Cognitive Behaviour Therapy

ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: https://www.tandfonline.com/loi/sbeh20

Mental health training, attitudes toward support,
and screening positive for mental disorders
R. Nicholas Carleton, Tracie O. Afifi, Sarah Turner, Tamara Taillieu, Adam D.
Vaughan, Gregory S. Anderson, Rosemary Ricciardelli, Renée S. MacPhee,
Heidi A. Cramm, Stephen Czarnuch, Kadie Hozempa & Ronald D. Camp
To cite this article: R. Nicholas Carleton, Tracie O. Afifi, Sarah Turner, Tamara Taillieu, Adam
D. Vaughan, Gregory S. Anderson, Rosemary Ricciardelli, Renée S. MacPhee, Heidi A. Cramm,
Stephen Czarnuch, Kadie Hozempa & Ronald D. Camp (2019): Mental health training, attitudes
toward support, and screening positive for mental disorders, Cognitive Behaviour Therapy, DOI:
10.1080/16506073.2019.1575900
To link to this article: https://doi.org/10.1080/16506073.2019.1575900

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COGNITIVE BEHAVIOUR THERAPY
https://doi.org/10.1080/16506073.2019.1575900

Mental health training, attitudes toward support, and
screening positive for mental disorders
R. Nicholas Carleton a, Tracie O. Afifi b, Sarah Turner b, Tamara Taillieu b,
Adam D. Vaughan c, Gregory S. Anderson d, Rosemary Ricciardelli e,
Renée S. MacPhee f, Heidi A. Cramm g, Stephen Czarnuch h, Kadie Hozempa
and Ronald D. Camp j

i

a

Anxiety and Illness Behaviours Laboratory, Department of Psychology, University of Regina, Regina, SK,
Canada; bCommunity Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg,
Canada; cSchool of Criminal Justice, College of Applied Arts, Texas State University, San Marcos, TX, USA;
d
Office of Applied Research and Graduate Studies, Justice Institute of British Columbia, New Westminster,
BC, Canada; eDepartment of Sociology, Memorial University of Newfoundland, St John’s, NL, Canada;
f
Department of Kinesiology & Physical Education, Wilfrid Laurier University, Waterloo, ON, Canada; gSchool
of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada;
h
Department of Electrical and Computer Engineering, Faculty of Engineering and Applied Science /
Discipline of Emergency Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John’s,
NL, Canada; iCollaborative Centre for Justice and Safety, University of Regina, Regina, SK, Canada; jHill /
Levene Schools of Business, Faculty of Business Administration, University of Regina, Regina, SK, Canada
ABSTRACT

ARTICLE HISTORY

Public Safety Personnel (PSP; e.g. correctional workers, dispatchers,
firefighters, paramedics, police) are frequently exposed to potentially
traumatic events (PTEs). Several mental health training program
categories (e.g. critical incident stress management (CISM), debriefing, peer support, psychoeducation, mental health first aid, Road to
Mental Readiness [R2MR]) exist as efforts to minimize the impact of
exposures, often using cognitive behavioral therapy model content,
but with limited effectiveness research. The current study assessed
PSP perceptions of access to professional (i.e. physicians, psychologists, psychiatrists, employee assistance programs, chaplains) and
non-professional (i.e. spouse, friends, colleagues, leadership) support,
and associations between training and mental health. Participants
included 4,020 currently serving PSP participants. Data were analyzed
using cross-tabulations and logistic regressions. Most PSP reported
access to professional and non-professional support; nevertheless,
most would first access a spouse (74%) and many would never, or
only as a last resort, access professional support (43–60%) or PSP
leaders (67%). Participation in any mental health training category
was associated with lower (p < .01) rates for some, but not all, mental
disorders, with no robust differences across categories. Revisions to
training programs may improve willingness to access professional
support; in the interim, training and support for PSP spouses and
leaders may also be beneficial.

Received 30 October 2018
Accepted 25 January 2019
KEYWORDS

Training; mental health
support; stigma; resiliency

CONTACT R. Nicholas Carleton
Nick.Carleton@uregina.ca
Anxiety and Illness Behaviours Laboratory,
Department of Psychology, University of Regina, Regina, SK S4S 0A2, Canada
© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any
medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

2

R. N. CARLETON ET AL.

Introduction
As a function of their occupations, Public Safety Personnel (PSP; e.g. correctional
workers, dispatchers, firefighters, paramedics, police; Oliphant, 2016) are frequently
exposed to a wide variety of potentially traumatic events (PTEs). An event is considered
potentially traumatic when exposure includes direct or indirect experiences of actual or
threatened death, serious injury, or sexual violence (American Psychiatric Association,
2013). Results from a recent survey with a large, Canadian PSP sample indicated the
average number of different PTE types experienced was approximately 11 out of 16
different PTE types that were assessed, with each type experienced 11 or more times by
up to 71.3% of respondents (Carleton, Afifi, et al., 2019). Relatedly, approximately
44.5% of PSP screened positive for one or more mental health disorders (Carleton,
Afifi, Turner, Taillieu, Duranceau, et al., 2018) as well as high proportions reporting
lifetime suicidal ideation (27.8%), planning (13.3%), and attempts (4.6%) (Carleton,
Afifi, Turner, Taillieu, LeBouthillier, et al., 2018a). Indeed, there is growing evidence
that PSP experience a diverse range of potentially problematic anxiety and depressive
symptoms (Paulus, Gallagher, Bartlett, Tran, & Vujanovic, 2018). The reported mental
health challenges among PSP may be related, at least in part, to frequent PTE exposures
(Carleton, Afifi, et al., 2019). High exposure frequencies to PTEs led to the creation of
a related category of events, called critical incidents. The critical incidents category
distinguishes relatively common PTE exposures from exposures thought more likely to
be problematic. Critical incidents are situations that cause PSP, “to experience unusually strong emotional reactions which have the potential to interfere with their ability
to function either at the scene or later” (Mitchell, 1983, p. 36) and can include, “all
physical custody (arrests), all vehicle and foot pursuits, all dispatched code responses
(emergency), all motor vehicle accidents that require physical work and all calls which
present an active threat to life and/or property” (Anderson, Plecas, & Segger, 2001,
p. 18). More recent research suggests individual perceptions, rather than objectively
identified PTEs, may be the defining factor for a PTE to be considered a critical incident
(Carleton, Afifi, et al., 2019).
Irrespective of how a PTE is identified as critical, several strategies have been
developed to minimize the impact of critical incidents—specifically, critical incident
stress management (CISM) programs and critical incident stress debriefing (CISD)
programs (Authors, 2016). The Mitchel Model was among the first of such programs
(Authors, 2016; Mitchell, 1983; Mitchell & Bray, 1990; Mitchell & Everly, 1996). The
CISM programs were intended to bolster mental health before, during, and after
exposures to potentially traumatic critical incidents, by reducing barriers to treatment
seeking and expediting access to support. CISD programs were originally intended to be
components of CISM programs, delivered following a critical incident (Authors, 2016;
Mitchell, 1983; Mitchell & Bray, 1990; Mitchell & Everly, 1996). The CISM and CISD
content shares foci common to cognitive behavioral therapy programs; for example, the
content encourages critical engagement with individual thoughts and emotional reactions, as well as evidence-informed psychoeducation about stress and coping (Authors,
2016; Shave, 2010).
In addition to the multitude of available programs for managing the impact of
critical incidents on PSP, there are a growing number of programs to train PSP to

