Volunteer Firefighters: Overlooked Mental Health?

 

When we think of firefighters, we often imagine brave men and women charging into burning buildings, ready to save lives. But what many people may not realize is that the majority of firefighters in Western countries are actually volunteers.

In the United States alone, 67% of firefighters are volunteers while only 33% are paid career firefighters. Though some may serve in both paid and volunteer positions. While both groups serve their communities with courage and dedication, there are distinct differences between them that should not be overlooked.

Although volunteer firefighters do not receive a salary for their service, they may be reimbursed for expenses such as food, transportation, and supplies. They may also receive certain benefits, including life insurance and health insurance, which equal about 20% of what a career firefighter earns.

One key difference is in the mental health support provided to these two groups. While much research has been done on the mental well-being of paid career first responders, studies have shown that volunteer firefighters often experience higher levels of PTSD symptoms after major traumatic events. They also have higher rates of depression and suicidal thoughts compared to their paid counterparts.

This could be due to a number of factors, including limited access to mental health resources within volunteer departments. Unlike paid career firefighters who undergo pre-employment psychological screenings and receive ongoing training on mental health and critical incidents, volunteers may not have the same level of support.

Volunteer departments often have fewer resources available for their members, however, there are organizations like the National Volunteer Fire Council (NVFC https://www.nvfc.org) that offer resources for volunteer firefighters and their families. Their "Share the Load" program provides a database of licensed mental health professionals, as well as courses, newsletters, and videos about suicide prevention and other mental health issues. The NVFC also offers multiple ways for volunteers to reach out for help through the Suicide Prevention Lifeline by phone, online chat, or text.

Additionally, the International Association of Fire Fighters (IAFF https://www.iaff.org) has a trained peer support network composed of fellow firefighters who understand mental health concerns and can connect members (mostly career firefighters) with community resources and mental health professionals if needed.

The nature of firefighting, whether voluntary or professional, exposes individuals to high levels of occupational stress and repeated traumatic events, leading to physical and psychological health issues. Studies have shown that the risk of developing PTSD increases with the number of traumatic events experienced by firefighters during their work. Unfortunately, first responders are often the last to admit they need help, as it goes against their role as providers of support rather than recipients. Seeking help may be seen as a weakness in this community, where toughness is essential. However, it is crucial for first responders to know how and where to find help in order to build resilience.

Support mechanisms, the removal of the stigma associated with experiencing emotional distress, and education about good mental health being just as important as good physical health need to be available and easily accessible to all first responders.

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

Firefighters' Mental Health Risks

 

Amongst first responders, firefighters are one of the most vulnerable groups and have a high risk of experiencing negative mental health impacts throughout their career. The unpredictable and intense nature of their job can cause significant stressors both on and off-duty. Their schedules often involve long shifts, followed by a limited amount of time off, causing disruption to their sleep patterns. This can lead to sleep disturbances, which is another occupational hazard.

Additionally, being away from family or working opposite shifts from a spouse can add to the existing stressors for firefighters. Missing important family moments like milestones or events can take a heavy toll on their mental well-being.

Despite choosing this profession out of a passion for helping others and saving lives, constantly being exposed to death, injury, and suffering can come at a cost. The cumulative stressors of physical strain, long hours, work-related sleep issues, and difficulty balancing work and home life can lead to symptoms like anxiety, irritability, nervousness, and problems with memory and concentration. Over time, this chronic stress can contribute to the development of anxiety and depression, with lasting effects on the brain. In fact, a 2014 report from the National Fallen Firefighters Foundation found that a fire department is three times more likely to experience a suicide in a given year than a line-of-duty death.

Among women in the US, the occupations with the highest suicide rates are Law enforcement officers and firefighters, with a rate of 14.1 per 100 000. According to the National Center for Injury Prevention and Control, CDC. Mental stress of the job can lead to substance abuse and alcohol abuse as a way of coping with the stress.

