By Karen Bradley
SETTING: A psychiatrist’s office.
- FF: A firefighter referred for evaluation and possible treatment.
- Dr. P: The psychiatrist.
FF: “Doc, I don’t know why I’m here. My wife and chief kept bugging me to see a counselor so I finally caved. But, I’M NOT CRAZY!”
Dr. P: “It’s not easy to come to a psychiatrist’s office, so I admire your courage. To help me understand why you’re here, I’d like to ask you a question or two. Would that be OK with you?”
FF: “Sure, I can take it. I’m not afraid of you.”
Dr. P: “Thanks. My first question is, Did your wife and chief tell you why they wanted you make this appointment? What were they noticing about you?”
FF: “They have a whole list of gripes and complaints. They say I’m getting grouchy and mean and I’m drinking too much. After a day of seeing the mess I do, YOU’D WANT TO DRINK, TOO. My wife keeps nagging me that I don’t talk to her and don’t spend enough time with her and the kids. The chief says that I don’t talk or hang out at the station with the guys like I used to.”
Dr. P: “Sounds tough. What do you think about their complaints? Are they just giving you a hard time?”
FF: “Well, you’d be grouchy too if nightmares kept waking you up. I used to sleep like a rock. Now, I’m lucky to get three hours of sleep. It’s getting harder and harder to concentrate or even care about work. And what’s wrong with having a few drinks to unwind? So what if I close the bar down sometimes? We see some bad stuff out there. Those accidents … seeing the kids is the worst. After a hard day, I just don’t feel like talking to anybody. I just want to be left alone.”
Dr. P: “Do you ever feel like you just don’t want to go on? Sometimes people dealing with what you do have thoughts like that.”
FF: “Sure, why should I go on feeling lousy and making my family miserable? They’d probably be better off without me. At least they’d get the life insurance money and could start a new life.”
Dr. P: “Honestly, it sounds like you’ve come to the right place. You may have PTSD and depression, which are both treatable. Would you be willing to come back soon to talk some more?”
What Is PTSD?
Does any of this sound familiar? Could this be you or some firefighter you know?
PTSD can look like this or worse, and PTSD and suicide are becoming much too common among firefighters and safety forces.
So, what exactly is PTSD? The American Psychiatric Association’s official diagnostic guide is the DSM-5. In this Diagnostic and Statistical Manual of Mental Disorders, the criteria require that there be an exposure to actual or threatened death, serious injury, or sexual violence. This exposure can be directly experiencing trauma, witnessing trauma to others, or learning about traumatic events that occurred to a close family member or close friend.
Of special note for first responders is the danger of experiencing repeated or extreme exposure to the aversive details of the traumatic event such as observing or collecting human remains or the details of child abuse.
This exposure then can result in intrusive, avoidant, or negative alterations of cognitions and mood symptoms. Examples of these intrusive symptoms would be recurrent and involuntary memories, distressing dreams (nightmares) related to the traumatic events, and dissociative reactions (flashbacks) in which the person feels or acts as if the traumatic events are actually recurring. These intrusive symptoms can be accompanied by intense or prolonged psychological or physiological distress.
Avoidance symptoms are attempts to avoid stimuli associated with the trauma by efforts not to think about nor feel emotions associated with the trauma. Stimulus reminders for these emotions can be people, places, conversations, activities, objects, or situations that arouse distressing memories, thoughts, or feelings about the traumatic events.
Negative alterations of cognitions and mood may be evidenced by an inability to remember important aspects of the trauma or persistent and exaggerated negative beliefs or expectations about oneself, others, or the world: “I am bad and a failure,” “It’s all my fault,” “The world is completely dangerous,” and “No one can ever be trusted.”
Negative emotions such as anger, fear, horror, guilt, and shame are persistent. They can be associated with an ongoing inability to experience positive emotions such as happiness, satisfaction, and loving feelings.
There can a loss of interest or participation in important and formerly enjoyable activities. A person may feel emotionally detached and estranged from others.
There can marked changes in arousal and reactivity evidenced by irritable behavior and angry outbursts of verbal or physical aggression with little provocation, reckless or self-destructive behavior, hypervigilance, and exaggerated startle response. Problems with concentration and sleep disturbance are also common.
Note: These symptoms need to last more than one month to lead to a PTSD diagnosis.
Understandably, these symptoms and behaviors can also lead to impairment in social relationships and occupational activities as well as suicidal thoughts or completed suicides.
In the Brain
So, what is going on in a person’s brain and body that may result in PTSD? Powerful systems evolved over thousands of years to protect individuals and ensure survival of our species. Most people have heard of the “fight or flight response” to threat or danger. When these systems start to malfunction, there can be serious sequelae.
Let’s delve into this a little deeper. The primary bodily defense system that is activated is the hypothalamic-pituitary-adrenal (HPA) axis. This may seem like a mouthful, but it is a system that describes the whole-body involvement.
The hypothalamus is an area of the brain known as “the seat of the emotions” with two significant subdivisions: the hippocampus and the amygdala. Pertinent to PTSD, the hippocampus is involved in short-term memory and contextual fear, and the amygdala is involved in conditioned fear responses.
|So, what is going on in a person’s brain and body that may result in PTSD? Powerful systems evolved over thousands of years to protect individuals and ensure survival of our species.|
The pituitary gland and the adrenal cortex are considered external to the brain proper and are central to the neuroendocrine system. The pituitary is sometimes thought of as the “master gland,” regulating hormone production in the body. The adrenal cortex is part of the cortisol system.