COGNITIVE BEHAVIOUR THERAPY

3

provide mental health support to their peers. Peer support refers to a wide range of
approaches, wherein participants with shared roles or experiences provide structured
assistance to their peers. The shared history before and after critical incident exposures
has been thought to facilitate empathy and trust (Kemp & Henderson, 2012; Solomon,
2004). Peer support is different from friends providing informal assistance because the
peers providing support are typically appropriately trained and potentially supervised in
providing mental health support (Grenier, Darte, Heber, & Richardson, 2007; Mead,
Hilton, & Curtis, 2001). Peer support also differs from professional mental health
support because no power differential is intended between supporters and those
supported (Greenstone, 2000). Peer support personnel typically receive special training
to provide support services in addition to their usual duties, including critical incident
management programs such as CISM, CISD, and mental health (or psychological) first
aid (Heber, Grenier, Richardson, & Darte, 2006). In Canada, there are several agencies
providing such training, in addition to diverse training provided by or within many PSP
organizations. The peer support training programs can include content related to
cognitive behavioral therapy models that overlaps with the critical incident programs
as well as training for PSP peers to deliver one or more of the critical incident programs
(Authors, 2016). Peer support training is also intended to reduce barriers to treatment
seeking and expedite access to support, therein supporting better mental health.
Other popular training programs have been designed to provide evidence-based psychoeducation about stress, trauma, and coping in an effort to build resilience, reduce
stigma, and minimize barriers to treatment seeking (Papazoglou & Andersen, 2014). The
Road to Mental Readiness (R2MR) program may be the most recognized of such programs
and was originally developed by the Canadian Department of National Defense. Their
website describes R2MR as designed to, “improve short term performance and long-term
mental health outcomes” through building a “solid foundation in the concept of resilience”
(National Defence and the Canadian Armed Forces, 2017). The R2MR training includes
cognitive behavioral therapy skills such as goal setting, mental rehearsal/visualization,
adapted cognitive monitoring (i.e. awareness of self-talk), and arousal management
through adapted breathing (i.e. tactical breathing). The Mental Health Commission of
Canada (MHCC) was the first to adapt the R2MR material for use with PSP (Mental Health
Commission of Canada 2017; Stuart et al., 2014; Szeto & Adair, 2016). In 2018, the
Canadian Armed Forces provided an adaptation for PSP of their most recent version of
R2MR (National Defence and the Canadian Armed Forces, 2017); however, to date, there is
only one published peer-reviewed study evaluating the effectiveness of MHCC adaption of
R2MR (Carleton, Korol, et al., in press). The study involved a sample (n = 147) of municipal
police assessed longitudinally including pre-training, post-training, 6-month followup and 12-month follow-up assessments. The results were consistent with other single
session interventions focused on improving various health behaviors (e.g. (Aveyard, Begh,
Parsons, & West, 2012; Leppin et al., 2014; Robertson, Cooper, Sarkar, & Curran, 2015;
Sagherian, Huedo-Medina, Pellowski, Eaton, & Johnson, 2016; Sullivan, Tetrault,
Braithwaite, Turner, & Fiellin, 2011); specifically, there were small but insignificant
(ds < .20; ps > .05) changes in mental health symptoms, resilience, and work engagement,
and a small but significant (d = .287; p < .05) reduction in stigma at post-training.
There remains a great deal of debate about CISM, CISD, peer support, and other
mental health support programs. The debate is fueled, in no small part, because of

4

R. N. CARLETON ET AL.

diverse program proliferation since the Mitchell model, such that in Canada alone,
there are at least 14 different programs (e.g. CISM, CISD, defusing, peer support,
psychoeducation, mental health first aid, R2MR), each with variability in perceived
intended use and delivery across agencies and provinces (Authors, 2016). Indeed, the
available research suggests less than 25% of implementations maintain program fidelity
(Authors, 2016). In addition, an investigation of skill decay following physical first aid
training has demonstrated rapid deterioration within 90 days post-training (Anderson,
Gaetz, Statz, & Kin, 2012) suggesting similar skill decay might potentially be expected
for mental health training. There is a critical absence of sufficient peer-reviewed
evidence of effectiveness for any of the current mental health training programs
(Authors, 2016). The result is that Canadian PSP leaders, faced with evidence of
substantial mental health challenges for their members (Carleton et al., 2018, 2018a,
2019), are now also faced with huge ambiguity regarding which critical incident
management and peer support program(s) to implement with the available resources.
Many of the current programs designed to mitigate the impact of psychological stress
among PSP are not federally or provincially funded; as such, the programs incur costs
for either the individual public safety services (e.g. a municipal fire service) or the
individual PSP. Therefore, identifying and prioritizing effective programs have become
crucial for supporting PSP and containing long-term health costs (Authors, 2016;
Wilson, Guliani, & Boichev, 2016).
The present study was designed to help inform decisions about several categories of
programs designed to support PSP mental health (i.e. CISM, CISD, mental health first
aid, peer support, R2MR). Specifically, we designed the study to assess PSP willingness
to access support from professional (i.e. physicians, psychologists, psychiatrists,
employee assistance programs, chaplains) and non-professional sources (i.e. spouse,
friends, colleagues, leadership) based on participation in different training programs.
We also designed the study to measure associations between different training programs and PSP screening positive for one or more mental health disorders. We
expected that training program participation would be associated with PSP being
more aware of available support, more willing to access support, and less likely to
screen positive for mental health disorders, but we had no specific hypotheses about
differences between training programs.