Where there’s a trauma or tragedy, firefighters are often the first on the scene. Firefighters are exposed to potentially traumatic situations by the nature of their work. On any given day, they may encounter house fires, car accidents, terrorist attacks, and other emergency situations. Repeated Exposure Trauma, the severity of the incidents that firefighters are involved in, and the emotional skills needed to cope with Cumulative Trauma can lead to Compassion Fatigue, Secondary Traumatic Stress, Vicarious Trauma, Burnout, and PTSD. Cumulative trauma refers to the psychological, emotional, and physical distress associated with repeated exposure to traumatic events, either directly or indirectly. Every individual's experience and risk of developing PTSD is unique; some may go through years of service before displaying symptoms while others may develop them after just one incident.

Unfortunately, firefighters, like other first responders we’ve discussed, are often the last to admit they need help, as it goes against their role as providers of support rather than recipients. Seeking help is often stigmatized or seen as a weakness in this community, where toughness is essential. However, it is crucial for first responders to know how and where to find the help they need when they need it.

Support mechanisms, the removal of the stigma associated with experiencing emotional distress, and education about good mental health being just as important as good physical health need to be available and easily accessible to all first responders.

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

The Mental Health Risks of being a Law Enforcement Officer

 

Law enforcement officers (LEOs) have an important role in our communities. They are responsible for protecting us and our property, but they also play a crucial role in providing emotional support to those in need. Whether it's offering comfort and information to victims of crime or natural disasters, LEOs serve as a beacon of stability in chaotic and traumatic situations.

But their job is not easy. LEOs face difficult situations every day and regularly encounter criminal and violent acts. It's their duty to maintain peace and order, show compassion towards victims, and save those who are in danger. However, due to circumstances beyond their control, they may not always be able to protect or support victims, or apprehend dangerous criminals. And when this happens, they may experience moral distress, a type of psychological pain that arises when an individual is expected to make the right decision but is unable to do so due to internal or external factors. This can greatly affect an officer's core values and lead to feelings of helplessness, powerlessness, shame, compromised integrity and justice, reduced sense of dignity, and emotional suffering.

While they are driven by a strong desire to protect and serve their communities, LEOs are also regularly exposed to traumatizing situations that can take a toll on their mental and emotional well-being.

One common issue among LEOs is compassion fatigue. This develops when LEOs are repeatedly exposed to the suffering of others, but are limited in their ability to help or make a positive impact. The constant feeling of being unable to alleviate the trauma of victims can lead to difficulties in emotionally disengaging from their experiences. This can have serious consequences, such as hindering decision-making abilities in critical situations and causing emotional detachment or numbness. In extreme cases, it may even lead to resignation from the job.

But the challenges faced by LEOs go beyond just caring for others. They are also exposed to dangerous and gruesome situations, such as hostage scenarios, drug busts, and responding to fatal accidents. The cumulative effect of these traumatic events, combined with the everyday stressors of the job like long hours, difficult people, and political tensions within the department, can greatly impact an LEO's mental health and ability to perform their duties effectively.

In some scenarios, LEOs may be forced to use lethal force, leading to immense psychological distress. Making a mistake resulting in the death of a colleague or being ordered to do something that goes against personal beliefs can also cause moral injury, similar to what soldiers experience on the battlefield. These experiences can leave LEOs struggling with feelings of guilt and shame that can greatly impact their mental well-being.

LEOs who have killed or severely injured a perpetrator are at higher risk of developing PTSD if they do not address their moral injury.

Suicide is also a significant concern among LEOs, though it is not exclusively caused by exposure to traumatic events. Lack of social support is a major factor contributing to feelings of hopelessness and suicide among LEOs. In 2017, 103 firefighters and 140 LEOs died by suicide, while 93 firefighters and 129 LEOs died in the line of duty.

