Treatment Experts on the Latest Research, Best Practices and Treatment Options – October 2015
For firefighters and first responders, maintaining optimum mental wellness is a critical part of remaining active and effective on the job as well as at home. Constant exposure to trauma, life-threatening situations, and the physical strain of working long hours on little to no sleep can negatively impact overall mental health, increasing the vulnerability and risk of substance abuse and addiction among firefighters and first responders.
It’s important to note, too, that there are various aspects of the job that can contribute positively to mental health. These include:
- Positive relationships with coworkers
- Meaningful and important work
- Productive and/or positive atmosphere in the workplace
- Livable wages and benefits
Finding balance when the negative issues begin to outweigh the positive is essential to maintaining optimum mental health.
“Because of the extreme things we see in our everyday line of duty…It’s easy to develop an ‘us-and-them’ attitude. It’s very tempting to want to stay with those who understand – and soon family and friends can even be excluded. We have to watch out for that.”
— Retired Fire Captain Michael Morse
Sometimes it takes conscientious effort to maintain positive relationships with friends and family members.
In the United States, treatment of all mental health disorders is essentially based on
scientific research and evidence that is objective and repeatable. The self-correcting process that comes with new and diversified research methods, the peer review of findings, and the transparency of research provided through publication in journals not only help to spread awareness of new and updated treatments but also demonstrate the differences among patients when exposed to different treatments and/or combinations of treatments in different contexts.
Because the United States is a melting pot of cultures, it becomes important then to discuss the significant impact that an individual’s culture and personal experience not only has on the development of mental health symptoms but on one’s willingness and ability to seek treatment, follow through with treatment, and benefit from the treatment services commonly applied to the care of different diagnoses.
“Culture” includes the views, beliefs, and values that an individuals holds as “normal” and can impact the experiences and choices of the client, the client’s family and community, the clinician, as well as the body of work informing treatment. Additionally, other cultural issues – such as gender, race, economic status, professional culture, religious views, and more – may contribute to an increased or decreased ability to access and benefit from different mental health treatment models or to work effectively with different clinicians. It’s important to take all these issues into consideration when determining the best course of action for treatment.
The Stigma of Mental Illness in the US
The 2007 Behavioral Risk Factor Surveillance System (BRFSS) by the Centers for Disease Control (CDC), suggest that the
stigma against those who are living with mental illness is a significant issue in the United States. For example, only
24.6 percent of participants who were living with mental health symptoms thought that people would care about their struggle.
Fortunately, this same study found that 57.3 percent of respondents who were not struggling with mental health symptoms
believed that people were sympathetic to the issue. These survey results could be interpreted as those with mental health
issue mistakenly underestimate the overall sympathetic nature of the general population when it comes to those suffering
from mental health issues. Furthermore, the study also found that almost 77.6 percent of people living with mental health
symptoms and almost 88.6 percent of those not living with mental health issues believed that treatment could assist in helping
the person to live a balanced and “normal” life. These survey results could be viewed as showing an overwhelming consensus
that treatment is a good thing.
What do these findings suggest? Possibilities include:
- Lower rates of people in need of treatment seeking help due to fear of being judged by others
- Increased self-judgment and incidences of depression and low self-esteem among those living with mental health symptoms
- Increased attempts to self-medicate mental health symptoms through drugs and alcohol rather than seeking treatment
- Decreased likelihood that family members will admit that the struggles of a family member are signs of anything more than
a passing phase or “normal,” especially among first responders given the nature of the job
- Less support for people in recovery from mental illness (e.g., professionally, among peers, in the community, etc.)
The Substance Abuse and Mental Health Services Administration (SAMHSA) among other mental wellness agencies is working to decrease stigma in the United States by dispelling myths and increasing awareness of the personal experience of those living with different mental health symptoms. One way in which SAMHSA is working to increase compassion and support for those living with mental health symptoms is by advocating for the development of peer support and social inclusion services for individuals and their families. These services seek to:
- Increase understanding of addiction and other mental health disorders
- Provide people in recovery for mental health issues with a forum to safely share about their experiences
- Provide people in recovery and their families a place to connect with others who are living with similar issues
- Allow the public to step forward, offer support, and share their experiences
For firefighters, first responders, and their families, the stigma against mental health issues can be an obstacle to treatment.
