Law enforcement

The demand to care for and interact with all members of the community often results in compassion fatigue among police officers.^[7] Additionally, the need to care for each individual, and specifically any victims, on a crime scene can create a feeling of moral suffering, which can be further broken down into either moral distress or moral injury^[8] Moral distress entails experiencing pain and mental health issues that affect the individual in situations during which they are expected to make the correct decision but they are unable to do so due to an external barrier.^[8] They may also experience moral injury, which causes individuals to lose perception of the world as a safe place and other human beings as individuals they can trust.^[8] Furthermore, Police Complex Spiral Trauma (PCST) addresses the cumulative effect of trauma experienced by police officers over the course of their career due to the frequency of their exposure to trauma.^[8]

Firefighters and search and rescue

Firefighters may experience Repeated Exposure Trauma, as they are often faced with recurrent severe stress when responding to life-threatening incidents during which their goal is oftentimes to save lives.^[9] The severity of the incidents that firefighters are involved in, and the emotional skills needed to cope with this stress can lead to acute stress disorder (ASD) and, eventually, PTSD.^[9]

Search and Rescue personnel are also repeatedly exposed to direct and indirect stressors as they are always putting their own safety at risk in order to come to the aid of others.^[10] Search and Rescue personnel share similar occupational experiences with firefighters, and the severity and degree of trauma of events that these teams must respond to might have an impact upon these individual's emotional and mental health.^[10] Both Firefighters and Search and Rescue personnel are also at great risk for developing compassion fatigue.^[11]

EMS Personnel

EMTs and paramedics, amongst other first responders, can suffer from posttraumatic stress symptoms and depressive symptoms as a result of repeated exposure to human pain and suffering on a daily basis.^[12] A study of paramedics reported more than 80% of paramedics in a large urban area experienced: the death of a patient while in their care, the death of a child, and violence.^[13] In addition to this, the same study reported that 70% had been assaulted on the job and 56% reported experiencing events which could have resulted in their own death.^[13] Often small scale triggers (in combination with larger events), such as the lonely death of an elderly person or a death by suicide which can trigger emotional responses.^[12]

In a study conducted by Regehr et al., researchers aimed to better understand by what processes do lasting effects take hold. Researchers found that through emotional empathy, the process by which an individual shares or experiences the feelings of another, paramedics move beyond a cognitive understanding of loss or suffering in stressful situations to experiencing emotional empathy in these situations.^[12]

Dispatchers

Emotional stress is an intrinsic part of emergency dispatchers’ occupational health; they work in critical situations, with an irregular work load, and no feedback regarding patient outcome.^[14] Acute stress is a fundamental adaptive response, but psychological stress at work can lead to illness and reduced productivity.^[14] Being at the beginning of the rescue chain, it is important that dispatchers are in good health to communicate vital information during critical phases of operations; errors can have serious consequences.^[15]

Research has largely focused on trauma among more stereotypical first responders such as firefighters or police officers, however, there is an increasing amount of research investigating the biometric stress parameters such as heart rate among emergency dispatchers.^[14][15] One study found dispatchers had elevated heart rates and reduced heart rate variability at the beginning and throughout a shift; additionally dispatchers showed a significant increased risk of work disability as compared to a control group.^[15]

Stigma and underreporting

Due to the stigma associated with having a mental health disorder among first responders, individuals at these jobs tend to under report symptoms to avoid judgment by peers and supervisors, demotion, or a decrease in responsibilities at work.^[2][21] On average, "about one in three first responders experiences stigma regarding mental health."^[2] Other barriers associated with under reporting are a lack of knowledge of where to receive treatment, scheduling concerns, and fear regarding confidentiality.

As Emergency Responders progress through their careers, each incident, each experience goes into their backpacks as a rock. A good example is that if a first responder is wearing a backpack, after each traumatic experience they add a rock. Eventually, the back pack will start to get incredibly heavy sooner rather than later. The idea of this is how much can someone carry, is the load heavy or light? First responders tend to not seek help, they carry and carry until they can no longer carry the weight/stress. Some first responders suffer from severe-critical incident stress. The rock metaphor describes the weight and load each first responder carries through the length of their careers. Some loads are heavier than others but nonetheless they all carry weight.^[22]

Comorbid disorders

Among law enforcement officers, “chronic pain, cardiovascular problems, arthritis, substance use, depression, anxiety, and suicide” present comorbid with PTSD.^[3] Similarly, firefighters experience “cardiovascular disease, respiratory problems, depression, acute stress disorder, interpersonal difficulties, substance abuse, and suicide.”^[3] Lastly, dispatchers can present with high cortisol and higher burnout rates with a PTSD diagnosis.^[3]

Awareness of available resources

Prior to a PTSD event, a first responder should be given the resources or be aware of what resources are available to them in the event of a traumatic experience. A list of resources can be found on the Code Green Campaign website.^[29]

During orientation, training, or an academy, first responders should be told about any job-related resources available to them. This include Critical Incident Stress Teams, Peer Support Teams, or Employee Assistance Programs. It is worth noting that social support has shown a decreased stress and lowered PTSD symptoms in first responders ^[30] When first responders can come together and talk about similar situations they showed resilience with the support network. Education at the academy on signs and symptoms of depressive behavior and resources available to first responders shows others are feeling the same way. The federal government is looking into promoting mental health training for each occupation.^[31] There is a stigma that comes from asking for help and this could be by the research on first responders is so low.

Screening

Prior to entering a first responder career, there is some evidence that screening can occur to help predict and train certain people who may have predictors of developing PTSD.^[32] During this study, new paramedic students were evaluated based on multiple factors. These factors included things like: their psychiatric history, trauma exposure, neuroticism, perceived resilience to stress, and depressive attributions. During this two-year study, it was determined that first responders who were at risk for developing PTSD or major depression could be identified within the first week of their training.^[32]

Those with a history of mental disorders are 6-times more likely to develop PTSD. It is important that providers receive adequate education on signs and symptoms of developing PTSD and know what resources are available to them because they are at a higher risk of experiencing a PTSD event.^[33]

This screening tool should only be used to help a provider with the awareness of developing PTSD. It is illegal for an employer to screen or deny a provider based on these findings.^[34]

Post-crisis interventions

Following a traumatic event, there are multiple treatments for post-traumatic symptoms used for individuals in these populations. Common treatment for first responders with PTSD are cognitive behavioral therapy (CBT), CBT as exposure therapy, prolonged exposure therapy (PE), brief eclectic psychotherapy (BEP), eye movement desensitization and reprocessing (EMDR), and Critical Incident Stress Debriefing (CISD).^[35][36][37]

Psychological Therapies

Psychological therapies are usually recommended first in people who have PTSD that require treatment. A mixture of a medication and psychological therapy may be recommended if you have chronic, severe or persistent PTSD. A doctor may refer you to a clinic that specializes in treating PTSD if there's one in your area.

Barriers to treatment

Barriers to receiving mental health care are not uncommon, however first responders face unique challenges. In a review of studies assessing barriers to care among first responders, 33.1% of participants reported experiencing some barrier to receiving treatment for PTSD.^[2] Common barriers included: difficulty scheduling appointments, not knowing where to go to get help, difficulty taking time off work, leaders discouraging getting treatment, not having transportation, fear of a negative impact on their career and fear that the services are not confidential.^[2] Stigma-related concerns create a significant barrier for first responders to seek treatment. Offering psychiatric assessment in general health care sites, making assessment and care routine rather than waiting for symptoms to present, offering assessment, feedback, and treatment that is easily accessible have been found to effectively decrease barriers to care and stigmas.^[41]