Methods
Procedure
Data were collected through a web-based, self-report survey of PSP from 1 September 2016
to 31 January 2017. The survey was available in English and French, and the project was
approved by the University of Regina Institutional Research Ethics Board (file no. 2016107). The survey was collaboratively designed by researchers from the University of Regina
as well as the Public Safety Steering Committee (PSSC) of the Canadian Institute for Public
Safety Research and Treatment (CIPSRT). Members of the PSCC included representatives
from the Canadian Association of Chiefs of Police (CACP); the Canadian Association of
Fire Chiefs (CAFC); the Canadian Association for Police Governance (CAPG); the
Canadian Police Association (CPA); Correctional Service of Canada (CSC); the

COGNITIVE BEHAVIOUR THERAPY

5

International Association of Firefighters (IAFF); the Paramedic Association of Canada
(PAC); the Paramedic Chiefs of Canada (PCC); the Royal Canadian Mounted Police
(RCMP; the federal police force in Canada); and the Union of Safety and Justice
Employees (USJE). The survey link was distributed through e-mail to currently employed
PSP by the PSSC and provincial and municipal PSP agencies. The federal Minister of Public
Safety and Emergency Preparedness created a video to raise awareness of the survey and
encourage participation. Participation was voluntary and anonymous, and each respondent
was provided with a unique login number and password to facilitate being able to pause the
survey and return at a later date to complete it. Further details of the survey procedure have
been published elsewhere (Carleton, Afifi, et al., 2019, Carleton, Afifi, Turner, Taillieu,
Duranceau, et al., 2018, Carleton et al., 2017, Carleton, Afifi, Turner, Taillieu, LeBouthillier,
et al., 2018a; Ricciardelli, Carleton, Cramm, & Groll, in press; Ricciardelli, Carleton,
Mooney, & Cramm, in press; Turner, Taillieu, Carleton, Sareen, & Afifi, 2018).
Data and sample
This survey employed convenience sampling; therefore, an exact response rate could
not be determined. In total, 8,520 respondents began the survey and answered the first
question that inquired about PSP role (i.e. “Please indicate which category of First
Responders or other Public Safety Personnel you feel best describes your current
occupation”). The respondents included in this analysis were limited to those who:
progressed far enough in the survey to complete the sections on mental health training
and attitudes toward mental health; were included in one of six broad PSP categories
(i.e. Municipal/Provincial Police, RCMP, Corrections, Firefighters, Paramedics and Call
Centre Operators/Dispatchers); and, correctly answered a control question that was
inserted near the end of the survey to identify random responses. There were 4,020
respondents included in the current sample.
Measures
Mental health training
Respondents were asked to indicate all the different categories of mental health training
they received in their PSP role. Response options included the following categories of
mental health training program types: 1) CISM; 2) CISD; 3) mental health first aid; 4)
peer support; 5) R2MR; and 6) other mental health training. Response options were not
mutually exclusive and, as such, respondents could indicate all that apply. An “any
mental health training” variable was created that was comprised of respondents who
received one or more of the first five categories of mental health training. The “other
mental health training” category had a small sample size and was not included as an
additional individual training type category, but was included within the “any mental
health training” variable.
Attitudes toward mental health support
Attitudes toward accessing both professional and non-professional mental health support were assessed with the following stem question: “Which of the following potential
support resources do you feel you can access if you needed help managing your mental

6

R. N. CARLETON ET AL.

health?” This question was created specifically for this survey by the survey developers
indicated above and back-translated for use among French participants by fluently
bilingual clinical doctoral students working in the area and then reviewed by a very
experienced professional translator working with the researchers. Professional health
supports included: 1) physician; 2) psychologist; 3) psychiatrist; 4) employee assistance
program personnel; and 5) PSP chaplain. Non-professional mental health supports
included: 1) spouse; 2) friend; 3) PSP colleague (that participants may have considered
as having occurred informally or as part of a structured peer support program); and 4)
PSP leadership. Response options included: 1) I can and would access as an early
resource; 2) I can access, but only as a last resort; 3) I can access but would never; 4)
I do not have access, but I would access as an early resource; 5) I do not have access but
would access only as a last resort; 6) I do not have access but would never access; and 7)
I do not know if I have access. Response options 2 and 3 were collapsed, and options 5
and 6 were collapsed to create a 5-point scale due to small n in each category, therein
supporting robust solutions and protecting against potential confidentiality concerns.
Mental disorder screens
Several validated mental disorder screens were used to indicate the presence of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized
anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder (PD), and
alcohol use disorder (AUD). Presence of past-month PTSD was assessed using the
PTSD Check List 5 (PCL-5; (Ashbaugh, Houle-Johnson, Herbert, El-Hage, & Brunet,
2016; Blevins, Weathers, Davis, Witte, & Domino, 2015; Bovin et al., 2016;
MacIntosh, Séguin, Abdul-Ramen, & Randy, 2015; Weathers et al., 2013); past
2-week MDD was assessed using the nine-item Patient Health Questionnaire
(PHQ-9; Beard, Hsu, Rifkin, Busch, & Bjorgvinsson, 2016; Kroenke, Spitzer, &
Williams, 2001; Kroenke, Spitzer, Williams, & Lowe, 2010; Lowe et al., 2004); past
2-week GAD was assessed using the seven-item GAD-7 (Beard & Bjorgvinsson,
2014; Kroenke et al., 2010; Spitzer, Kroenke, Williams, & Lowe, 2006); past-week
PD was assessed using the PD Symptoms Severity Scale–Self-Report (PDSS-SR;
Furukawa et al., 2009; Shear et al., 1997, 2001); current SAD was assessed using
the Social Interaction Phobia scale (SIPS; Carleton et al., 2009, 2014; Duranceau,
Peluso, Collimore, Asmundson, & Carleton, 2014; Menatti et al., 2015; Reilly,
Carleton, & Weeks, 2012); and past-year AUD was assessed using the
AUDs Identification Test (AUDIT; Gache et al., 2005; Saunders, Aasland, Babor,
Delafuente, & Grant, 1993). Positive screens were indicated by the following established cut-off scores; the PHQ-9 required a score >9 (Manea, Gilbody, & McMillan,
2015); GAD-7 required a score >9 (Swinson, 2006); the PDSS-SR required
a score >7 (Shear et al., 1997); SIPS required a score >20 (Carleton et al., 2009);
the AUDIT required a score >15 (Gache et al., 2005); and the PCL-5 required
a score >32, plus meeting the minimum criteria for each PTSD cluster as described
in the Diagnostic Statistical Manual-5 (DSM-5) (American Psychiatric Association,
2013; Weathers et al., 2013). For the PCL-5, the Life Events Checklist (LEC-5) of the
DSM-5 (American Psychiatric Association, 2013) was used as a list of PTEs to
identify index events indicative of possible PTSD as well as a category to describe
an “other” experience. Two events were modified to distinguish between common