Not wanting to call attention to their struggle and preferring instead to focus on the job, many in the profession do
not want to acknowledge that they might be in need of treatment or that their symptoms may be complicating their ability
to function physically and/or mentally.
The organization that writes standards for firefighter safety – NFPA – gave behavioral health a distinct chapter in 2013. And the organization generally leads the charge in taking proactive measures to ensure firefighter safety.
This indicates that while preventative behavioral health has taken a while to gain broad scale traction, things are changing
for the better.
An upsurge in prevention and education efforts across support organizations for active firefighters and first responders as well as retired veterans, including organizations like the National Fire Protection Association, has helped to increase awareness of how common mental health issues may be among first responders and firefighters. It has also improved access to appropriate care and treatment.
Common Mental Health Issues Identified Among First Responders
Common Mental Health Issues Identified Among First Responders
Law enforcement officers, firefighters, paramedics, and other first responders must continually see the worst of human experience. The ravaging effects of fire, the emotional and physical damage caused by accident and abuse, the threat of personal attack, constant stress, and an inability to save everyone they attempt to help take a toll.
Additionally, long shifts, working with others who are similarly struggling with mental health disorders, difficulties at
home, and other personal issues can all contribute to the high rates of the mental health disorders commonly diagnosed among
Furthermore, retirement can uncover or exacerbate alcohol, drug, and mental health disorders that may have been masked or
submerged during active duty.
Dr. Ralph Tenney, a therapist who works with law officers at American Addiction Centers, sees the period right after retirement as a vulnerable time for first responders. Submerged emotional issues suddenly become amplified; self-medicating tendencies run amok. Tenney says that retired first responders have a window, about a year-and-a-half, to make a healthy transition from active duty. Typically it involves refocusing on new interests and finding fulfillment apart from the force or the department.
First responders who have trouble making the transition are even more vulnerable to the host of mental health disorders that
target first responders, such as:
There are different manifestations of post-traumatic stress disorder, and not all people who may be living with the disorder will exhibit the same symptoms. Exposure to significant trauma – like the experiences that could happen on any given shift for a first responder – are known to trigger the different types of PTSD. According to the National Institute of Mental Health (NIMH), the three types of PTSD include:
- Re-experiencing: Overwhelming fears, unexpected flashbacks of trauma events that include the same rapid breathing and sweating originally experienced, nightmares, and other intrusive symptoms characterize this type of PTSD.
- Hyperarousal: Often feeling on edge, intense anger response, insomnia, and/or being easily startled are all signs of hyperarousal.
- Avoidance: Feelings of guilt and depression (or having no feelings of attachment at all), difficulty remembering traumatic events, lack of interest in former hobbies, and avoiding places that trigger memories of trauma are all signs of avoidance.
Anxiety symptoms that last for six months or more generally qualify for a diagnosis of generalized anxiety disorder (GAD), social anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), or phobia. The specific symptoms will vary depending upon the disorder but may include intense fears of specific places or things, obsessive thoughts that are intrusive, disrupted sleeping and eating patterns, substance abuse, and more.
Though everyone may occasionally get the blues, or feel sad or down about a specific event or problem in their lives, first responders often suffer from ongoing and deep feelings of hopelessness, loss, suicidal thoughts and behaviors, guilt, insomnia, and other issues related to the disorder. Depression can be diagnosed as mild (dysthymia), moderate, or severe, or it can be a symptom of another mental health disorder like post-traumatic stress disorder (PTSD). It can also be worsened or driven by substance abuse and addiction.
Addiction to drugs or alcohol is defined by compulsive use of the drug (or drugs) of choice despite the negative consequences that result. It is a chronic disease that causes physical and discernible changes in the brain and thus in the person’s mental and physical health and personality. People who are diagnosed with addiction will be unable to stop using or drinking on their own and require professional detox and addiction treatment.