When the HPA axis is functioning well, there is a smoothly running regulatory system for the entire body. Trauma can temporarily or permanently disturb and dysregulate this system, resulting in excessive anger, fear, anxiety, and sadness. If the trauma is not prolonged or repeated, the body has a chance to restabilize. If trauma is prolonged or repeated, this system does not have time to return to normal, and a maladaptive state occurs in which negative emotions and behaviors are easily triggered.
Fortunately, human beings can be amazingly resilient. Studies show that for nonintentional trauma, there can be significant recovery. One study showed a decrease in prevalence of PTSD from 30.1 percent to 14 percent over one year. With prompt and proper intervention within the first month, PTSD may not occur at all.
PTSD and First Responders
So, what about firefighters and other first responders who experience repeated exposure to traumatic scenes and events? This a predictable and expected part of their job – a true occupational hazard.
An important question is how prevalent PTSD is among firefighters. Estimates vary from 7 to 12 percent, but these may not be accurate. Because of the culture of minimizing symptoms as signs of weakness and of being “less than a man,” surveys may underreport the incidence.
Anecdotally, many firefighters and fire instructors have reported to me that it is a serious problem in their departments. In conversations, there often is a long pause followed by mention of a firefighter “lost to suicide” within the past year.
How can firefighters care for themselves and others? For the firefighter, knowing that he or she is part of the solution, not part of the problem, is very important. Having good education and training in emotional as well as physical rescue is crucial.
What are some of the components of a good response to trauma? An important intervention is psychological first aid within the first four days posttrauma. After four days, the value of psychological first aid has been questioned.
There are eight core components to psychological first aid, including the following:
- Use of a nonintrusive, compassionate, and helpful approach.
- Immediately ensuring physical safety and comfort.
- Emotional stabilization by reassurance and containment.
- Obtaining information to prioritize needs, concerns, and subsequent interventions.
- Practical assistance for immediate needs and concerns.
- Connecting the person or persons with social supports (i.e., family, friends, or community).
- Educating the person or persons about what are normal stress responses and coping strategies.
- Ensuring that the person or persons are connected with services needed both immediately and in the future.
This is a daunting list for firefighters trained to use hydraulic rescue tools but not trained in psychological or social service rescue work. Clearly, here is a need and a role for a fire department chaplain.
For the first responder firefighter, a healthy use of such psychological defenses as suppression (not repression) of emotions (putting them temporarily in a box), rationalization and intellectualization, as well as empathy and compassion for the victims and for oneself is beneficial.
What is NOT HELPFUL is the use of intensive psychological debriefing such as ventilation by describing the events surrounding the trauma in detail. Use of benzodiazepines is also contraindicated. Research has shown that both interventions can actually worsen the problem. They can enhance consolidation and entrenchment of emotional memories and delay or prevent a normal spontaneous recovery.
In the face of all this disturbing information, it is very heartening to learn about efforts by fire departments, fire organizations, and firefighters to increase awareness, educate, and develop plans and strategies for a “first response” to signs and symptoms of possible PTSD, depression, and suicide risk.
There is also a developing awareness that, by breaking the macho culture of silence and denial at the firehouse level, appropriate and effective interventions can provide the needed safety valve immediately after severe traumatic exposures.
In my very recent and brief introduction to the extent of PTSD and suicide among firefighters, I have been impressed by the work of people in the fire service to speak out and address these problems. This is undoubtedly a small sample of those concerned about the emotional safety and well-being of firefighters around the country.
At the April 2017 Fire Department Instructors Conference International, I was fortunate to hear Jeremy Hurd’s presentation, “Help, This Job Is Killing Me.” He spoke about a statewide initiative in Florida to develop strategies and training for firefighter and fire departments. There is a Florida Firefighters Safety and Health Collaborative (www.floridafirefightersafety.org).
Matt Olson, who helped create the Fire Fighter Peer Support program in Illinois, described the important work there (www.ilffps.org).
Michael Ung, a member of the national champion Blackheart Extraction Team, informed me about The Brotherhood Initiative started by his union, Local 1403 ([email protected]).
FireRescue and Fire Engineering are providing media leadership by featuring relevant articles including the following:
- “Creating the Illinois Fire Fighter Peer Support Team,” Matt Olson, FireRescue, August 2016.
- “Addressing Post-Traumatic Stress Disorder in the Fire Service,” Christine Pay and Jana Tran, FireRescue, March 2017.
- “Firefighter Family Tragedy and Loss,” Jeremy Hurd, Fire Engineering, March 2017.
So, where does all this information leave us? Hopefully, it leaves us with an awareness and understanding of some key points.
- Witnessing serious trauma is an expected part of a firefighter’s occupation.
- The human body has a very effective and tightly regulated response system to danger and severe stress.
- Certain emotional and physical responses are a normal and expectable part of an acute stress response.
- Emotional rescue is as important as physical rescue.
- Psychological first aid is an important intervention within the first four days.
- Two harmful emergency interventions to be avoided are intensive psychological debriefing and the use of benzodiazepines.
- It is extremely important for firefighters to develop and maintain a healthy mind, body, and spirit. Tending to one’s interpersonal relationships and avoiding abuse of alcohol or drugs (prescribed or illegal) are crucial.
Working as a firefighter can “eat you alive,” destroying a person physically, emotionally, and spiritually. But … this does not need to happen.
Karen Bradley, M.D., is a physician psychiatrist who retired after 30 years from her active private practice. Since then, she has worked as a volunteer psychiatrist in Cleveland, Ohio, and Ouanaminthe, Haiti. Bradley is a clinical advisor for environmental health and safety for Turtle Plastics, a company founded and owned by her husband, Tom Norton. She can be reached at [email protected]