Historically, traumatic stress and Post-Traumatic Stress Disorder have been conditions associated with those that have experienced combat or been in the military. Recently, there has been mounting evidence that first responders are also experiencing these conditions at alarming rates, and that we need to make our own mental health a priority.
For a long time mental health, self-care, and peer-care have been taboo subjects among first responders. Recently there has been a positive shift in the culture, and discussion of these topics has been encouraged. Knowing more about first responder mental health can help you participate in the conversation, help yourself, and help your peers.
1. KNOW WHAT CHRONIC STRESS AND TRAUMATIC STRESS ARE, AND WHY THEY CAN BE HARMFUL.
Stress is a normal reaction to the physical and mental demands placed on a person. When a person is under stress their brain reacts by providing a quick burst of hormones, endorphins, and neurotransmitters all designed to help the body function more efficiently. Stress can become harmful when it is prolonged or occurs secondary to a traumatic event. [1, 2, 3]
Chronic stress results in your body having all those extra chemicals floating around in it all the time, which can have a negative effect on things like blood pressure, sleep, and your immune system. Traumatic stress occurs secondary to a situation that overwhelms a person’s ability to cope. [1, 2, 3]
Chronic stress has been linked to increased rates of anxiety, depression, and a number of physical ailments. Traumatic stress can result in the development of an Acute Stress Reaction or Post-Traumatic Stress Disorder. [1, 2, 3]
2. KNOW THE RATES OF POST-TRAUMATIC STRESS DISORDER AND SUICIDE.
Part of discussing a problem is knowing the scope. Based on studies currently available it is estimated that the rate of Post-Traumatic Stress Disorder in first responders is 15-25%, with possibly another 15-25% meeting the criteria for partial Post-Traumatic Stress Disorder. [4, 5, 6]
First responder suicides are not tracked by the government like line of duty deaths are, leaving the task up to independent groups. The Firefighter Behavioral Health Alliance is the primary group tracking fire and EMS suicides in the US, with The Code Green Campaign assisting in gathering data. Per the FFBHA there have been 73 validated fire/ems suicides so far in 2016. Last year the FFBHA brought in an expert to analyze the numbers and it was estimated that at best, we are catching about 30% of first responder suicides. This means that we may be losing one fire/EMS responder a day to suicide. More if law enforcement is included. 
3. KNOW WHAT THE SIGNS AND SYMPTOMS OF POST-TRAUMATIC STRESS DISORDER ARE.
Post-Traumatic Stress Disorder (PTSD) is a psychological disorder that can develop in some people after being exposed to either a single or multiple traumatic events. In simple terms when someone has PTSD, their “fight-or-flight” response gets stuck on, or turns on excessively. PTSD symptoms fall into four categories: arousal, avoidance, cognition, and re-experiencing. A person must experience a certain number of symptoms from each category for PTSD to be diagnosed. 
You can read the National Institute of Mental Health’s explanation of the individual symptoms here.
4. KNOW WHAT RESILIENCY IS AND HOW TO BUILD IT.
Resilience is an individual’s ability to deal with stress and recover from traumatic events. In other words, how well you are able to “bounce-back” from these experiences. There are many things that factor into how resilient a person is, including their upbringing, family life, social life, and past trauma. The good thing about resilience is that it can be developed and increased, often on your own. The American Psychological Association’s Road to Resilience guide is a helpful resource to learn about resilience factors. 
5. KNOW THE SIGNS THAT SOMEONE IS IN CRISIS.
It is important to know what to look for when you are worried about someone. There are a number of different warning signs, including changes in behavior, changes in mood, and statements that someone might make. Extrinsic factors, like job loss or divorce can also increase the risk of someone having a crisis or attempting suicide.
Check out the SAMHSA site for Warning Signs and Risk Factors for Emotional Distress and the American Foundation for Suicide Prevention’s site on Risk Factors and Warning Signs for detailed information on what to look out for. [9, 10]
6. KNOW HOW TO TALK TO SOMEONE YOU ARE WORRIED ABOUT.
If you’re worried about someone, talk to them! You may be the only person who sees something and saying something may save a life. It is normal to be anxious when having a conversation with someone about their mental health and having a plan ahead of time can make it easier to talk to them. There are 3 key steps to talking to someone about their mental health:
- Have a plan ahead of time.
