The mental health of police personnel: what we know & what we need to know and do (CACP-MHCC Conference 13–15 February 2017)

Record of Proceedings

The mental health of police personnel: what we know & what we need to know and do (CACP-MHCC Conference 13–15 February 2017)

Astrid Ahlgren*

ABSTRACT

The issue of mental health and wellness has gained greater attention in society as a whole in the past decade. The Canadian Association of Chiefs of Police (CACP) has had this topic on its radar for even longer, and continued this sustained emphasis at the 13–15 February 2017 conference entitled “The Mental Health of Police Personnel: What We Know & What We Need to Know and Do”. The dynamic and fast-paced conference was organized by the CACP and moderated by Norman E. Taylor. It brought together 222 delegates and speakers representing the broad sectors of policing, mental health and research, with equal numbers of men and women, at the Hilton Lac-Leamy in Gatineau, Quebec. Collaborating in this initiative were the Mental Health Commission of Canada (MHCC), Canadian Police Association (CPA), the Canadian Association of Police Governance (CAPG), the CACP Research Foundation (CACP-RF), the Canadian Institute for Public Safety Research and Treatment (CIPSRT), and Public Safety Canada (PSC). This paper provides a comprehensive report on the proceedings as submitted, and has been approved for publication in this Journal by the board of directors of the CACP.

Some speakers provided the CACP with permission to post the visual aids they used for their presentations. These are available on the CACP website at https://www.dropbox.com/sh/pfjkme79redafon/AADGWJPod7K2jOJzlmwnFIsEa?dl=0

Key Words: Police mental health, conference, police chiefs

THE BACKSTORY

As early as 2002 the Canadian Association of Chiefs of Police (CACP) held the first of five annual conferences on Police/Mental Health Systems Liaison, entitled “Psychiatrists in Blue” (Montreal 2002, Saskatoon 2003, Hamilton 2004, Vancouver 2005, and Ottawa 2006). Each year representatives of both sectors convened to promote liaison at policy and operational levels, and to discuss specific dimensions of mental health and policing. In 2006 the CACP Annual Conference, held in St. John’s, was on the theme “To Your Health”, with a focus on the health of police chiefs and senior executives and the impact of good health on leadership in the profession.

By 2012, the CACP had established itself as a leader in increasing police awareness of mental health issues at the community level. The Association, through conference sessions and learning events, profiled effective practices that include joint police and mental health worker units established to respond to incidents within the community. Focus widened to include the police profession itself, with recognition that the risk of post-traumatic stress injuries among police requires psychological resiliency, the need for training managers in dealing with this issue among employees, police agency policy to manage stress-related leave and re-entry into the workforce, and the legal implications of police agency duty to accommodate.

CACP members Dr. Dorothy Cotton and Dr. Terry Coleman, M.O.M. (Chief, Ret.) have represented the policing community in a continuing relationship with the Mental Health Commission of Canada (MHCC) throughout this time, serving as a link between the two organizations. In March 2014 the CACP and MHCC held a national conference in Toronto entitled “Balancing Individual Safety, Community Safety and Life Quality: a Conference to Improve Interaction for Persons with Mental Illness”. One tangible result of this collaboration was the MHCC’s development of an e-learning module called Mental Health First Aid that is available to all police in the country through the Canadian Police Knowledge Network.

In the context of national discussions about the costs of policing in 2014–2015, analysis of public calls for police service revealed the significant percentage of police time spent responding to the 20% to 40% of incidents in which mental health was a factor. Mental health issues in the community remain a major driver in police workload and cost, with police time spent not only in responding to incidents, but also in apprehending individuals under mental health legislation and waiting for apprehended individuals to be admitted to medical facilities.

The policy agenda of the CACP includes mental health as a strategic priority. The CACP has continued its partnership with the MHCC, with the objective of increasing police awareness and competencies in both professional interactions in the community and the police agency workplace environment. A subsequent joint event held in February 2015 in Mississauga, Ontario, “The Conference on Mental Readiness: Strategies for Psychological Health and Safety in Police Organizations” reflected this shift in emphasis from police interactions with the public to police mental health in the workplace.

THE 2017 CONFERENCE OBJECTIVE, GOALS AND STRUCTURE

The overall objective of the February 2017 conference was to focus on strategies that could be put into action—beginning now.