COGNITIVE BEHAVIOUR THERAPY

7

and more severe experiences for PSP: 1) “natural disaster” was revised to “a lifethreatening natural disaster”; and 2) “transportation accident” was revised to “a
serious transportation accident”. When participants indicated their worst trauma,
they were then asked to rate their past-month symptoms using the PCL-5 based on
that experience.
Statistical analysis
Cross-tabulations were used to determine the prevalence of attitudes toward each of the
mental health supports (i.e. professional and non-professional) for each mental health
training category as well as any training and no training. Results for the “other” mental
health training category were not reported due to small sample size. Cross-tabulations
were used to determine the frequency of positive screens for mental disorders for each
mental health training category. Logistic regression was used to examine the association
between mental health training categories and each mental disorder screen. Covariates
included sex, age, marital status, provincial region, ethnicity, education, years of service,
and PSP category. There were two adjusted models computed that adjusted for: 1) sex,
age, marital status, provincial region, ethnicity, education, years of service, and PSP
category; and 2) all variables mentioned in model one in addition to all other categories
of mental health training.

Results
The results in Table 1 describe participant attitudes toward professional mental health
support (i.e. physician, psychologist, psychiatrist, employee assistance program, chaplain)
for each mental health training category. For all training categories, physicians had the
highest prevalence of respondents indicating that they “can and would access as an early
resource” if they needed help managing their mental health (prevalence ranged from
51.81% to 55.64%), and chaplains had the lowest prevalence (prevalence ranged from
15.77% to 19.91%). A similar or higher prevalence of respondents indicated that they “can
access but would never/only as a last resort” for all professional mental health supports
compared to the “can and would access as an early resource” response option. Few
respondents indicated “I don’t know if I have access” for physicians, psychologists, and
employee assistance program (i.e. less than 5% in any training category), whereas between
5.74% and 11.05% indicated “I don’t know if I have access” for psychiatrists and
chaplains. For all professional mental health support categories, a lower prevalence of
indicating “I can and would access” was seen for the “no mental health training” group
compared to the “any mental health training” group.
The results in Table 2 describe participant attitudes toward non-professional mental
health supports (i.e. spouse, friends, PSP colleagues, and PSP leadership) for each
mental health training type. Spousal support was the most commonly endorsed option
for “can and would access as an early resource” for all mental health training categories
(prevalence ranged from 72.89% to 75.16%), followed by friends (prevalence ranged
from 62.25% to 67.68%). PSP indicates low prevalence of going to leadership as an early
resource. Very few respondents (less than 1.44% in any training category) indicated
they “didn’t have access, but would access” for friend, PSP colleague, or PSP leadership

8

R. N. CARLETON ET AL.

Table 1. Prevalence of mental health training categories and attitudes toward accessing professional
mental health support.
I can and
I can access but I don’t have
I don’t have
would access
would never/
access, but access, but would
as an early
only as a last
would
never/only as
resource % (n)
resort % (n)
access % (n) a last resort % (n)
Physician
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training
Psychologist
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training
Psychiatrist
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training
Employee Assistance
Program
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training
Chaplain
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training

I don’t know
if I have
access % (n)

53.96 (784)
54.28 (723)
55.64 (355)
54.77 (511)
51.81 (614)
52.68 (1,325)
47.53 (702)

41.78 (607)
41.37 (551)
40.75 (260)
40.62 (379)
44.05 (522)
42.78 (1,076)
46.65 (689)

1.45 (21)
1.58 (21)
1.57 (10)
1.39 (13)
1.69 (20)
1.63 (41)
1.42 (21)

1.93 (28)
1.95 (26)
0.94 (6)
1.82 (17)
1.60 (19)
1.75 (44)
2.71 (40)

0.89 (13)
0.83 (11)
1.10 (7)
1.39 (13)
0.84 (10)
1.15 (29)
1.69 (25)

38.85 (561)
40.12 (530)
39.59 (251)
43.10 (400)
41.86 (491)
38.44 (961)
34.99 (513)

46.47 (671)
44.81 (592)
44.32 (281)
43.00 (399)
45.78 (537)
45.56 (1,139)
45.43 (666)

6.02 (87)
6.13 (81)
7.41 (47)
5.93 (55)
5.46 (64)
6.40 (160)
7.50 (110)

4.78 (69)
4.69 (62)
4.10 (26)
4.09 (38)
4.18 (49)
5.40 (135)
6.96 (102)

3.88 (56)
4.24 (56)
4.57 (29)
3.88 (36)
2.73 (32)
4.20 (105)
5.12 (75)

24.70 (353)
25.38 (332)
26.39 (166)
28.06 (257)
25.60 (298)
24.54 (608)
21.59 (315)

54.09 (773)
51.91 (679)
50.72 (319)
50.66 (464)
53.44 (622)
52.26 (1,295)
49.69 (725)

7.91 (113)
7.95 (104)
8.90 (56)
7.31 (67)
8.25 (96)
8.39 (208)
8.77 (128)

7.56 (108)
7.87 (103)
7.00 (44)
8.08 (74)
6.87 (80)
8.31 (206)
9.87 (144)

5.74 (82)
6.88 (90)
7.00 (44)
5.90 (54)
5.84 (68)
6.50 (161)
10.08 (147)

39.13 (567)
38.76 (514)
39.40 (249)
40.73 (378)
36.68 (431)
36.33 (909)
26.58 (390)

55.14 (799)
55.35 (734)
55.70 (352)
53.34 (495)
58.98 (693)
57.43 (1,437)
63.74 (935)

1.73 (25)
1.81 (24)
1.42 (9)
1.51 (14)
1.28 (15)
1.76 (44)
2.66 (39)

2.62 (38)
2.41 (32)
2.69 (17)
2.69 (25)
2.04 (24)
2.76 (69)
4.16 (61)

1.38 (20)
1.66 (22)
0.79 (5)
1.72 (16)
1.02 (12)
1.72 (43)
2.86 (42)

18.19 (263)
19.88 (263)
19.91 (126)
19.72 (182)
15.87 (187)
15.77 (394)
10.38 (152)

56.98 (824)
56.01 (741)
57.03 (361)
54.82 (506)
66.64 (785)
59.97 (1,498)
54.03 (791)