Unfortunately, LEOs, like other first responders we’ve discussed, are often the last to admit they need help, as it goes against their role as providers of support rather than recipients. Seeking help is often stigmatized or seen as a weakness in this community, where toughness is essential. However, it is crucial for first responders to know how and where to find help in order to build resilience.

Support mechanisms, the removal of the stigma associated with experiencing emotional distress, and education about good mental health being just as important as good physical health need to be available and easily accessible to all first responders.

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

Responding to Mass Casualty Incidents: The Traumatic Distress Faced by First Responders

 

First responders are exposed to and must handle situations that most civilians would never want to encounter. Disasters, whether man-made or natural, can have a profound effect on the well-being of those involved. When a disaster strikes, various first responder departments, including the military, fire department, police department, emergency medical, and search and rescue teams, may all be called upon to assist. Unfortunately, these high-stress environments put first responders at an increased risk of developing symptoms of post-traumatic stress disorder (PTSD).

During a mass casualty incident (MCI), first responders face extremely critical and challenging scenarios. While most people may only experience one disaster in their lifetime, first responders often encounter multiple incidents throughout their career.

One crucial thing first responders have had to respond to with alarming regularity lately are the ongoing active shooter tragedies that seem to multiply in frequency every year. Active shooters, or violent attacks by organized groups, have placed increased violent crime response and physiological stressors on law enforcement officers (LEOs). These violent attacks and chaotic scenes often result in multiple critically injured persons and mass casualties. In an active shooter situation, LEOs are the first to enter the scene. Fire and/or emergency medical service (EMS) personnel cannot enter the incident scene until the situation is deemed safe, which means LEOs often encounter victims while pursuing the shooter. In these cases, they cannot stop to perform emergency medical lifesaving procedures. Remember when we mentioned moral injury? This is one of those cases. It is the right course of action to secure the scene, find the shooter, and prevent more injuries. However, for that LEO facing a potentially dying person, the inability to help them in that moment can have lasting effects on their psyche.   

Whether a disaster or active shooter situation, ground zero is a chaotic and overwhelming place to be, filled with potentially wounded, disoriented, confused, in shock, and scared people. Only when a shooter has been apprehended or the scene is deemed safe can EMS, fire, and search and rescue teams begin to assess, triage, and provide care to the injured.

By this point, the immediate danger may have passed, but this is where the toll on mental health is intensified. Due to the nature of their work, first responders must maintain emotional control in order to effectively help victims. There is no time to process their reactions or the emotions they’re experiencing as they treat severely injured individuals, handle deceased bodies or body parts, comfort those who have lost loved ones, and cope with unsuccessful attempts to save victims.

MCIs evoke intense emotions that cannot be processed immediately and have the potential to cause later psychological difficulties.

In the immediate aftermath of an MCI, first responders have reported that what affected them the most was not when their own safety was threatened, but rather when they were unable to alleviate the suffering of others. Incidents involving children, suicides, and severe mutilation are especially traumatic, and the lack of control in these situations greatly increases their level of distress.

On a global scale, there has been a 10x increase in disasters since 1990 and disasters are predicted to continue increasing in frequency along with the demand for first responders. The incidence of psychological issues such as PTSD is also predicted to continue to rise as first responders are exposed to more of these highly traumatic incidents.

I know it sounds all doom and gloom, but you need to know that even staring into that dark horizon, there is hope.

Providing emergency psychological care has consistently been shown to reduce chronic mental illness in trauma survivors, and it is widely accepted that first responders involved in MCIs require immediate support. Knowing what works and how to help has led to the development of culturally sensitive, evidence-informed, early intervention strategies like Psychological First Aid (PFA) which can be established within the disaster environment. PFA is a widely endorsed and promising evidence-informed early intervention model grounded in research on trauma recovery and resilience.

Findings from studies on PFA suggest it has a positive impact on survivors of MCIs and first responders, with most reporting reduced symptoms of anxiety, depression, posttraumatic stress, as well as improved ratings of mood, the experience of safety, connectedness, and a sense of control.