A number of pre-set questions set out the goals that guided participants, while giving ample space for discussion and suggestions of additional angles, challenges, and real-life practices and experiences. The stated goals were as follows:

  1. Examine the current state of research and available evidence in support of proven strategies, practices and policy frameworks that can assist police organizations to prevent, respond, treat, and support the accommodation of recovery needs of police personnel across a full range of mental health issues.

  2. Examine a range of promising and/or proven practices in Canada and elsewhere, across the continuum of care, with a view to making such practices more available to all police organizations, and to identify additional requirements for evaluation and reliable outcomes measurement.

  3. Consider the potential risks and mental health implications of major incidents and mass casualty events, building on experiences elsewhere, with a view to advancing Canada’s general readiness in this regard.

  4. Identify, examine and/or develop informed strategies and related policy and practice solutions for addressing the human resource management and operational and business challenges associated with mental health issues in the policing workplace.

  5. Develop and consolidate collaborative strategies among the conference partners and participating delegates to communicate and carry forward priority actions determined through three concurrent tracks of in-depth study and discussion.

The structure of the conference was designed to achieve this objective by identifying three strong and intersecting tracks: research and evidence, continuum of care, and human resources and police operations. A clear link was formed from the theoretical to the practical and operational, which reinforced the need to implement evidence-based approaches and responses. The three tracks were dissected, analyzed and elaborated within sessions as follows:

  • ■ Session 1: What we know and what we are learning about mental health of police personnel

  • ■ Session 2: Promising practices along the mental health of police personnel continuum of care, with a feature segment on understanding and preparing for the impacts for first responders from mass victimization incidents

  • ■ Session 3: Operational and human resource management strategies in response to mental health of police personnel

  • ■ Session 4: What do we need to know and do?

  • ■ Session 5: Concurrent track discussions

  • ■ Session 6: Plenary discussion: highlights of track deliberations

  • ■ Session 7: Consolidation panel and collective forward action

SESSION SUMMARIES

Introductory Session: Taking Action on Mental Health…Together

Presenters opened with their individual perspectives on the objective of the conference. Directeur Mario Harel, O.O.M., President of the CACP spoke to the priority the Association places on this issue. The strong desire of CACP members to propel the current partnership work forward was the impetus behind this conference. The intention is that the collective work done here will reap constructive results. Louise Bradley, President of the MHCC, underlined the significance of police addressing this issue, as it sets an example for workers right across the country and places mental health awareness on the same footing as protective gear for physical health and safety. She reminded delegates that mental health resources should be available for all who require them, including those working in remote, rural, and indigenous communities.

Maureen Shaw, Chair of the Human Resources Committee of the Victoria and Esquimalt Police Board, called for a culture that recognizes psychological, as well as physical, health and safety. She outlined the elements of the 2013 National Standard of Canada for Psychological Health and Safety in the Workplace, a voluntary standard issued by the Canadian Standards Association, which she encouraged police agencies to use as a resource for creating safe workplaces.

Session 1: What We Know and What We Are Learning About Mental Health of Police Personnel

The first session consisted of three sections, moderated by Dr. R. Nicholas Carleton, University of Regina, CIPSRT, who also presented with Steve Palmer of CIPSRT in the section 1A entitled “The State of the Nation on Mental Health Research for First Responders”. They presented the recent history of research, dating from 2015, noting important milestones before moving to work being done now by CIPSRT. This body has begun its research work and is moving towards establishing single portal access to research results. They laid out the short-, medium-, and long-term agenda for CIPSRT. They issued cautions about the appropriate use of research tools by qualified, licensed professionals, and urged police agencies to resist adopting programs that promote cures for PTSI without an evidentiary basis.

In section 1B, “The Vital Importance of Evidence for Our Members’ Health and Safety”, Tom Stamatakis, M.O.M., President of the Canadian Police Association (CPA), took a more sober tone as he summarized the results of an online survey of 1,200 respondents from two Canadian urban police agencies. In his assessment, very little has changed since 2015, with police officers experiencing high levels of depression and burnout caused more by internal police agency structures and policies than by the day-to-day work in the community, which most find rewarding and validating. He cited examples of police agency practices that contribute to stigmatizing and ostracizing officers who have experienced a PTSI after an incident or mistake, and posed the question: “What is discipline? Is it correction, or is it punishment?” His challenge to police agencies was to create a recruitment and working culture suitable for this century, by valuing the individuals who choose to take on a career in public safety.

