By Karen Jackson
I have been a psychologist for 20 years, and I have worked with firefighters or their family members for the last 10 of those years. I’ve estimated that I have spent somewhere over 10,000 hours talking with firefighters who walked through my door for help with a wide range of life’s struggles. Sometimes, the problem was post-traumatic stress disorder (PTSD) or burnout or the secondary effects (divorce, alcohol abuse, discipline issues at work, etc.). I’ve started to wonder: What’s the difference between PTSD and burnout? Are they uniquely different or versions of the same phenomenon? Ultimately, the goal of understanding this at a deeper level is to provide more effective prevention of, and treatment for, PTSD and burnout. One promising approach is mindfulness-based training, which I’ll discuss later in this article.
Emergency responders are exposed to human suffering, tragedy, and personal danger as part of their daily work. They are also told that they should not have any emotional response to facing the dark underside of life again and again. In fact, it is common to encourage detachment as a way to stay healthy. But does this really work? Emergency responders too frequently experience burnout or PTSD and, without treatment, they may also experience the subsequent unraveling of their lives. Below, I describe burnout, PTSD, and complex PTSD (C-PTSD).
Burnout can include the following:
- Cynicism: Anger and criticism toward the general public using 911.
- Judgment: Harsh criticism of the administration, officers, other crew members, and family.
- Detachment: Feeling disconnected from others including work colleagues, friends, and family.
- Irritability: anger, short fuse.
- Lack of satisfaction from work.
- Feelings of being ineffective.
- Unhealthy life choices: alcohol abuse, lack of exercise, poor nutrition.
PTSD can include the following:
- Intrusive symptoms: intrusive thoughts, images, and other sensory memories; nightmares; and intense distress when exposed to reminders of the trauma.
- Avoidance: Actively trying to push away images and memories, avoiding exposure to reminders, and inability to recall certain aspects of the trauma.
- Negative thoughts and mood: Persistent negative thoughts about oneself or others, distorted thoughts about the cause of the trauma, negative emotional states, diminished interest in previously enjoyed activities, feelings of detachment or estrangement from others, an inability to experience positive emotions.
- Physiological changes: irritability, angry outbursts, reckless self-destructive behaviors, hypervigilance, exaggerated startle response, problems with concentration, problems with sleep.
Complex PTSD was first described by Dr. Judith Herman in her book Trauma and Recovery, and it will be included as a diagnosis in the 11th International Coding for Diseases (ICD-11) in 2018 (Cloitre).
C-PTSD may result when a person is exposed to sustained, repeated, or multiple forms of trauma. C-PTSD includes all the above symptoms of PTSD plus three additional dimensions: affective dysregulation, negative self-concept, and disturbed relationships. Generally, we think of C-PTSD as developing when a person has experienced severe and repeated trauma during childhood. When abuse or neglect is experienced during children’s development, their assessment of themselves becomes negative; their ability to manage their emotions is compromised; and their ability to enter healthy relationships is hindered.
In terms of their assessment of themselves, they believe they were responsible for their poor treatment, and thus they see themselves as inferior and unworthy. They may deeply long for connection with others – seeing attachment as central to their very survival – or they may fear attachment as the road to being further betrayed and abandoned. As children, they lived in a world that was unsafe, and they often took on the herculean challenge of trying to “fix” their parents (to stop their parents from using drugs or alcohol, to stop one parent from beating another parent, or to protect a younger sibling). They may also work on fixing themselves – being good enough to be loved. Children will often be overwhelmed with emotion and dissociate to survive. The tendency to dissociate, or “check out,” may continue into adulthood, and the individual may alternate between being numb and being flooded with emotional outbursts.
Other situations besides childhood trauma can also lead to the development of C-PTSD. Emergency responders are repeatedly exposed to multiple forms of trauma and thus are also susceptible to the development of C-PTSD.
