dimensions of both stigma and resentment, as well as monitoring how education efforts impact perceptions of systemic abuse related to mental health among PSP.

Across participant groups, there was also evidence of concerns regarding the legitimacy of mental injuries stemming from diverse potentially traumatic events. Future researchers should continue efforts to understand the types and frequencies of PSP exposures to potentially traumatic events, including whether some events are more or less likely to be problematic than others; however, mental health education should also be provided to underscore the subjective and contextually-driven nature of experiencing events as traumatic. Future researchers should also explore elements underpinning mental health legitimacy for PSP, carefully assessing the interactive influence of resource constraints, and assess whether perceptions of legitimacy can be made consistent with current research.

Internationally, accessing mental health services is a complex phenomenon affected by many factors. Stigma, resilience, and help-seeking are interrelated and multidirectional (Crowe et al., 2016). In a Norwegian study of police officers and their help-seeking behaviors, the likelihood that this PSP group sought out services such as physiotherapists and chiropractors was much greater than those of psychologists or psychiatrists, even when serious suicidal ideation was reported (Berg et al., 2009). In a Canadian study, chronic pain was found to be a factor that can lay at the nexus of the comorbidities of physical health and mental health issues (Carleton et al., 2018) and presents as a possible avenue for greater exploration in help-seeking patterns of behavior. Even though PSP appear to experience higher rates of mental disorders than the general population, the culture of self-reliance and concerns about loss of confidentiality that could impact career trajectories contribute to reduced help-seeking behaviors for mental health needs (Jones and Hanley, 2017).

There were pervasive concerns raised by participants about suitability based on individual characteristics that might be identified as part of hiring processes. Many reported believing that some people are simply unsuited for PSP work and should have known better before entering the career; such beliefs appear consistent with victim-blaming in other areas, but may be based in, or exacerbated by, the resource constrains caused by care-seeking. In any case, such beliefs may be associated with stigmatizing both mental disorders and care-seeking, compounding challenges for injured PSP. Despite concerns about perceptions of suitability, participants were dissatisfied with the degree to which potential recruits were informed about the nature of PSP work or screened for suitability and that they were provided training to protect mental health and the workload support they received when injured colleagues are off work. The discourse surrounding suitability for PSP work also highlights a need for additional research as well as additional education about the current state of evidence surrounding predicting mental disorder development. Several previous researchers have recommended longitudinal studies designed to address such concerns, but consideration should also be directed toward how recruitment policies and practices might interact with the capacity to predict susceptibility for mental injuries during PSP recruitment screening. We caution, however, that efforts be taken to refrain from discourses and policies that could unintentionally support discrimination against persons in need of psychological supports being hired or recruited into PSP roles. Thus, we argue for greater emphasis on resilience training and other preventive practices rather than reactive processes, which is consistent with other international researchers who identify the value of community engagement (Jones, 2017) and resilience enhancement programs (Kleim and Westphal, 2011). We suggest that a more rounded approach to understanding mental health will result in more appropriate and supportive responses that ensure all PSP have tailored supports in response to trauma.

Limitations

Our study is limited in that only those who chose to respond to the open-ended request for comments were included in the analysis. The anonymous nature of the data collection method meant we could not follow up with any participants. We analyzed the comments of the responding participants who specifically remarked about stigma and treatment-seeking emergent themes; as such, our results may appear imbalanced because we have no positive results about stigma and treatment-seeking to report. Nevertheless, the results do accurately represent the voluntary feedback provided by our participants even after completing a lengthy survey, which we believe emphasizes the importance placed on the issues by PSP. Future interview studies may further inform how representative the current themes are of PSP experiences in general. In the interim, we are confident that the concerns raised by our participants and presented herein reflect their voices and important considerations for all PSP, in Canada and beyond.

Conclusion

Mental health concerns are not infrequent realities for PSP internationally, which makes the results important and powerful, but unsurprising, to those working with these specialized populations. The results of this study provide important insights into PSP perceptions, offering potential directions for future researchers and PSP leaders to support mental health internationally. First, there appear to be ongoing pervasive challenges with perceptions of mental health, the ways in which organizations are working to resolve mental health concerns, and the associated stigmas. Existing organizational structures, limited by significant resource constraints, may be challenged by the disadvantages facing individuals who suffer from mental health concerns, as well as their coworkers. Second, the challenges of managing mental health may be facilitating a pernicious mental health cycle that risks broad delegitimization of mental health, which would compromise the many recent gains made by PSP and their organizations. Third, more positively, there appear to be several opportunities to reduce stigma and support PSP mental health through evidence-based education and the provision of sufficient resources for sustainable health among PSP. Pervasive notions of unsuitability and organizational failures at screening and training may be particularly important avenues for such education, and recognition of the personal, societal, and economic costs of insufficiently resourcing PSP mental health may help to prioritize resource allocation.

Footnotes

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: In part from the Ministry of Public Safety and Emergency Preparedness through the Policy Development Contribution Program; Memorial University of Newfoundland (Office of the Vice President Research), and University of Regina.

Notes

ORCID iD

Rose Ricciardelli

Author biographies

Rosemary Ricciardelli is a professor of Sociology at Memorial University of Newfoundland, a Senior Research Fellow with Correctonal Services Canada, and a member of the scientific directorate of the Canadian Institute for Public Safety Research & Treatment (CIPSRT).

R Nicholas Carleton is a registered clinical psychologist, a Professor of Psychology at the University of Regina, and the Scientific Director of the Canadian Institute for Public Safety Research & Treatment (CIPSRT).

Taylor Mooney earned her Master Degree from Memorial University of Newfoundland. She is an Ottawa-based policy analyst with the federal government.

Heidi Cramm is an occupational therapist and researcher on faculty at Queen’s University, and a member of the scientific directorate of the Canadian Institute for Public Safety Research & Treatment (CIPSRT).

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