Helping the helpers: supporting first responders

Emergency service work takes a big psychological and physical toll, and the GP relationship is crucial.

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The police officer sitting in front of me slumped his broad shoulders and stared at the ground, wishing his emotions to vanish so he could resume his stoic, upright stance.

He took a deep breath and attempted to sit up straight but could not bring himself to look at me, staring out of the window instead. I could see his eyes start to water and his voice trembled as he attempted to describe to me the horrors he had seen, in a job that made him question the world and his place in it.

I have spent over a decade specialising in the psychological assessment and treatment of police officers and other emergency service personnel (or first responders), and it has opened my eyes to the traumatic nature of their work.

Routine exposure to dead bodies, pressure to intervene in life-threatening situations and being first on scene to disasters are all part of a “normal” day in the life of a first responder.

But it is not only these operational stressors emergency personnel have to deal with; they are also required to manage organisational stressors such as shift work, poor management and high workloads. Unless properly managed, these stressors can lead to poor mental health outcomes including depression, posttraumatic stress disorder (PTSD), acute stress disorder and burnout^1-5.

Research indicates that emergency workers are also at increased risk of developing physical health problems including insomnia⁶, cardiovascular disease and hypertension⁷.

Further, first responders experience elevated levels of anger, cynicism and social isolation, which can lead to interpersonal problems including marital difficulties⁸. Rates of alcohol consumption in the police population are high^9,10 and they are more than twice as likely to suffer from fatal alcoholic liver disease than the general population¹¹.

One of the first questions I ask emergency service workers when they present to therapy is “do you have a supportive GP?”

In my experience, the role of the GP is vital. Emergency workers are generally reluctant to engage in psychological treatment, and their GP is often the first medical professional they have contact with. It is therefore of the utmost importance that their relationship with their GP is a genuine, open and supportive one.

Here are five tips to maximise the support you offer your patients who are first responders:

1. Have a conversation about mental health. Emergency service workers often find it easier to discuss physical problems with their GP and will not always express concerns regarding their mental health, even if they are struggling. If an emergency worker presents for a physical problem, remember to ask how they are coping with the demands of their job. For example, you might ask what the most challenging thing about work has been over the last month, if they have felt more stressed than usual, or how they are getting along with their manager. Remember, you may be the only medical professional they have contact with, so it is important to communicate interest in both their physical and mental health.
2. Ask how their partner or family would say they are coping. Many first responders struggle to discuss their own mental health and are more likely to be open to having the conversation if you involve the perspective of loved ones. For example, if your patient says they are fine, ask if that is what their wife / husband / partner would say if you asked them the same question. You might be surprised at the different response you receive, which can open up the opportunity to have a conversation centered around their mental wellbeing.
3. Check in to see how they are coping with both organisational and operational stressors. Many emergency service workers report that daily organisational stressors, such as shift work, managerial problems and lack of resources cause more distress than coping with the traumatic nature of their work. These organisational stressors also make it more difficult to cope with traumatic stressors when they arise. You are likely to build good rapport with your first responder patients when you acknowledge the organisational difficulties of the job, which are often more subtle than the traumatic events they are exposed to, but very dangerous to their long-term mental health.
4. Normalise help-seeking behaviours. Remind people that support can come from all different places including colleagues, family, friends and professionals. Seeking help requires strength and is not a sign of weakness. Have in mind local psychologists and psychiatrists you can refer to if your patient is interested in seeking professional help. It can also be helpful to explain to patients that the evidence-based treatment for trauma is called cognitive behavioural therapy (CBT) and will involve processing traumatic memories and beliefs in a safe, supported environment. When first responders are informed that treatment is based on decades of scientific research, they are often more confident to seek help.  
5. Follow up and encourage regular consults. Emergency workers are often reluctant to seek help and will likely require gentle follow up at their next appointment. If they are not ready to access psychological treatment, perhaps suggest that they make a follow-up appointment with you in the coming month so you can review their health, and the reasons that are holding them back from accessing further psychological care. Think of their willingness to seek psychological help as being on a continuum, and every positive interaction or conversation you have with them inches them further up the scale of wellness. It can take years for someone to feel comfortable enough to reach out for help, and they often need a supportive GP to get them there. 

Although first responders are at an increased risk of developing mental health issues, with the right support they can lead long, fulfilling and healthy careers¹². As a society, we benefit so much from the sacrifices emergency workers make to ensure we and our communities remain safe and well. Together, it is our professional responsibility and privilege to do all that we can to ensure they remain well in a job that demands so much.

Michelle Daymond is a registered psychologist who specialises in the treatment and support of emergency workers, currently practicing at the Talbot Centre in Baulkham Hills, NSW.

References:

1. Berger W, Coutinho E, Figueira I, et al (2012). Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers. The International Journal for Research in Social and Genetic Epidemiology and Mental Health Services, 47(6), 1001-1011. doi:10.1007/s00127-011-0408-2
2. Carlier V, Lamberts D, & Gersons P(1997). Risk Factors for Posttraumatic Stress Symptomatology in Police Officers: A Prospective Analysis. The Journal of Nervous &amp Mental Disease, 185(8), 498-506. doi:10.1097/00005053-199708000-00004
3. Fullerton C, Ursano R, & Wang L(2004). Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers. The American journal of psychiatry, 161(8), 1370.
4. Inslicht S, Otte C, McCaslin S et al (2011). Cortisol Awakening Response Prospectively Predicts Peritraumatic and Acute Stress Reactions in Police Officers. Biological Psychiatry, 70(11), 1055-1062. doi:10.1016/j.biopsych.2011.06.030
5. Marmar C, McCaslin S, Metzler T et al (2006). Predictors of Posttraumatic Stress in Police and Other First Responders Yehuda, Rachel [Ed] (2006) Psychobiology of posttraumatic stress disorders: A decade of progress , Vol 1071 (pp. 1-18). xxiii, 547 pp. Malden: Blackwell Publishing.
6. LeBlanc V, Regehr C, Jelley R & Barath I (2008). The relationship between coping styles, performance, and responses to stressful scenarios in police recruits. International Journal of Stress Management, 15(1), 76-93. doi:http://dx.doi.org/10.1037/1072-5245.15.1.76
7. Franke W, Kohut M, Russell D, et al (2010). Is Job-Related Stress the Link Between Cardiovascular Disease and the Law Enforcement Profession? Journal of Occupational and Environmental Medicine, 52(5), 561-565. doi:10.1097/JOM.0b013e3181dd086b
8. Thompson B, Kirk A & Brown D(2005). Work based support, emotional exhaustion, and spillover of work stress to the family environment: A study of policewomen. Stress and Health: Journal of the International Society for the Investigation of Stress, 21(3), 199-207. doi:http://dx.doi.org/10.1002/smi.1056
9. Ballenger J, Best S, Metzler T, et al (2011). Patterns and Predictors of Alcohol Use in Male and Female Urban Police Officers. American Journal on Addictions, 20(1), 21-29.
10. Kohan A & O’Connor B(2002). Police Officer Job Satisfaction in Relation to Mood, Well-Being, and Alcohol Consumption. The Journal of Psychology, 136(3), 307-318. doi:10.1080/00223980209604158
11. McNeill M(1996). Alcohol and the police workplace : factors associated with excessive intake / Michelle McNeill. Payneham, S. Aust.: Payneham, S. Aust. : National Police Research Unit.
12. Hart P, Wearing A & Headey B(1995). Police stress and well-being: Integrating personality, coping and daily work experiences. Journal of Occupational and Organizational Psychology, 68(2), 133-156. doi:http://dx.doi.org/10.1111/j.2044-8325.1995.tb00578.x