3.53 (51)
3.33 (44)
3.00 (19)
2.60 (24)
1.87 (22)
2.96 (74)
3.69 (54)

11.69 (169)
11.72 (155)
10.74 (68)
11.81 (109)
9.25 (109)
11.65 (291)
16.26 (238)

9.61 (139)
9.07 (120)
9.32 (59)
11.05 (102)
6.37 (75)
9.65 (241)
12.64 (229)

Training Categories are not mutually exclusive; CISM—Critical Incident Stress Management; CISD—Critical Incident
Stress Debriefing; R2MR—Road to Mental Readiness.

support, whereas a higher percentage indicated they “didn’t have access, but would
access” for spousal support (prevalence range from 4.18% to 5.21%).
The prevalence of screening positive for a mental disorder associated with having
received each mental health training category is presented in Table 3. For all positive
screens for mental disorders, participants who received any training category had
a smaller prevalence of screening positive for all mental disorders when compared to
participants who did not receive training (prevalence range from 5.8% to 24.0% for any
training compared to 6.2% to 31.3% for no training). Table 4 presents the results
examining the associations between mental health training categories and positive

COGNITIVE BEHAVIOUR THERAPY

9

Table 2. Prevalence of mental health training categories and attitudes toward accessing nonprofessional mental health support.

Spouse
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training
Friend
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training
PSP Colleague
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training
PSP Leadership
CISM
CISD
Mental Health First Aid
Peer Support
R2MR
Any Training
No Training

I can and
would access
as an early
resource % (n)

I can access
but would
never/only as
a last resort
% (n)

I don’t have
access, but
would access
% (n)

74.28 (1,054)
74.10 (964)
72.89 (457)
75.16 (684)
73.70 (852)
73.47 (1,800)
72.50 (1,044)

12.97 (184)
13.30 (173)
12.76 (80)
11.65 (106)
13.93 (161)
13.80 (545)
14.37 (207)

5.21 (74)
4.69 (61)
4.47 (28)
4.18 (38)
4.58 (53)
5.02 (123)
4.51 (65)

4.93 (70)
5.30 (69)
5.74 (36)
5.93 (54)
5.80 (67)
4.65 (114)
5.63 (81)

2.61 (37)
2.61 (34)
4.15 (26)
3.08 (28)
1.99 (23)
3.06 (75)
2.99 (43)

63.62 (918)
64.05 (848)
64.20 (407)
67.68 (626)
62.35 (737)
62.25 (1,558)
52.70 (772)

32.36 (467)
31.80 (421)
31.39 (199)
28.86 (267)
32.83 (388)
33.32 (834)
39.59 (580)

1.04 (15)
0.98 (13)
1.10 (7)
0.65 (6)
1.44 (17)
1.16 (29)
1.30 (19)

2.15 (31)
2.04 (27)
2.80 (12)
1.95 (18)
2.20 (26)
2.20 (55)
3.82 (56)

0.83 (12)
1.13 (15)
1.42 (9)
0.86 (8)
1.18 (14)
1.08 (27)
2.59 (38)

48.24 (700)
49.89 (665)
47.26 (302)
52.69 (489)
42.37 (500)
44.56 (1,119)
33.33 (489)

48.24 (700)
46.59 (621)
47.73 (305)
43.64 (405)
53.73 (634)
51.21 (1,286)
57.94 (850)

0.21 (3)
0.45 (6)
0.94 (6)
0.32 (3)
0.51 (6)
0.52 (13)
1.30 (19)

2.00 (29)
1.95 (26)
2.66 (17)
1.94 (18)
1.69 (20)
2.15 (54)
3.54 (52)

1.31 (19)
1.13 (15)
1.41 (9)
1.40 (13)
1.69 (20)
1.55 (39)
3.89 (57)

26.55 (385)
28.09 (373)
28.21 (180)
28.05 (260)
22.29 (263)
23.63 (593)
15.11 (222)

65.31 (947)
63.63 (845)
61.76 (394)
63.32 (587)
68.22 (805)
66.80 (1,676)
68.35 (1,004)

0.28 (4)
0.45 (6)
1.10 (7)
0.43 (4)
0.68 (8)
0.68 (17)
1.43 (21)

4.48 (65)
4.44 (59)
4.70 (30)
5.07 (47)
5.08 (60)
4.90 (123)
8.10 (119)

3.38 (49)
3.39 (45)
4.23 (27)
3.13 (29)
3.73 (44)
3.99 (100)
7.01 (103)

I don’t have access, I don’t know
but would never/only
if I have
as a last resort % (n) access % (n)

Training Categories are not mutually exclusive; CISM—Critical Incident Stress Management; CISD—Critical Incident
Stress Debriefing; R2MR—Road to Mental Readiness.

screens for mental health disorders. Virtually all categories of mental health training
were associated with significantly decreased odds in positive screens for PTSD, MDD,
GAD, and SAD (odds ratio [OR] range: 0.66–0.80). None of the mental health training
categories were significantly related to changes in PD or AUD. After adjusting for
sociodemographic variables (i.e. sex, age, marital status, province of residence, ethnicity,
education, years of service, and PSP category) relationships were slightly attenuated, but
many remained significant (adjusted odds ratio [AOR] range: 0.65–0.79).
After adjusting for other mental health training categories, very few significant results
remained; specifically, CISM remained associated with decreased odds of screening positive
for MDD (AOR = 0.81, 95% CI: 0.70–0.99), CISD was associated with decreased odds of
screening positive for SAD (AOR = 0.77, 95% CI: 0.60–0.99) and with decreased odds of
screening positive for any mental health disorder (AOR = 0.82, 95% CI: 0.70–0.99). Mental
health first aid was associated with decreased odds of screening positive for GAD
(AOR = 0.74, 95% CI: 0.60–0.97). R2MR was not significantly associated with decreased

10

R. N. CARLETON ET AL.

Table 3. Prevalence of screening positive for mental disorders among PSP who have had different
mental health training categories.
PTSD
Training Category
% (n)
CISM
20.1 (292)
CISD
19.7 (262)
Mental Health First Aid 19.2 (122)
Peer Support
19.0 (176)
R2MR
21.4 (252)
Any Training
20.7 (518)
No Training
26.8 (390)

Major
Depressive
Disorder
% (n)
22.3 (325)
22.2 (297)
22.6 (145)
22.5 (211)
22.8 (272)
24.0 (606)
31.3 (464)