When people are living with both drug or alcohol dependence disorder and a diagnosed mental health condition, they are diagnosed with co-occurring disorders. The two issues often significantly impact one another, making it difficult to impossible to treat one disorder without also comprehensively treating the other. For example, those who struggle with anxiety and who use drugs and alcohol to calm their fears may not benefit from stopping the use of drugs of alcohol for long if they are not given the coping mechanisms they need to manage their anxiety issues without feeling the urge to drink or get high.
Firefighters, First Responders, and Law Enforcement Have High Rates of Mental Health Disorders
The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that about one in five adults – or
43.8 million Americans – in the United States was living with a diagnosable mental health disorder in 2013. Additionally,
they found that about 9.3 million Americans considered taking their own lives that year. These are numbers that resemble
reports from 2012. First responders, including law enforcement and firefighters, are certainly part of this statistic,
but unfortunately, as compared to the general public, there are often higher rates of mental illness, including substance
abuse, addiction, and suicide.
Every year, new lists are released highlighting the professions most commonly linked to specific mental health disorders, including substance abuse and addiction. In additio to first responders, included on this list are often:
Police officers are often included in these top 10 lists but rarely are firefighters, paramedics, and EMS workers despite the evidence that these professions often suffer great loss due to suicide and experience high rates of mental health disorders. For example
- The Firefighter Behavioral Health Alliance notes that 105 firefighters took their own lives in the United States in
2014. Because this number is based on reported suicides, actual numbers may be higher.
- The US Firefighters Association (USFA) reports that about 10 percent of firefighters may be abusing illicit substances
and that alcohol abuse among this population is more than twice the rates seen in the general public.
- Post-traumatic stress disorder, depression, and suicidal thoughts and behaviors among first responders are also
common and believed to be triggered or worsened by repeat exposure to trauma, including physical abuse and death among
the people they serve, loss of people close to them, and life-threatening situations.
Perceived Barriers to Treatment
Perceived Barriers to Treatment
There should be nothing stopping people who struggle with a mental health disorder or substance abuse issue from connecting with treatment that will help them to change their lives. Unfortunately, there are often perceived barriers cited by people living with these disorders that may postpone them getting the help they need. Firefighters and other first responders are often deeply impacted by these issues.
Some commonly cited reasons for avoiding treatment or denying the need for treatment include:
When people recognize that there are changes – negative changes – that have occurred in their lives and relationships
due to their substance abuse or mental health issues, it is hard to deny that treatment is needed. The simplest way
to avoid having to contemplate change and what that would look like – and often the biggest barrier to treatment –
is to simply deny there is a problem. Denial is not just personal. People in denial will often work hard to cover up
their use of drugs/alcohol and do the same thing with their mental health symptoms to avoid addressing issues. This
makes it more difficult for others to recognize the problem in its early stages or to see how serious the issue is
so they can turn the focus toward getting necessary treatment.
Stigma on the Job
Firefighter and law enforcement cultures and first responder work environments are not particularly conducive to the
exploration of “feelings.” These are tough jobs, and there is the perception that people need to be tough to do them.
Though it is recognized that people on the job may struggle with the dangers they have to deal with every day and things
they have seen in the line of duty, it is not always readily acceptable to discuss it openly or to admit the need to
talk to someone about it on the therapeutic level. Rather than deal with the
stigma against working through, for example, post-traumatic stress disorder related to the job, first responders
may instead drown the experience at the bar or use other drugs in an attempt to escape – not only avoiding treatment
that can help them but also inadvertently developing a second disorder that is equally debilitating.
Fear of Job Loss
Many first responders believe that if they discuss their issues with post-traumatic stress,
depression, anxiety, and substance abuse that they will put their jobs at risk. In most cases, this fear is unfounded.
In fact, the earlier people get help, the more likely they will be stabilize more quickly and return to work more functional
than before. Unfortunately, avoiding treatment for a serious mental health condition including addiction will almost
certainly result in job loss when the issues related to that disorder cause the person to make deadly mistakes on the
job. These mistakes often reveal the problem as well as its depth and severity at the worst possible time and in the
most public way. In addition, the mistakes put coworkers and the people being served at risk.