Stéphanie Durant, A/Assistant Deputy Minister, Emergency Management and Programs Branch, PSC, spoke in section 1C, “Mental Health Research for First Responders—Government of Canada Action Plan on Post-Traumatic Stress Injuries”. She reminded participants of the mandate letter from the Prime Minister to the Minister of Public Safety, requiring collaboration with the provinces, territories, and Minister of Health “to develop a coordinated national action plan on post-traumatic stress disorder, which disproportionately affects public safety officers”. It is noted that “public safety officers” is a category that encompasses police and other first responders. She also noted that Budget 2016 committed funds for treatment. She referenced the October 2016 report of the House of Commons Standing Committee on Public Safety and National Security entitled “Healthy Minds, Safe Communities: Supporting Our Public Safety Officers Through a National Strategy for Operational Stress Injuries”. It was issued following the Committee’s study of Operational Stress Injuries (OSIs) and Post-Traumatic Stress Disorder (PTSD) in public safety officers and first responders. The report’s 16 recommendations are guiding the federal response, which includes an Action Plan of three components: research and data collection; prevention, intervention and reduction of stigma; and support for care and treatment.

Session 2: Promising Practices Along the Mental Health of Police Personnel Continuum of Care, with a Feature Segment on Understanding and Preparing for the Impacts for First Responders from Mass Victimization Incidents

This session, also in three main sections, was moderated by Dr. Dorothy Cotton and Dr. Terry Coleman, M.O.M., both Advisors to the MHCC. It was designed to establish a common understanding of the continuum of care as related to the mental health of police personnel. Drawing from a variety of examples, the speakers noted the effects and outcomes of those varied approaches. There was specific reference to the differing needs and limitations within urban, rural, and remote policing environments. The session ended with a short presentation on the use of cannabis in the treatment of PTSI, and a special section on what has been learned in the aftermath of the September 11, 2001 terrorist attacks in the United States.

Session 2A, “Addressing the Full Continuum of Care: Prevention, Treatment and Support, Recovery”, was presented by Dr. Coleman. In his address, entitled “Strategic Approaches to Psychosocial Factors/Organizational Stressors”, he provided a list of stressors contributing to police officers’ mental health issues, drawn from extensive research that he cited throughout the presentation. He promoted the adoption of the voluntary National Standard of Canada for Psychological Health and Safety in the Workplace, which remains largely unknown by police agencies despite its usefulness. He singled out, as a major and common stressor, the tendency of police leaders to upset organizational stability for no obvious reason other than to place a personal stamp on it. Furthermore, there is often a practice of placing police officers in specialized human resources jobs rather than hiring human resource professionals who can more effectively be the agents of change in an organization.

In Session 2B, Sergeant Stephen Bishopp, Associate Director for Research, Caruth Police Institute, Dallas, Texas, spoke on “Negative Affective Responses to Stress Among Urban Police Officers: a General Strain Theory Approach”. Sergeant Bishopp defined the terminology used in his title and drew upon his PhD work, in which he had examined three large police agencies in that state. He distinguished between environmental and organizational stress, noting that the latter is more insidious in leading to the negative affective responses of anger, depression, and burnout. He explained general strain theory, developed by American criminologist Robert Agnew building on the earlier work of sociologist Robert K. Merton, and applied it to the policing environment. Here, he stated, stressful circumstances lead to negative feelings, which in turn lead to behaviours that are associated with alleviating pressure (notably substance abuse and problematic relationships). He suggested that general strain theory can be helpful to explain occupation-related outcomes in the policing environment.

Session 2C consisted of three presentations in the “Continuum of Care Showcase of Promising Practices”. In the first two, Corporal Steve Oster, National Use of Force, Royal Canadian Mounted Police (RCMP) and Sergeants Glen Klose and Colleen Mooney, Member Re-Integration, Edmonton Police Service (EPS), presented on their respective programs. Corporal Oster discussed the RCMP adoption of a sport psychology approach to preparing officers pre-incident, so that they learn coping mechanisms that reduce anxiety, result in less trauma, and facilitate a timely return to work. He pointed to the need for supervisor training in how to handle officers post-incident, and identified the organization’s post-incident treatment of officers as a main stressor. The EPS Critical Incident Training and Re-integration Program has been credited with saving lives by facilitating the safe and gradual re-entry of officers after traumatic incidents. It began in 2009 as a post-shooting, short-term program, but by 2013 had become a long-term program that by now has worked with 24 officers with PTSI. The program is overseen by a psychologist, with information-sharing among the treatment team voluntarily authorized by the police officers. It has resulted in an impressive 50% reduction in the number of officers who do not want to return to work following a traumatic incident.