Emergency responders are first and foremost individuals with different personalities, coping styles, and family histories. They may have been raised in a healthy family, their needs being met, feeling loved and safe and able to simply grow and develop. They may also have come from backgrounds where their needs were not being adequately met or they may have faced abuse. In some cases, they came into their profession with some degree of C-PTSD already. Burnout may be directly related to working conditions that do not involve the impact of trauma. These working conditions include a lack of sleep, feeling unsupported, and just too many calls that don’t feel satisfying. However, burnout may also involve exposure to human suffering and, in some cases, be better explained by C-PTSD.
Mindfulness-based training is recognized as a highly effective tool for stress management, chronic pain, addiction, depression, PTSD, and anxiety disorders (Kabat-Zinn, J.). Mindfulness training was successfully used to help prepare marines for deployment (Johnson, D.C., et al.). Those marines who went through mindfulness training experienced significantly fewer markers of stress than the control group. Below, I will describe a mindfulness approach I have developed specifically for emergency responders that I have found to be highly effective.
We often think of burnout as related to compassion fatigue. That is, when we overload our system from “suffering with” others, it can lead to a complete system shutdown. Compassion avoidance can be just as destructive. Many emergency responders are highly avoidant of having any compassion for the people they are helping – that is, they shut it off from the beginning. This avoidance may come from the belief that having emotions displays weakness, having emotions will hinder their ability to perform their job, or they will be rejected by their colleagues. But, all our emotions seem to be on the same rheostat control knob, and when you turn off one you turn them all off. This results in becoming emotionally numb.
|Pick three different activities for mindfulness practice. These activities should be something mundane where your mind would normally wander. This could be having a cup of coffee, walking the dog, brushing your teeth, walking to your car, etc.|
Not all emergency responders develop PTSD, C-PTSD, or burnout. What makes the difference? Could it be family history, personality differences, or biological differences? The answer is yes, yes, and yes. Different reactions to trauma result from individual differences in emergency responders. In my experience, those firefighters who show the greatest resilience are those who DON’T detach from their patients. Of course, when immediate action needs to be taken on a call, that is the focus. Action, not empathy, is required. But afterward, when the call is over, the more resilient firefighters experience sorrow, empathy, and compassion in the face of human suffering. Resilient people do not see compassion as weakness or shame. They experience it, and they can then let it go. Being able to both experience and then let go is crucial. One way to let it go is to simply talk it over with trusted people (crew, spouse, clergy, or counselor). If more firefighters could view their work in this way, I believe there would be less burnout among firefighters and other emergency responders.
Meet each person you encounter with compassion rather than judgment. This can be difficult at times, but detaching yourself from the people you serve, seeing yourself as separate and different, leads to burnout. These are human beings, and you know nothing of what they have experienced in their lives. Simply connect with them as imperfect human beings – just like you. By doing so, you are making some degree of a change, in yourself and in the person you just encountered. There will be times when this simply does not work. If you run on the same addicted, mentally ill, homeless person more than once on every shift, compassion may be understandably out of reach. In this case, notice how long the call lasts and compare it to how long you feel angry and frustrated. Did the call last 10 minutes but you thought about it for two hours or more? Your anger does not change the situation, but it does ruin your day.
Focus on what you can control. Our emotions should give us accurate and useful information. If we feel fear, there should be some danger we need to avoid. If we feel anger, there should be an injustice we need to address. But when we feel anger and there is no action to take, like being angry and frustrated about going on calls that you feel are pointless, this leads to stress and burnout. There are many huge social problems, such as addiction and severe mental illness, that you can’t fix. Allow yourself to feel frustrated for no more than a few minutes, and then let it go. There are many things in life that we have no control over, but there is one thing that is always available to us: We have control over how we respond to what life throws at us. A tool to help you with this is how to live in the present. You also may have other actions available to you depending on the size of your department. For example, you may want to consider making a change such as promoting, transferring to another station, or going to a support position for a while.