Stigma from the Community
In addition to the above concerns about how people at work may respond to the admission that a mental health symptom,
trauma, or substance abuse disorder has become an unmanageable issue that requires treatment, many first responders
fear the response of the community at large. They may not want to admit to their family at home or to extended family
members that they are struggling, and they have concerns that they may be treated differently as a result. They may
also be concerned that others in the community – people they serve – may find out or know about their health issues
and that will affect their ability to take charge of situations when necessary. Again, however, the stigma against
choices made under the influence, or choices that put others in emotional or physical harm’s way caused by untreated
mental health issues and addiction, is far worse and more difficult to overcome.
Belief that treatment won’t work
Many continue to live with disruptive mental health and substance abuse issues because they mistakenly believe that
there will be
no benefit to getting treatment. Rather than risk issues of stigma or job loss, they characterize what they are
living with as unavoidable and continue to try to deal with it on their own.
Some treatment programs can be expensive, but everyone has
access to affordable health insurance coverage that will help to bear the brunt of the cost of treatment services
for mental health issues as well as substance abuse and addiction. Additionally, many first responders are afforded
increased care and coverage for the treatment of issues that occur on the job.
Access to Treatment
Many believe that there are few treatment resources in their area or that waiting lists are too long to make it worthwhile
to apply. There are, however, numerous in-state and out-of-state treatment options available. While some have the benefit
of offering nearby outpatient treatment services, others provide increased confidentiality protection and anonymity
by putting some physical distance between the person’s home and the place of recovery.
There are numerous options available in mental health treatment services for all types and combinations of symptoms. The issue may be a commonly diagnosed mental health disorder like depression or anxiety, or symptoms of depression and anxiety may be indicative of a personality disorder, post-traumatic stress disorder, or another complex illness. Mental health issues may be exacerbated by drug and/or alcohol abuse or addiction.
Regardless, there is a range of inpatient and outpatient treatment services that are available. Each person who enters treatment should begin with a complete diagnostic evaluation in order to facilitate the creation of a unique treatment plan designed to connect with the services that will be most beneficial to the individual’s needs.
Affordable Care Act has improved the ability of insurance holders to get coverage for medical and therapeutic care
for mental health issues, including substance abuse and addiction.
problem and begins to impact the person’s ability to function in everyday life, none of the perceived issues above that
could potentially justify avoiding treatment are valid any longer.
When is it time for treatment?
Signs that help is necessary include:
- Increased arguments at home with a spouse or significant other due to choices made under the influence or the impact of
changes caused by mental health symptoms and/or drug and alcohol abuse
- Difficulties at work that range from showing up late or calling in sick to being unable to function at optimum levels
due to issues related to substance abuse and mental health
- Health problems related to mental health symptoms or drug abuse (e.g., insomnia, poor eating habits, and chronic illnesses
related to the drug or drugs of choice, or an inability to manage underlying medical issues)
- Mental health issues that impact others, including changes in personality or extreme/violent mood swings
- Any choices related to
substance abuse (e.g., drinking and driving) or ongoing mental health symptoms (e.g., suicidal behaviors, violent
outbursts) that put the person or others at risk.
Each person should have a unique experience in treatment and recovery just as each person had a unique experience that led
up to the need for treatment. There is, however, a general structure that is often utilized to make sure each client who
enters treatment is connected with the services and support necessary to make
efficient and steady progress in recovery.
Some people wait until they are in the midst of medical and/or mental health crisis before they begin treatment. In these
cases, the first order of business is stabilization. Urgent medical care to manage acute medical issues like overdose
and/or any injuries incurred due to accident or self-harm will be addressed first with stabilization as the goal.
In the case of addiction, some clients will experience physical and mental health withdrawal symptoms during the first days
and weeks of recovery. If this is the case, medical care is available via pharmacological assistance, therapeutic support,
and medical treatment if necessary to ensure that this process is as safe and swift as possible.
Evaluation and diagnosis
Once stabilized, the client can undergo appropriate evaluation in order to obtain a diagnosis or diagnoses that pinpoint
the driving force underlying the symptoms experienced.
Based on the findings of the evaluation process, each client will have developed a unique treatment plan that incorporates
a range of treatment services and resources to address symptoms. In addition, the plan will provide the client with coping
mechanisms that will enable the ability to learn how to self-manage the disorder or disorders independently.