The third presentation in this session was by Marisa Cornacchia, Vice-President Operations, Aleafia Total Health Network. This is an Ontario-based company that offers services to high-risk employment populations. Raf Souccar, formerly of the RCMP and a member of the federal Task Force on Cannabis Legalization and Regulations, prefaced his introduction of the speaker with a reality check for police—that legalization is coming and police must be prepared for it. Ms. Cornacchia spoke on “Emerging Trends on the Mental Health of Police Personnel Continuum of Care” by explaining briefly the effects of cannabis on the brain, and focusing on the different effects of THC, the psychoactive element of cannabis, and CBD, which is non-psychoactive. The use of cannabis for health purposes is now well entrenched, and knowledge of its impact is becoming more and more refined.

The feature segment of this section of the agenda was by Mary Fetchet, a clinical social worker and Founding Director of VOICES, an organization she co-founded in 2001 following the death of her 24-year-old son Brad in the World Trade Center attacks. She identified the wide range of victims, from professional first responders to civilian volunteers to community members, who continue to deal with the devastating physical and mental health after effects of 9/11. She now works in assisting communities impacted by other tragedies by sharing lessons learned through VOICES’ 12 years of experience. Her powerful and poignant presentation came to an end with the following statement: “In life we are given stones, with which we can build walls or bridges”…

Session 3: Operational and Human Resource Management Strategies in Response to Mental Health of Police Personnel

This session was moderated by Steve Schnitzer and Deputy Chief Mark Chatterbok, M.O.M., Co-chairs of the CACP Human Resources and Learning Committee. In three sections, the session highlighted a number of critical questions and challenges that remain in the policing world, in both human resources and operational areas.

Session 3A, “Case Studies in Implementing Sustainable Workplace Mental Health Strategies”, featured a presentation by Robert St. Germain, Public Safety Group, Bell Canada, on “Workplace Mental Health Services for Bell Canada Employees”. Bell Canada, sponsor of the Let’s Talk public service campaign, has implemented a number of measures and events throughout the year, following five steps to building a psychologically health workplace. The company’s workplace program, which has been certified by Queen’s University, has resulted in a 20% reduction in the cases of disability among employees. The presentation was followed by an invitation for conference delegates to offer their own case study examples.

Session 3B, “The Human Resource Management and Legal Considerations in the Mental Health of Police Personnel”, consisted of a presentation by Dr. Martin Shain, SJD, University of Toronto, entitled “Occupational Stress Injuries, Mental Injuries and the Psychologically Safe Workplace in the Era of Canada’s National Standard”. Dr. Shain, educated in both law and social science, clarified that occupational stress injuries occur from incidents outside the organization in the operational setting, whereas mental injuries occur within the organizational environment. He set out 10 factors that can foreseeably lead to a mental injury, which, he stressed, has a lower legal threshold than the psychiatric threshold for mental illness. He spoke of the recent decisions by courts and tribunals in penalizing employers for environments that are unsafe psychologically, and noted the risk of legal liability and potential class actions that may result from employer inattention to this issue. The challenge, he stated, is to respect the principles of the National Standard of Canada for Psychological Health and Safety in the Workplace and to adopt those standards within organizations.

Session 3C, “The Challenges and Opportunities for Managing Mental Health Issues in Policing Operations”, was an invigorating presentation by Ontario Provincial Police (OPP) Commissioner J.V.N. (Vince) Hawkes, C.O.M. The Commissioner spoke about “The Ontario Provincial Police Experience to Date with a Comprehensive Mental Health Strategy”. This came about as a result of the Ontario Ombudsman’s review of the OPP following comments by retired OPP officers and a number of police suicides. At a cost of roughly $4 to $5 million, the OPP developed a program called “Thrive”, which consists of education and training; measures to reduce stigma; expanded programs to support employees; better and regular internal communication; partnerships within and outside the organization; connections to members, retirees and their families; and a continuing program evaluation component. From a workforce strength of 9,000 employees, some 6,200 have participated in the voluntary wellness check managed by a third party. Commissioner Hawkes challenged the police community to put in place a system for accommodation of mental injury, as it has for physical injury. He stressed that the push for change must come from the people who do the work every day, because they are most in touch with the policing reality and most affected by organizational policies.