Remain mindful of dual realities. Reality #1: There is pain and suffering in this world, sometimes random, sometimes self-inflicted, and sometimes caused by people who are “bad actors.” Reality #2: There is also joy, beauty, and people who are caring and compassionate – people who do good in the world. Being aware of only one of either of these realities is not accurate or helpful. Remember that your work is part of this second truth.
Remember the “good” calls. It is important to recall all the good calls at the end of each shift or keep a journal as a reminder. Firefighters have a negativity bias in their memories of the multitude of calls they experience over their career. That is, they recall the “bad” calls. These are the calls of child abuse, the death of a child from a random tragic accident, or similar events of human loss and suffering. They are less likely to recall the good calls – when someone was saved, for example. While there are the “big” good calls – bringing someone back, saving a child from a burning structure – there are many smaller but also “good” calls. While it was insignificant to the emergency responder, it may have been a much bigger crisis for the people who received help. In fact, it may be something they never forget. Yet, the firefighter may not even recall this event. In addition, the view that a call was “bad” may ignore aspects of the call that were profoundly significant. For example, being with someone as he takes his last breath; being present with parents whose child has died; and testifying at a trial of someone who killed his child are all examples of deeply significant human experiences if only the firefighter will allow himself to acknowledge them as such.
Live in the present. Mindfulness is the experience of being fully present in the moment. We are often living in the past with thoughts of a conversation we had, worry we hurt someone’s feelings, anger at someone who betrayed us, etc. We just as often live in the future with thoughts of what we need or want to do, worry about what might happen, and anxiety about potential failure. How much time do you spend in either the past or the future? For most people, living fully in the present is rare. This can rob us of truly experiencing our lives. It also leads to an anxious and depressed mind. Mindfulness is powerful and simple; you can practice being mindful anytime and anywhere.
Building the Muscle
Becoming more mindful is like building a muscle or learning a new skill; it takes practice and time. To begin, set an alarm on your phone or watch to go off at three random times a day. When the alarm goes off, focus on the moment by noticing physical sensations, thoughts, emotions, sights, smells, and tastes – basically, light up the moment. Do this exercise for 30 to 60 seconds three times a day.
A second way to build this skill is to pick three different activities for mindfulness practice. These activities should be something mundane where your mind would normally wander. This could be having a cup of coffee, walking the dog, brushing your teeth, walking to your car, etc. For a small portion of the activity, about 30 to 60 seconds, light up your sensory experiences. If you are walking, notice your footsteps, notice the air on your skin, notice what you are seeing, and notice what you are hearing.
Most people find these simple exercises relaxing. While you will begin to notice a difference right away, to make lasting and significant change you will need to continue to do these exercises several times a day, every day, for some time. Most people also say that they soon spontaneously engage in being present without needing to schedule it. Over time, you will be more relaxed in general. Then, when a problem emerges, it will be easier to not let it dominate your thoughts. It will also be much easier to let a 10-minute frustrating call last only 10 minutes.
1. Cloitre, M. “An assessment of the construct validity of ICD-11 proposal for complex posttraumatic stress disorder,” Psychological Trauma: Theory Research Practice and Policy, Vol. 9, No. 1, 1-9, 2017.
2. Herman, Judith, Trauma and Recovery, Harper Collins Publications, 1992.
3. Johnson, D.C., Thom, N.J., Stanley, E.A., Haase, L, et al. “Modifying Resilience Mechanisms in at-risk individuals: A controlled study of mindfulness training in marines preparing for deployment,” American Journal of Psychiatry, 171(8): 844-853, 2014.
4. Kabat-Zinn, Jon, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness, New York: Bantam Dell, 1990.
Dr. Karen Jackson is a clinical psychologist in private practice in Denver, Colorado. For the last 10 years of her 20-year career, she has worked with firefighters. In addition to providing treatment for firefighters and their families, she also provides peer-support team training, development, and consultation. In addition, Jackson conducts training workshops for fire departments on PTSD, resilience, mindfulness, suicide prevention, healthy relationships, grief, and recovery from substance abuse. She serves on the committee for the Colorado Firefighter Peer Support Conference.