This is an excellent example of how recognizing the need for psychological support and making help available to those experiencing trauma can deliver a positive outcome.

PFA is useful as a first line of support during disaster situations but it shows the clear impact of having support mechanisms in place, removing the stigma associated with experiencing emotional distress, and how providing education and good mental health and coping options can go a long way to mitigating major psychological damage.  

This is an important tool, but we can’t only think about mental heal during a disaster. There is still work to do, especially when it comes to removing stigmas and providing more access and support, but it shows how protecting the mental health of people experiencing trauma can be implemented when needed.

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

Moral Injury Among First Responders

 

In the 1990s, the term Moral Injury was coined by psychiatrist Jonathan Shay and colleagues and defined it as “A betrayal of what is right by someone who holds legitimate authority in a high stakes situation.”

In 2009, the term “Moral Injury” was modified by Brett Litz and colleagues, adding,

“Perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

In simple terms, it means acting in a way (witnessing, participating, or failing to prevent something) that goes against a person’s moral beliefs. These “transgressive acts” violate an individual’s acceptable boundaries of behavior.

Journalist Diane Silver describes Moral Injury as “A deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The pain of Moral Injury is a sign of a working conscience and the loss of deeply held beliefs and/or trust. It challenges our fundamental core values and eats away at us, undermining the trust we had in ourselves, in others, and the world we live in.

While Moral Injury research has mainly focused on military service members and veterans, it is gradually gaining recognition as a significant and widespread issue among first responders.

This isn’t surprising considering the constant exposure to traumatic events that come with their job. First responders have a multitude of responsibilities, including advocating for patients, providing social services, enforcing laws, and protecting the community. As professionals in bureaucratic systems, first responders must follow strict codes of conduct, adhere to standards of practice, and follow the law when making decisions.

The unpredictable and potentially traumatic nature of their work often requires first responders to make split-second decisions. These decisions are often made in high-stress situations where their own safety and that of others are on the line and may go against their personal morals. Even if a first responder's actions don’t violate their morals at the time, an unfavorable outcome such as the death of a victim or serious injury to a team member can reveal the injury in later feelings of deep remorse, guilt, and shame. As lifesavers and problem-solvers by nature, any deviation from this perception can have a damaging effect on a first responders' mental well-being.

 

Scenarios that could lead to moral injury:

• A firefighter being unable to save a victim or having to choose between victims to save.
• A law enforcement officer having to use physical or lethal force to resolve a criminal incident.
• A paramedic having a patient die in route to the hospital or finding out that their patient died after arriving at the hospital.
• Being forced to make difficult decisions about how to allocate resources during a crisis
• making a mistake that led to the death of a colleague
• A fellow first responder dying by suicide

 With Moral Injury, the trauma and its meaning need to be processed. We need to stare into the belly of the beast and process betrayal, anger, self-loathing, and the desire to self-harm. A 2018 meta-analysis found that exposure to potentially morally injurious events were significantly associated with Post-Traumatic Stress Disorder, depression, and suicidality.

Signs of Moral Injury

• Feeling demoralized
• Feeling guilt/shame
• Feeling “haunted” by decisions, actions or inactions that have been made
• Anger in particular following betrayal
• Feelings of worthlessness, helplessness and powerlessness
• Sense of loss of identify and role
• Questioning our sense of self and a loss of trust in oneself and in others
• Persistent self-blame or blaming others
• Negative beliefs and self- condemnation
• Self-isolation, avoidance and withdrawal from others
• Reduced empathy or wanting to interact with others
• Increase in substance use
• Loss of spirituality or religious beliefs (if previously held).
• Suicidal ideation

 It's important for first responders to recognize when their work has begun to take a toll and seek support and professional help. It’s time to drop the stigma. If you feel you are suffering from moral injury and from some of the symptoms above, please seek social support and professional help. Seeking help is not a sign of weakness, it's a necessary step towards healing and maintaining overall well-being.

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD