First Responder Mental Health: A Clinician’s Guide
As a volume weighing in at 911 pages, First Responder Mental Health: A Clinician’s Guide isn’t a small book. It’s a collection of 28 chapters written by a variety of authors, each with their own perspective on various aspects of first responder mental health. From the outside in, all first responders are the same. However, as the chapters explain, there are differences in cultures and receptivity to mental health within the different groups. One of the valuable aspects of the book is the broadness it brings to first responders by including crime scene investigators and emergency communications operators (911 operators). These important roles are first responders, too – even if they’re not always perceived that way.
On the Outside
One of the persistent problems I face when speaking with first responders is overcoming the sense that I’m somehow an outsider. For many kinds of first responders, there’s a belief that if you’ve never done the “job,” then you have no way of understanding what it’s like. There is a kernel of truth to this. I can’t fully understand what it’s like, because I’ve not lived it. However, this isn’t a world of absolutes.
It’s not that I understand nothing about the jobs – it’s that I don’t understand everything. The truth is that a fellow law enforcement officer from Billings, Montana, will have little in common with the New York City Police department detective. Some basics are the same, but fundamentally, the job is different.
One of the objections is how can someone who has never done it understand what it’s like. You can’t put that into a book. (I read a lot of books and make no secret about that fact.) The answer is, of course, that books don’t help you to understand. Instead, they prepare you for the real learning that you get in conversations and ride alongs.
I have no illusions that I understand completely. I know that I learn from nearly every interaction. I know that I respect my lack of understanding and want to understand as much as possible. For me, it’s personal. Most of my children could be considered a first responder of one kind or another, and I don’t want their service to be the cause of their suffering.
I’m not advocating that everyone should immediately be accepted into the “in” group and trusted. Instead, I’m highlighting that the degree to which there is a sense that others can’t understand anything about the job is exaggerated, and it’s harmful. It prevents first responders from trusting mental health professionals who may be able to help them.
Stuck to CISM
There are several references to CISM integrated into the volume. It’s no surprise given the prevalence in first responder organizations. However, it doesn’t change the challenges of the approach. Rather than address these concerns again here, I’ll refer readers to Critical Incident Stress Management and Opening Up.
Fit for Duty
One of the barriers to receiving professional mental health care is the concern about the implications – either formally or informally – in terms of fitness for duty. While not every first responder is required to submit to evaluation for their psychological fitness, it’s required in most law enforcement contexts.
In my conversations with active military personnel, the SF-86 form is scary. It’s the form for national security clearance. Most roles inside the military require clearance so failing to receive the clearance is a big problem. They’ve said that even though the form complies with the provisions of the Americans with Disabilities Act (and revisions) by only asking about mental healthcare that may impact performance, many members of the military are concerned that any kind of mental health treatment may be considered a disqualifying condition. In the healthcare context, it’s the chief goal of the Dr. Lorna Breen Heroes Foundation – to ensure every healthcare worker feels comfortable getting help for their mental health concerns.
Whether there’s risk for being evaluated unfit for duty or not, the fear of being declared unfit makes mental health professionals sufficiently unsafe that many first responders won’t seek help. This is true even if the things that they experience are beyond what any human should be able to adapt to.
The larger problem with all assessments is that there’s a falsehood inherent to them. They’re there to predict future behaviors – particularly, unhelpful or harmful behaviors. However, we’re pretty lousy at doing that. In the suicide space, the best clinicians are slightly better than random chance at predicting short term suicide. (Short term being defined generally defined as six months.)
In fitness for duty, the goal is to look out years into the future to see if the professional might do something bad. Of course, there’s no data that supports efficacy at this, but we do it anyway. Too many people have bought into The Cult of Personality Testing, and that includes the standards bodies and judges that make determinations for agencies being negligent in their hiring practices.
Peer Perception
Sometimes, the problem isn’t the management concern of fitness for duty. Sometimes, it’s the way that other members of your shift, house, or crew will see you. The culture of some organizations is such that weakness results in teasing or worse. The brave people who seek out mental health support are “rewarded” by a loss of trust. Instead of reaching out for help being seen as a sign of strength, the perception of weakness follows them.
Until the culture changes so that discussing hard feelings – with the crew or with a professional – can be seen as a source of strength, it will remain hard for people to seek help.
Rub Some Dirt in It
The problem is broader than just mental health concerns. There are stories of people injured on the job who are told to “rub some dirt in it” and continue on like a 1960s football coach. Fortunately, some of those attitudes are reducing because of workers compensation legislation and the organizational risks for not providing appropriate support – but the sentiment remains.
It’s in this context that comments like “Shrinks are for the weak” make sense. If you wouldn’t send someone for an x-ray to determine if they have a broken bone, why would you send them for tools to help them heal mentally?
One of my daughters is a physical therapist. I’ve learned that, sometimes, just knowing how to exercise can make a huge difference. The small adjustment about how you’re holding yourself during an exercise can create the right results. We don’t have the same sense that the right mental exercises will lead to better mental health.
Protecting the Family
It’s chilly outside of Washington, D.C., when my wife and I sit down with a master chief and his wife at a tiny bar. They’re lovely people and each hugely compassionate in their own way. However, a comment catches me off guard. He is justifying the silence that he has with his wife at times. It’s not about operational security. It’s about not wanting to share some of the trauma that he does – and did – experience in his career. It’s an open secret. There are things he will not share.
The master chief isn’t alone. Many first responders believe that they are shielding their families from the realities of their job (or the world). It may come not just from the desire to protect them but also because they view home – or their relationship – as a sanctuary. They don’t want to let the things they see and do intrude on this safe place.
Many spouses admit they know when their spouse has had a bad day or a bad shift. They often don’t press but a simple nod makes it clear that the master chief’s wife knows when he’s had a bad one. Over the years, they’ve fallen into the pattern. But the wall that protects the family can also keep them on the outside.
Before our son died by suicide, I had to find a language to talk to him about his work that didn’t compromise his clearance. It took us years, and I finally could ask about how he felt – and even about his friends. (Generally, first name only with only a handful of exceptions.) We could talk about his world without the details in a way that helped him feel heard – but it was far from easy.
The Mission
Not for everyone, but for some, “the job” isn’t a job. It’s a mission or a calling. It’s their identity. It’s the place where they feel the most themselves and the most in tune with destiny. This can make them excellent at what they do. It can also place first responders at risk. There are the obvious “hero” types who aren’t able to separate risk from their need to be the savior. There are also those who push away others because they have a different perspective and calling.
More troubling is that those for whom the job is a mission often have a specific way of looking at the work and aren’t always amenable to change – even change that can help them and their “second family” survive and thrive.
You Don’t Forget Elephant Events
If you ask a first responder about the call they can’t forget, you’ll get an answer. It might even be a few answers. Every first responder I’ve spoken to has “that call,” “that patient,” or “that accident” they’ll never get out of their minds. The reasons why it’s unforgettable vary – but they all involve some sort of trauma. There’s some part of the event that’s not fully let go of the person and they know it can come back at any time.
Sometimes with work, these events can become less active in someone’s mind. It may still be able to recall them, but they don’t leap to the front on their own. However, that requires processing the trauma and coming to terms with it.
The Life You Thought You Could Save
The stories that seem to haunt first responders are those people who they’ve seen or heard die. Even more troubling seem to be those where the first responder expected that the person would live. Whether it’s a car accident or a violent attack, it seems like the gap between the expectations and outcomes complicates the processing process and makes them stick. While this makes sense from a cognitive processing perspective, it doesn’t make it any easier.
The Righteous Mind and Mindreading both propose that we are creatures designed to predict. We have survived and thrived by being able to predict what comes next. What seems to happen with those we thought we could save is that we stack the trauma of the loss on top of the need to adjust our perspectives to account for the reality of the death despite our predictions.