- Encourage them to get help and get safe.
- Provide them with information on where to get help.
Be sure to use active listening and let the person know you are listening to what they are saying. Don’t be afraid to ask direct questions such as “are you thinking about suicide?” or “do you have a plan to kill yourself?” You will not put the idea of suicide in their head.
7. KNOW WHAT NOT TO SAY OR DO WHEN TALKING WITH SOMEONE ABOUT THEIR MENTAL HEALTH.
If someone confides in you that they are struggling with a mental health problem there are some things you should definitely avoid saying:
- Avoid platitudes like “it’s always darkest before the dawn” or “Trust God and he’ll sort it out”.
- Avoid telling the person to “suck it up” or “man-up”. Statements like these only contribute to the stigma!
- Don’t shut the person down or tell them to stop talking about it.
- Don’t schedule an intervention or “gang-up” on the person.
8. KNOW HOW TO ACCESS MENTAL HEALTH RESOURCES QUICKLY.
Keep information on hand for different mental health resources, such as your agency’s EAP, a local crisis line, or national hotline. SafeCallNow operates a 24/7 crisis hotline staffed by first responders which can be reached at 206-459-3020. The Code Green Campaign also maintains a database of first responder friendly mental health resources on their website.
9. KNOW HOW TO IMPROVE THE CULTURE AND REDUCE THE STIGMA AROUND MENTAL HEALTH.
Unfortunately, among first responders there tends to be a culture of silence when it comes to mental health. We are the ones who people call when they need help, and no one wants to admit that sometimes we need help too. Changing the culture and reducing the stigma can go a long way towards improving the situation.
You can help by avoiding making jokes about mental health or statements that might be seen as mocking mental health patients. When you see or hear people contributing to the stigma, speak up and say something so they understand that what they are saying and doing may be harmful to their fellow first responders.
10. KNOW HOW TO HELP RAISE AWARENESS AND EDUCATE OTHERS.
You don’t have to learn everything about first responder mental health in order to help the cause! There are many groups working to improve awareness and education. Familiarize yourself with some of these organizations so that you can refer people to them if they want to learn more.
1. What Is Traumatic Stress?. International Society for Traumatic Stress Studies, n.d. Web. 24July 2016.
2. Post-Traumatic Stress Disorder. National Institute of Mental Health, n.d. Web. 22 July 2016.
3. Fact Sheet On Stress. National Institute of Mental Health, n.d. Web. 22 July 2016.
4. Bennett, P. "Levels of Mental Health Problems among UK Emergency Ambulance Workers." Emergency Medicine Journal 21.2 (2004): 235-36. Web.
5. Lima, Eduardo De Paula, and Ada Ávila Assunção. "Prevalência E Fatores Associados Ao Transtorno De Estresse Pós-Traumático (TEPT) Em Profissionais De Emergência: Uma Revisão Sistemática Da Literatura." Rev. Bras. Epidemiol. Revista Brasileira De Epidemiologia 14.2 (2011): 217-30. Web.
6. Almeida, Maiara Luvizon Biancon De. "Prevalence Of Posttraumatic Stress Disorder In Rescue Workers: A Systematic Review." Psic., Saúde & Doenças Psicologia, Saúde & Doenças 13.2 (2012): 220-37. Web.
8. The Road to Resilience. American Psychological Assocation, n.d. Web 24 July 2016.
9. Warning Signs and Risk Factors for Emotional Distress. Substance Abuse and Mental Health Services Administration, n.d. Web. 22 July 2016.
10. Risk Factors and Warning Signs. American Foundation for Suicide Prevention, n.d. Web. 22 July 2016.
ABOUT THE AUTHOR
Ann Marie Farina is a NR-P in Washington state. She has been in EMS since 2003 and has worked in a variety of positions in Alaska and Washington since then. Over the years her jobs have included working as a wildland fire medic, a dual-role firefighter/paramedic, a 911 transport medic, and as an educator. In March of 2014 Ann founded The Code Green Campaign, a mental health awareness campaign that raises awareness about mental health conditions and suicide in first responders. Through Code Green, Ann has worked as an educator, researcher and consultant in order to assist agencies in improving their mental health programs. Ann is a member of the EMS1 Editorial Advisory Board.