Most treatment programs are based upon traditional models of care in recovery, including the 12-Step program as well as cognitive
and behavioral therapies provided on a one-on-one basis. Additionally, a range of support group options is often made
available that may center on a specific need shared by the group or may simply offer participants a chance to work on
different coping mechanisms.
A range of alternative treatment options exists to help clients explore issues and possible coping mechanisms for stress
and trauma outside of verbalization. Active and interactive therapies like outdoor and adventure therapies, nutritional
therapy, sports therapies, and others can provide first responders with more physical ways of regaining confidence and
self-esteem and rebuilding connections with others.
Learning how to lower overall levels of stress can significantly contribute to a person’s ability to manage acute stressors
on the job. By using holistic methods, such as meditation, exercise, massage, yoga, and others, clients can explore different
options until they find a combination of resources that works for them.
Family members often struggle just as deeply as the person living with mental health issues and drug/alcohol abuse or addiction.
As a result, family members require their own comprehensive care and treatment programs. Connecting with other family
members who are experiencing the same issues in their families can provide a sense of support and community that breaks
down the commonly experienced feelings of isolation and desperation that come with untreated mental health and addiction
The cessation of formal treatment is not the end of recovery but the beginning of life defined by the new principles learned
in treatment. In order to sustain these new lifestyle choices, it is important to remain actively engaged in the recovery
community and connected to appropriate treatment services. Personal therapy, 12-Step meetings or other support group sessions,
family counseling, and alternative or holistic treatment choices are recommended.
No matter what treatment resources are chosen, prospective clients can rest assured that their experiences in treatment –
and even the fact that they underwent treatment and why – will remain completely confidential. Though in some cases it may
be helpful to have a frank discussion with employers in order to manage certain issues related to the job or to ensure that
the job will still be available when treatment is over, no details need ever be shared on any level unless the client makes
the decision to discuss those details. Anonymity and confidentiality are huge components of treatment and part of why it
can be so effective.
The Journey Toward Recovery
The Journey Toward Recovery
Making the choice to enter mental health treatment, even when the need for treatment services is quite clear, isn’t always
straightforward process. It can take time, reflection, and a few false starts before treatment begins in earnest. Often,
family members and
concerned friends and coworkers may be called upon to aid in that process by staging an intervention.
“Everyone in the department knows who has a drinking problem…In some departments, they may not talk about it, and
unless there’s some kind of awareness program, they are even less likely to talk to the drinker directly. But you’ll
know they know – you start getting shadowed on a run; conversation drops off when you walk in a room. At that point,
the problem is no longer anyone’s secret.”
An intervention is a formal discussion held between a person living with addiction and/or untreated mental health symptoms and a handful of concerned friends and family members who would like to help the individual not only recognize the need for treatment but also agree to immediately begin treatment services.
For those considering staging an intervention for a loved one, the following may be helpful in handling the details:
- Keep the total number of people involved to fewer than five. Though the whole department may like to come out and support the person in need of treatment, an intervention can be more effective if done in a small group.
- Do not include people who are similarly struggling with mental health issues or substance abuse and addiction.Because these issues are so common among first responders, it may be that some people who are struggling with their own untreated issues may wish to attend the intervention. Though they may have the best of intentions, their request
for the person to get treatment may sound hollow if they too are in need of the same help.
- Consider hiring a professional interventionist. An experienced and objective person can lend an air of formality to the intervention and make it clear to the person that this request to enroll in treatment is medically based and serious.
- Hold a planning meeting in advance of staging the intervention. This will allow everyone involved to make sure they understand what is expected to happen and what their respective roles will be in the process.
- Plan what to say in advance. Each participant will have an opportunity speak directly to the individual who is the focus of the event. It is advisable to plan this out in advance in order to eliminate the risk of an overly emotional moment and to ensure that everything that needs to be said is covered.
Law enforcement, fire fighters, paramedics, EMTs, and other first responders may commonly struggle with depression, anxiety,
post-traumatic stress, and substance abuse or addiction, but they do not have to live another day without treatment that
can be lifesaving.