Generalized
Anxiety
Disorder
% (n)
15.1 (221)
15.0 (201)
13.8 (89)
15.6 (146)
16.2 (193)
16.6 (419)
21.8 (323)

Social
Anxiety
Panic
Disorder Disorder
% (n)
% (n)
13.1 (191) 8.0 (111)
12.2 (163) 7.8 (100)
13.4 (86)
7.4 (45)
12.3 (115) 8.7 (77)
13.3 (159) 8.3 (93)
13.6 (343) 8.4 (200)
19.0 (281) 10.1 (138)

Alcohol
Use
Disorder
% (n)
5.3 (77)
5.6 (74)
6.3 (40)
5.9 (55)
5.2 (61)
5.8 (145)
6.2 (91)

Positive Screen
for any mental
disorder % (n)
38.6 (540)
38.10 (488)
39.03 (242)
38.04 (337)
39.63 (451)
41.02 (987)
50.07 (698)

Training Categories are not mutually exclusive; CISM—Critical Incident Stress Management; CISD—Critical Incident
Stress Debriefing; R2MR—Road to Mental Readiness.

odds of screening positive for any specific disorder, but overall was associated with
significantly decreased odds of screening positive for “any mental health disorder”
(AOR = .80, 95% CI: 0.70–0.90).

Discussion
In the current study, we assessed PSP willingness to access support from professional
(i.e. physicians, psychologists, psychiatrists, employee assistance programs, chaplains)
and non-professional sources (i.e. spouse, friend, PSP colleagues, PSP leadership) based
on participating in different training program categories (i.e. CISM, CISD, mental
health first aid, peer support, R2MR). In examining associations between the different
training program categories and PSP screening positive for one or more mental health
disorders (i.e. PTSD, MDD, GAD, SAD, PD, AUD), we expected participation in
a training program would be associated with higher willingness to access support and
less likely to screen positive for mental health disorders, but we had no specific
expectations about differences between training programs. Training programs were
associated with more willingness to access support and decreased odds of screening
positive for most mental disorders. There were few differences between the program
training categories. None of the training programs were associated with lower levels of
PD or AUD.
The current results indicate that, even without any mental health training, most
participants believe they have access to professional mental health resources including
physicians, psychologists, psychiatrists, employee assistance programs, and chaplains.
Participants with training reported modestly higher levels of perceived access, indicating that any mental health training was associated with at least small increases in
perceived access to support. Accordingly, perceived access to support appears fairly
pervasive and stable. In contrast, participant willingness to access professional support
varied based on the type of professional. Participants with no mental health training
were most willing to access support from a physician as an early resource (47.53%), but
a similar proportion reported never being willing to access support from a physician, or
only as a last resort (46.65%). Participants without training reported their willingness to
access support from other professions as even lower than for physicians (10.38% to

Major Depressive
Disorder
0.69 (0.6, 0.8) ***
0.69 (0.6, 0.8) ***
0.81 (0.7, 0.99) *
0.70 (0.6, 0.8) ***
0.70 (0.6, 0.8) ***
0.83 (0.7, 1.0)
0.77 (0.6, 0.9) *
0.79 (0.6, 0.97) *
0.93 (0.7, 1.2)
0.75 (0.6, 0.9) ***
0.78 (0.6, 0.9) **
0.98 (0.8, 1.2)
0.75 (0.6, 0.9) ***
0.76 (0.6, 0.9) **
0.84 (0.7, 1.0)
0.69 (0.6, 0.8) ***
0.71 (0.6, 0.8) ***
–

PTSD (PCL-5)

0.78 (0.7, 0.9)***
0.79 (0.7, 0.9) **
0.96 (0.8, 1.2)

0.75 (0.6, 0.9) ***
0.76 (0.6, 0.9) **
0.86 (0.7, 1.1)

0.77 (0.6, 0.9) *
0.75 (0.6, 0.9) *
0.85 (0.7, 1.1)

0.74 (0.6, 0.9) ***
0.78 (0.6, 0.9) **
0.91 (0.7, 1.1)

0.88 (0.7, 1.0)
0.78 (0.7, 0.9) **
0.83 (0.7, 1.0)

0.71 (0.6, 0.8) ***
0.71 (0.6, 0.8) ***
–

0.71 (0.6, 0.8) ***
0.73 (0.6, 0.9) ***
–

0.80 (0.7, 0.96) *
0.78 (0.6, 0.95) *
0.85 (0.7, 1.0)

0.77 (0.6, 0.9) **
0.79 (0.6, 0.97) *
1.01 (0.8, 1.3)

0.67 (0.5, 0.8) ***
0.65 (0.5, 0.8) ***
0.74 (0.6, 0.97) *

0.69 (0.6, 0.8) ***
0.70 (0.6, 0.8) ***
0.83 (0.7, 1.1)

0.69 (0.6, 0.8) ***
0.71 (0.6, 0.8) ***
0.85 (0.7, 1.1)

Generalized Anxiety
Disorder

0.67 (0.6, 0.8) ***
0.71 (0.6, 0.9) ***
–

0.78 (0.6, 0.9) *
0.79 (0.6, 0.99) *
0.85 (0.7, 1.1)

0.71 (0.6, 0.9) **
0.73 (0.6, 0.9) **
0.86 (0.7, 1.1)

0.81 (0.6, 1.0)
0.84 (0.6, 1.1)
0.98 (0.7, 1.3)

0.66 (0.5, 0.8) ***
0.69 (0.6, 0.9) ***
0.77 (0.6, 0.99) *

0.73 (0.6, 0.9) ***
0.78 (0.6, 0.9) **
0.98 (0.8, 1.2)

Social Anxiety
Disorder

0.82 (0.7, 1.0)
0.84 (0.7, 1.1)
–

0.88 (0.7, 1.1)
0.91 (0.7, 1.2)
0.95 (0.7, 1.3)

0.96 (0.7, 1.2)
0.98 (0.7, 1.3)
1.15 (0.8, 1.6)

0.78 (0.6, 1.1)
0.77 (0.5, 1.0)
0.79 (0.6, 1.1)

0.80 (0.6, 1.0)
0.82 (0.6, 1.1)
0.83 (0.6, 1.1)

0.82 (0.6, 1.0)
0.87 (0.7, 1.1)
0.97 (0.7, 1.3)

Panic
Disorder

0.93 (0.7, 1.2)
0.87 (0.7, 1.2)
–

0.81 (0.6, 1.1)
0.88 (0.6, 1.2)
0.93 (0.7, 1.3)

1.0 (0.7, 1.4)
0.91 (0.7, 1.3)
1.04 (0.7, 1.5)