Session 4: What Do We Need To Know and Do?

This session brought together selected panelists to assemble the themes discussed so far, and to identify and refine the questions that guided those discussions. The aim was to establish the framework for the concurrent sessions to follow, and the ultimate consolidation of priorities for action. Moderator Norman E. Taylor, Maureen Shaw, Commissioner Vince Hawkes, Deputy Chief Mark Chatterbok, Steve Palmer, Sergeant Colleen Mooney, and Sergeant Glen Klose formed the panel, with delegates offering their own ideas from the floor.

Participants listed the most significant facts and perspectives they had learned in the sessions thus far, many of which fell into the “need to do” category:

  • ■ recognizing the 10 factors that can cause stress,

  • ■ the need to overcome management reluctance to bring people back to work following a PTSI absence,

  • ■ the risks of defence counsel raising an officer’s health background in courtroom proceedings to discredit testimony,

  • ■ the need for individualized treatment and a carefully phased and monitored re-entry,

  • ■ the wisdom of establishing a budgetary contingency for officers when they are out of the workforce and during their re-entry,

  • ■ the need for better education of civilian oversight bodies so that mental health is considered on the same footing as physical health,

  • ■ the necessity of keeping this issue on the front burner within police agencies and governments,

  • ■ the need for mental health and wellness strategies both broadly focused and specific to each police agency, and

  • ■ the need to bring the research world to the forefront of this issue so that findings can lead to more timely collaboration and application of evidence.

Session 5: Concurrent Track Discussions

For this session, delegates pre-selected which topic interested them the most and divided into three groups for more incisive discussions on each of the three tracks: 1) research and evidence, moderated by Dr. R. Nicholas Carleton and Steve Palmer; 2) continuum of care, moderated by Dr. Terry Coleman and Dr. Dorothy Cotton; and 3) human resources and police operations, moderated by Steve Schnitzer and Deputy Chief Mark Chatterbok. Guiding questions had been posed in advance for each track, to stimulate discussion and frame the outcomes.

Session 6: Plenary Discussion: Highlights of Track Deliberations

One moderator from each track presented on the deliberations that had taken place.

Steve Palmer summarized the discussions from the Research and Evidence track, noting the need for a common vocabulary to facilitate information sharing; a desire to close the knowledge gap between research and operations; and the need for a stronger and more effective connection among research, operations, and the command structure, since research in this area is intended to meet operational needs.

Dr. Dorothy Cotton set out the main discussion points from the Continuum of Care track: the need for a common source of information and knowledge, which is currently quite dispersed and therefore under-used; evaluations of programs so that those that do not work, such as some peer support programs, are not adopted by police agencies whose budgets are already tight; and the need to unify efforts so that waste of financial and human resources can be avoided.

Steve Schnitzer rounded out the plenary by reporting on highlights from the Human Resources and Police Operations track discussions. He urged a national focus and national coordination—and ideally a national strategy—that would include a robust national portal where information and knowledge would be readily and easily accessible. He cited the CIPSRT portal as such an entity. With respect to a national strategy, and with no expectation that the federal government would take on the role of developing and sustaining it, he pointed to the need for federal funding to allow its development under the leadership of the CACP and its partners. He proposed annual conferences as an effective means of strengthening coordination and information sharing, and urged the CACP to retain mental health as a strategic priority.

Following these presentations, conference moderator Norman E. Taylor posed questions to the delegates, who supplemented the presentations with their own perspectives and ideas generated from the wider discussion. There was extensive discussion on the current situation of information portals and websites, because many exist and yet remain unknown to the broader audience that might benefit from their content (for example, CIPSRT, MHCC, the Canadian Best Practices Portal, the Canadian Association of Evidence-Based Policing). There is information overload and no mechanism to sift wheat from chaff. A single information portal would facilitate coordination, encourage adherence to set standards, and alleviate the fatigue experienced by those who are asked to implement new initiatives that are not based on evidence.