Conditions for PTSD
The conditions for PTSD are somewhat narrow. Getting recognition for trauma has had a long and difficult history. From shell shock to finally being recognized in DSM-III, we’ve struggled to accept trauma as real. (See A Sadly Troubled History and Trauma and Recovery for more.) According to DSM-V, the criteria for PTSD are, in part: “Exposure to actual or threatened death, serious injury, or sexual violence…” The fourth of the identified ways is, “Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)…” However, there’s a note, “Criterion A4 does not apply to exposure to electronic media, television, movies, or pictures, unless this exposure is work related.”
There’s so much wrong with the definition. First, people can feel trauma when their sense of identity or their sense of how the world works is threatened – not just physical life. Second, it’s incredibly clear from decades of research that the brain doesn’t have an “on-off” switch for work. It can’t even tell the difference between a movie and reality – that’s why our hearts beat faster when watching an action-adventure or horror movie. Recently, Renzo Bianchi published, “Most people do not attribute their burnout symptoms to work.” It supports one of the things that we say in our Extinguish Burnout work while highlighting the broader point that we can’t distinguish between work and non-work when it comes to what we experience. (The World Health Organization classification only supports burnout as an “occupational phenomenon” – which we believe is clearly incorrect.)
The problem with the definition with so many challenges is that many suffering people who are impacted by what they’ve seen, heard, and done don’t meet the criteria for PTSD where they might be able to find treatment.
Cumulative Trauma
There is another definition for posttraumatic stress disorder – but it’s complex. Complex posttraumatic stress disorder (C-PTSD) is recognized by the World Health Organization in ICD-11 – but the APA, who publishes the DSM, has not yet recognized it as a disorder. C-PTSD requires repeated exposure to trauma – which is part and parcel to the work of most first responders.
Because of the inconsistencies around recognition of C-PTSD, it’s often difficult to get recognition that it’s a real problem – and the result may be that first responders will give up before getting the care they need.
After Disconnect
During a visit to a 911 center, the operator I was sitting with disconnected the call after the arrival of the emergency medical staff. He sighed slightly and, in a hushed voice, said that he’d never know the outcome of the person he’d spent a few minutes talking to during one of the scariest times in their lives. He’s not alone. First responders are, by definition, first, but unless there’s a negative outcome while they’re with someone, it’s unlikely that they’ll know the outcome.
There are, of course, those people who reach out to thank the operator who was their lifeline, but that’s vanishingly rare. Most of the time, whether it’s the 911 operator, the emergency medical staff, or the ER staff, the outcomes aren’t known. Live or die, they’re unlikely to know.
The problem with this is one of burnout. Burnout is about not feeling effective. Feeling effective requires knowing that you’re making an impact – in this case, that people are living or thriving because of your intervention. One of the biggest suggestions for first responder organizations that want to reduce burnout is to do what is possible to increase visibility of outcomes. (See Extinguish Burnout for a long list of burnout related resources.)
Alcohol Abuse
In the US, we tried banning alcohol. The broader societal outcomes were so bad that we repealed an amendment to our Constitution – the one and only time we’ve done it. It’s an open secret that many first responders – and other professions – leave work and go home for a drink or more. It’s estimated that about 25% of police officers drink to detrimental levels. The same is said for about 50% of firefighters.
When I was trying to seek details about the relationship between suicide and mental illness, I noticed that included in the list of mental illness for suicide was substance use disorder (of which alcohol use disorder is a sub category). The problem with this inclusion was that the rates of excessive alcohol consumption are much larger than anyone wants to acknowledge. (See Deaths of Despair.)
The Glass of Water and the Goldfish
There’s a goldfish gasping in need of water sitting right next to a glass of water, but the goldfish can’t make the leap to get into the water. Such is the situation with those working for progressive agencies that make mental health and wellness curriculum available. In many cases, they don’t even know it’s there. When people do know that the curriculum is available, they can’t get past the stigma and barriers to take it. Ultimately, if we could support the fish, it could get the water it needs.
Done well, agencies can help people get the tools and therapy they need to be their own therapist – for most things. Until we can make the resources available and create the cultures to encourage the use of those resources, we’ll have to worry about First Responder Mental Health.