1.07 (0.8, 1.5)
1.02 (0.7, 1.5)
1.14 (0.8, 1.7)

0.90 (0.7, 1.2)
0.83 (0.6, 1.1)
0.92 (0.6, 1.3)

0.84 (0.6, 1.1)
0.78 (0.6, 1.0)
0.80 (0.6, 1.2)

Alcohol Use
Disorder

0.69 (0.6, 0.8) ***
0.72 (0.6, 0.8) ***
–

0.76 (0.7, 0.9) ***
0.73 (0.6, 0.9) ***
0.80 (0.7, 0.9) **

0.71 (0.6, 0.8) ***
0.74 (0.6 0.9) ***
0.91 (0.8, 1.1)

0.77 (0.6, 0.9) **
0.77 (0.6, 0.9) **
0.91 (0.7, 1.1)

0.68 (0.6, 0.8) ***
0.70 (0.6, 0.8) ***
0.82 (0.7, 0.99) *

0.69 (0.6, 0.8) ***
0.72 (0.6, 0.8) ***
0.88 (0.7, 1.1)

Positive Screen for any mental
disorder

Training Categories are not mutually exclusive; CISM—Critical Incident Stress Management; CISD—Critical Incident Stress Debriefing; R2MR—Road to Mental Readiness; OR—unadjusted
odds ratio; AOR1—adjusted odds ratio for sex, age, marital status, province of residence, ethnicity, education, years of service, and PSP category; AOR2—adjusted odds ratio for the same
variables as in AOR1 in addition to all other categories of mental health training, which cannot be computed for any mental health training; *p < .05, **p < .01, ***p < .001.

Training
Category
CISM % (n)
OR (95% CI)
AOR1 (95% CI)
AOR2 (95% CI)
CISD
OR (95% CI)
AOR1 (95% CI)
AOR2 (95% CI)
Mental Health First Aid
OR (95% CI)
AOR1 (95% CI)
AOR2 (95% CI)
Peer Support
OR (95% CI)
AOR1 (95% CI)
AOR2 (95% CI)
R2MR
OR (95% CI)
AOR1 (95% CI)
AOR2 (95% CI)
Any Training
OR (95% CI)
AOR1 (95% CI)
AOR2 (95% CI)

Table 4. Associations between screening positive for mental disorders among PSP who have had different mental health training categories.

COGNITIVE BEHAVIOUR THERAPY
11

12

R. N. CARLETON ET AL.

34.99%). Many participants without training reported they would never access such
support or only as a last resort (45.43% to 63.74%), with the largest proportion being
associated with Employee Assistance Programs (63.74%). Participants with mental
health training reported higher levels of willingness, with the largest difference being
a 9.75% higher willingness to access Employee Assistance Programs. The proportion of
participants who reported being willing to access each type of professional was comparable across the different training program categories, suggesting that the training
categories provide similar core content or at least yield comparable results. Consistent
with reports that PSP perceive substantial stigma in accessing support and therein
barriers to support (Oliphant, 2016; Ricciardelli, Carleton, Cramm, et al., in press,
Ricciardelli, Carleton, Mooney, et al., in press), the current results suggest that perceived access to support may be less important than willingness to access the support
that is available. Even with training, half of participants reported being extremely
unwilling to access professional support.
Most participants without mental health training also reported believing they have
access to non-professional mental health resources including a spouse, a friend,
a PSP colleague, or a PSP leader. Participants with training reported modestly higher
levels of perceived access, indicating any mental health training was associated with
at least small increases in perceived access to support. Accordingly, like perceived
access to professional mental health support, perceived access to non-professional
mental health support appears pervasive and stable, but participant willingness to
access non-professional support varied based on the type of non-professional.
Participants with no mental health training were most willing to access support
from a spouse (72.50%) or a friend (52.7%) as an early resource, with very few
reporting they would never or only as a last resort access a spouse (14.37%) or
a friend (39.59%). Participants without training reported being less willing to access
support from a PSP colleague (33.33%) or PSP leader (15.11%), with many reporting
never, or only as a last resort, being willing to access a PSP colleague (57.94%) or
PSP leader (68.35%). Participants with mental health training reported modestly
higher levels of willingness to access a PSP colleague or PSP leader. The proportion
of participants who reported being willing to access each type of non-professional
support was comparable across the different training program categories, suggesting
the training categories cover similar core content or at least yield comparable results.
Accordingly, the results remained consistent with reports that PSP perceive substantial stigma and are unwilling to access support from PSP colleagues and leaders, but
are willing to reach out to family and friends (Oliphant, 2016; Ricciardelli, Carleton,
Cramm, et al., in press, Ricciardelli, Carleton, Mooney, et al., in press).
The current results indicated that any mental health training was associated with
lower proportions of PSP screening positive for any mental health disorder (41.02%
relative to 50.07%). The largest difference in screening proportions was for MDD (7.3%)
and the smallest was for AUD (0.4%). The differences between training categories for
screening positive on any mental health disorder was minimal, suggesting again that the
training categories cover similar core content or at least yield comparable results.
Indeed, most categories of mental health training were associated with significantly
decreased odds in screening positive for PTSD, MDD, GAD, and SAD (OR range:
0.66–0.80), results that were largely maintained after adjusting for sociodemographic