This led to discussion on the need for postings that have been vetted, so that viewers can distinguish between peer-reviewed research and anecdotal reports on practices that have not been subject to evaluation. The latter might have some value either because they are promising or because they are identified as ineffective. A strategic business planning process, that would include a generic template linked to the National Standard of Canada for Psychological Health and Safety in the Workplace, would integrate mental health and wellness into the operational objectives of a police agency. Measures of success would support an evaluative approach, allowing agencies to refine and improve their existing programs, or desist in offering those not proven to be effective.

OUTCOMES

In summary, the following were presented as “outcomes” to be attained.

  1. Programs, research and implementation all need active senior executive support from governments, oversight bodies, chiefs of police, and police associations; furthermore, all of these elements ought to integrate members, professional leaders, peer supports, and mental health service providers.

  2. Business plans should include strategies for mental health investments, as a tangible expression of a policing culture that supports the wellbeing of personnel, and identifies budgetary expenditure in the short and longer term to address not only current mental health crises but ongoing mental health wellness.

  3. The issue of stigma, including self-stigma, needs to be addressed through a culture change that recognizes the diversity of stressors and their potential effects on individuals who are foremost “people” before they collectively are “personnel”.

  4. Mental health service providers require more education and experience specific to policing, so that they can understand the distinct impacts of stressors on police and thereby enhance confidence and trust among stake-holders and the community.

The discussion led to the potential role of the CACP as the body identified by consensus as an appropriate leader of some of the work ahead. The CACP Human Resources and Learning Committee has led this work to date, but its relatively small membership of senior police officials and resource people cannot sustain work on this single issue. Therefore, a proposal could be taken to the CACP Board of Directors to form a sub-committee of psychologists and peer-support groups who work with police.

Consolidation Panel and Collective Forward Action

In this last session, panelists Directeur Mario Harel, Tom Stamatakis, Dr. Nick Carleton, and Carolanne Inglis-McQuay reacted to the challenges posed to this point: to propose potential solutions, identify what needs to be done, offer mechanisms for taking the issue forward, and shoulder responsibility for certain actions. Mario Harel stated succinctly that there has been enough talk and committed the CACP to specific leadership actions. In so doing, he pointed out that leadership is not ownership. Therefore, while the CACP will assume responsibility to lead, the onus is on partners and stakeholders to own the content and momentum of next steps.

The key players agreed on what needs to be done:

  • ■ adapting and building models for police agency responses to address mental health issues, tailored and scaled to the needs and capacities of the agency;

  • ■ examining examples of proven and promising practices;

  • ■ promoting and disseminating research;

  • ■ integrating academics’ findings, front-line officers’ knowledge and expertise, as well as community resources, into policy and operations;

  • ■ continuing collaboration with the MHCC;

  • ■ making incremental and immediate changes to policy and practice in order to realize results in the short and longer term;

  • ■ tackling a clearly-stated set of objectives with a systematic, coordinated, and collective approach in order to limit splintering and loss of focus;

  • ■ monitoring the methods employed to achieve these objectives; and

  • ■ evaluating the outcomes.

In concluding, CACP President Mario Harel made the following specific commitments:

  1. To request that the CACP Human Resources and Learning Committee continue leadership on the issue of mental health of police personnel on behalf of the CACP, its partners, and stakeholders. When: in March 2017.

  2. To take to the CACP Board of Directors a proposal from the Human Resources and Learning Committee that a sub-committee be formed to formally integrate the input of psychologists. When: in March 2017.

  3. To initiate discussions with police and first-responder partners for the purpose of establishing short-term objectives, leading to a concrete action plan and identification of deliverables feasible within the next six months. When: in March 2017.

The conference adjourned on 15 February, with participants expressing great satisfaction with the proceedings and optimism in carrying the work forward.

CONFLICT OF INTEREST DISCLOSURES

The author declares there are no conflicts of interest.

AUTHOR AFFILIATIONS

*[on behalf of] Canadian Association of Chiefs of Police, Kanata, ON, Canada.


Correspondence to: Astrid Ahlgren, 608–1000 Wellington St. West, Ottawa, ON K1Y 2X9. E-mail: ahlgren.astrid@gmail.com

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Journal of CSWB, Vol. 2, No. 2, June 2017

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.