COGNITIVE BEHAVIOUR THERAPY

13

variables; however, no specific mental health training category was significantly related
to changes in PD or AUD. The apparent ineffectiveness for PD and AUD suggests
something may be unique about either or both of these disorder categories. After
adjusting for other mental health training categories, very few significant results
remained, suggesting again that the different training categories yield comparable
results. Indeed, consistent with prior conclusions (Authors, 2016), the current results
do not suggest any one specific category of training is superior to any other category,
but the results do suggest any mental health training may be beneficial for improving
mental health; as such, right now, decision-making regarding program selection may be
able to justify taking economic concerns into consideration.
Strengths and limitations
The current results represent the first large-scale comparative assessment of mental
health training categories that includes several screening assessments for mental health
disorders. The novel assessment evaluated perceptions of access to resources, both
professional and non-professional, willingness to access those resources, association
with mental health, and comparisons across mental health training categories. The
results are based on a very large and diverse sample of PSP. Despite many strengths,
there are also several limitations to the current study that offer important directions for
future research. First, the sample was self-selected and, although demographically
representative of PSP in Canada (Carleton, Afifi, Turner, Taillieu, Duranceau, et al.,
2018, Carleton, Afifi, Turner, Taillieu, LeBouthillier, et al., 2018a), may not be entirely
representative. Second, participant responses were based on anonymous online selfreport, making the reliability and validity ambiguous (Bethlehem, 2010), even though
a recent meta-analysis suggested comparable rates of identified mental disorders across
self-report and interview assessments (Berger et al., 2012). A fully representative sample
based on interview data would be beneficial, but extremely resource intensive and
differentially impacted by stigma. Third, the current data are cross-sectional, therein
precluding discussions of causation regarding the impact of any mental health category
on perceptions of access to support, willingness to access support, or mental health.
Participants who receive such training may be working in more supportive or more
psychologically safe environments, which may influence the current results. Future
research in line with the recent R2MR longitudinal study (Carleton, Korol, et al., in
press) is required. Fourth, the data collection used broad categories for each of the
training options, which means there may be important differences between training
models that were overlooked. For example, there may be important differences in CISM
models and delivery (Authors, 2016), or between the R2MR as delivered to PSP by the
MHCC, and the original or recently updated R2MR as delivered to PSP by the
Department of National Defense (Carleton, Korol, et al., in press; National Defence
and the Canadian Armed Forces, 2017). The overall comparability of results across
diverse training categories suggests against massive differences, but without research
assessing the shared and unique content across the growing number of training
programs and direct comparisons remain impossible. Fifth, the items assessing prevalence of mental health training and attitudes toward accessing mental health support
were created specifically for the current study. The items were translated by a highly

14

R. N. CARLETON ET AL.

experienced professional English–French translator who worked closely with the
research team. There was no reason to believe language influenced the responses, and
comprehensive psychometric analyses are beyond the current project scope; nevertheless, future researchers could assess for such nuances among the psychometric
properties of the items. Sixth, the small numbers of participants who endorsed some
of the options for willingness to access mental health supports caused us to collapse
categories we believed were effectively comparable to support a robust solution. There
may yet be potentially meaningful nuanced distinctions between the categories, but
such psychometric details are beyond the current project scope and could be explored
by future researchers. Seventh, while the current results suggest that PSP perceptions of
professionals and non-professionals may affect willingness to access as a mental health
resource, the current results did not assess the specific rationale for willingness to access
a type of professional or non-professional, which makes specific recommendations for
change speculative. For example, insufficient mental health literacy, perceptions of
stigma, and concerns about negative consequences may all be important factors underlying PSP unwillingness to seek mental health care. Future researchers should explore
the rationale and therein inform how targeted improvements might be made to substantially improve PSP mental health.
Summary
Overall, the current results indicate that, irrespective of mental health training, PSP
perceive substantial access to professional and non-professional options for mental
health support, but their willingness to access that support varies substantially. The
results suggest that PSP in need of mental health support are much more likely to reach
out to spouses or friends than to any other resource. Participants in need of mental
health support appear most unwilling to access Employee Assistance Programs and PSP
leaders. The presence of training appears associated with very small changes in perceptions of access and relatively small changes in willingness to access support; however,
the presence of any mental health training appears associated with significantly lower
proportions of PSP screening positive for some (i.e. PTSD, MDD, GAD, SAD), but not
all (i.e. PD, AUD), mental health disorders. Given the apparent comparability of impact
from the current training categories, selecting or developing highly accessible, efficient,
and economical delivery modalities might be important while PSP await more nuanced
research support for mental health training.
The results indicate there may be areas for improvement associated with the current
employee assistance programs to address the reasons PSP appear unwilling to access
such resources, or only as a last resort; however, such changes would require additional
research to understand the rationale PSP have for concern regarding employee assistance programs. Apparent reluctance to access PSP leaders suggests there may also be
important opportunities to provide PSP leaders with new skills for reducing stigma and
better supporting PSP mental health. Given PSP reports of selecting spouses as a first
choice for mental health support, there may particularly significant benefits in providing mental health training for PSP spouses, such as evidence-based psychoeducation
regarding symptoms, self-care, coping skills, and resources for escalating access to
professional mental health support.

COGNITIVE BEHAVIOUR THERAPY

15

Acknowledgments
Special thanks for recruitment support provided by (alphabetically): Badge of Life Canada,
Behind the Red Serge, Canadian Association for Police Governance (CAPG), Canadian
Association of Chiefs of Police (CACP), Canadian Association of Fire Chiefs (CAFC),
Canadian Institute for Military and Veteran Health Research (CIMVHR), Canadian Ministry
of Public Safety and Emergency Preparedness, Canadian Police Association (CPA), Community
Safety Knowledge Alliance, Correctional Service of Canada (CSC), Families of the RCMP for
PTSD Awareness, First Responder Mental Health Network Collaboration, International
Association of Firefighters (IAFF), Justice Institute of British Columbia, Mood Disorders
Society of Canada, Nova Scotia Operational Stress Injury Clinic - Capital Health, Paramedic
Association of Canada (PAC), Paramedic Chiefs of Canada (PCC), Royal Canadian Mounted
Police (RCMP), Tema Conter Trust, Union of Safety and Justice Employees (USJE), Union of
Canadian Correctional Officers Syndicat des Agents Correctionnels du Canada Confédération
des Syndicats Nationaux, and Wounded Warriors Canada.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
R. Nicholas Carleton’s research is supported by the Canadian Institutes of Health Research
(CIHR) through a New Investigator Award [FRN: 322308] and research grants [FRN: 285489
and FRN: 411397]. T.O. Afifi’s research is supported by a CIHR New Investigator Award and
Foundation Scheme Award. This research was also funded in part by the Ministry of Public
Safety and Emergency Preparedness through the Policy Development Contribution Program.

ORCID
R. Nicholas Carleton
http://orcid.org/0000-0002-6083-8935
http://orcid.org/0000-0002-5099-9815
Tracie O. Afifi
http://orcid.org/0000-0003-2541-6072
Sarah Turner
http://orcid.org/0000-0001-5856-8131
Tamara Taillieu
http://orcid.org/0000-0002-2670-8635
Adam D. Vaughan
http://orcid.org/0000-0002-1307-1719
Gregory S. Anderson
http://orcid.org/0000-0002-0905-8968
Rosemary Ricciardelli
http://orcid.org/0000-0001-8791-6270
Renée S. MacPhee
http://orcid.org/0000-0002-8805-063X
Heidi A. Cramm
http://orcid.org/0000-0002-9192-4107
Stephen Czarnuch
http://orcid.org/0000-0003-0458-4616
Kadie Hozempa
http://orcid.org/0000-0003-2485-0571
Ronald D. Camp

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