Grief On the Front Line: Managing Our Hidden Wounds

Couple, holding hands and above for empathy in home for care, connection and motivation for mental health. People, comfort and partner for help with kindness, bonding and support for grief on table.
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By Rachael N. Belcher, NRP

First responders frequently witness tragedy, suffering, and heartbreaking situations—experiences often referred to as just part of the job. Yet, in over 20 years in EMS, I’ve never heard the mention of “first responder grief,” or anything that even hints at its existence. For lack of an established term, I will call it duty-bound grief. While grief takes many forms, this article will focus specifically on duty-bound grief, the type experienced by First Responders. I will discuss what makes it unique and ways we can grow through it.

Understanding duty-bound grief is much like understanding first responders themselves—it’s complicated. Due to the unique nature of the job, we are especially susceptible to a combination of grief types. These include disenfranchised grief, which involves a loss that is not or cannot be openly acknowledged, socially sanctioned, or publicly mourned; cumulative grief, arising from repeated exposure to trauma; and delayed grief, as we are often required to maintain a calm and composed demeanor while carrying out our duties. We also feel deeply the unexpected loss of colleagues, even those within the broader brotherhood we may not have known personally.

As grief researcher Ken Doka explains, “Most occupations are not tasked with routine exposure to the violent, unexpected, and horrific life-changing situations that occur in emergency medicine, and yet we are given so few tools to help us manage this firehose of grief.”1

Compassion Fatigue

Often referred to as “the cost of caring,” compassion fatigue is a mental state of exhaustion brought on by continuous exposure to traumatic events and suffering. Cumulative grief is a significant contributor to compassion fatigue. Since the grief experienced by first responders is rarely discussed or validated; caregivers can feel isolated in their experience of grief. It’s important to remember that this is a universal phenomenon, and you are not alone.

It’s important to note that grief is the healing process, not the injury.2

The Unique Experience of First Responders

As first responders, we quickly learn how to “turn off” our emotions to focus on the job at hand. We manage by compartmentalizing. Picture it as packing a suitcase: each time we encounter a natural emotion that could distract or deter us from our task, we set it aside in a mental “suitcase.” We might have a suitcase for grief, one for anger, another for fear—the list goes on. Over time, however, these suitcases can become so full that they start to overflow into other areas of our lives.

This overflow can manifest as depression, intrusive thoughts, anger, substance abuse, apathy, and a diminished sense of joy. It can also appear as overworking, excessive gym visits, or any activity that helps us avoid confronting these overflowing emotions. When the suitcase is full, even the mildest emotional experience can feel overwhelming. That’s why it’s essential to start “unpacking” and processing this emotional baggage to maintain resilience over the long term. Additionally, we can learn techniques to recognize and process emotions after each incident, allowing us to avoid simply adding more to the suitcase.

Grief isn’t only experienced when someone we love dies—it can be a response to any significant loss. One notable factor that can intensify grief is when we identify with the patient or their family in some way. For example, when responding to cases involving children, the experience can change dramatically for those who are parents. As one first responder shared in a classroom of fellow responders and nurses, “What changed for you when responding to and treating children after you became a parent?” The answer was unanimous: “Everything.2

Each of us brings different backgrounds, risk factors, resilience levels, and life experiences to every 9-1-1 call. What deeply affects one responder may have little impact on their partner. “This is because it’s never just the call—it’s the call plus everything else: a tough call plus a difficult divorce, a career-impacting injury, a parent’s declining health, financial hardships, or struggles with substance abuse. Often, it’s the call that triggers the underlying risk factors we carry with us every day.”2

What is Resiliency?

Resiliency is our ability to withstand or recover quickly from difficulties—a critical skill in a career that’s filled with constant challenges. First responders contend with unusual schedules, irregular sleep, and the expectation to perform at high levels under any conditions, in any environment, and in all types of weather. We carry out our duties under high-stress circumstances, often in situations that are life-threatening for us, and frequently life-or-death for those we’re there to help. These factors alone demand strong resiliency practices.

Now, add to this the repeated exposure to violence, death, and other unexpected, life-altering situations. This combination certainly qualifies as difficulties.

According to statistics, “firefighters and law enforcement officers are more likely to die by suicide than in the line of duty; and EMS clinicians are more likely to take their lives than members of the general public.3 In fact, an estimated 100 to 200 first responder suicides occur each year—double the rate found in the general population.4

Several factors are known to impact a first responder’s resiliency, including but not limited to stress levels, sleep disturbances, trauma exposure, long hours, work-related injuries, and personal life stressors.

Building and maintaining strong resiliency practices can help mitigate certain risk factors to which first responders are especially susceptible, such as PTSD, burnout, physical disability, chronic fatigue, depression, substance abuse, and suicide.

With robust support from employers—including training, open dialogue and a trusted peer support network—issues like staff retention, employee disability, sick time usage, unexpected resignations, and long-term disciplinary actions that remove personnel from field operations could potentially improve.

Pay Now or Pay Later

These are our options: pay now with regular mental hygiene practices, or pay later with the consequences of pushing our feelings aside. Just as we brush our teeth as part of our dental hygiene routine to avoid cavities and disease, practicing mental hygiene is essential for maintaining our mental health and is a crucial aspect of preventative self-care.

I have specific calls, memories, and patients that are “stuck” with me—memories that “haunt” me and resurface even after a month, a year, or even ten years. Is there anything I can do about this?

YES!

  • Acknowledge that you don’t need to personally know the person to feel grief.
  • Self-assess to determine if stored grief is affecting your life (work, personal, spiritual). This experience is unique for each individual.
  • Do you suffer from depression, anxiety, anger, irritability, restlessness, sadness, intrusive thoughts, a refusal to discuss difficult calls, substance misuse, or a weakened immune system? Symptoms of PTSD, such as nightmares, flashbacks, or anxiety attacks without an identified source can indicate “stuck” emotions.
    • If so, seeking professional help to unpack these feelings is the most efficient and effective approach. According to a recent randomized clinical trial, the “significant therapy” methods for trauma processing were found to be Eye Movement Desensitization and Reprocessing Therapy (EMDR) and Cognitive Processing Therapy (CPT).5
    • Other modalities that have been shown to reduce PTSD symptoms are cognitive therapy (CT), narrative exposure therapy (NET), prolonged exposure (PE), cognitive behavioral therapy (CBT) or a combination.5

How you can access resources: You can search for practitioners of these modalities through your insurance website, your Employee Assistance Program (EAP), EMDRIA.org, or Brainspotting.com.

How can I practice working through difficult calls shortly after they happen?

  • Develop a process that works best for you to bring your body and emotions into a more neutral state on a regular basis.
    • Connect with trusted friends, family, peers, and your shift family.
    • Utilize grounding and resiliency methods.
    • Engage in mindfulness practices such as meditation or yoga.
    • Consider therapies like acupuncture, vibroacoustic therapy, and movement therapy (just to name a few).
    • Write or journal about your experiences—be sure to protect patient confidentiality.
    • Complete the Stress Response – What we know as “Fight or Flight.”
      • Allow yourself to cry or feel your emotions. If you’re not a crier, that’s perfectly fine! What works for some may not work for others; laughter can also be a valid release. Both crying and laughing help complete the stress response, allowing our bodies and minds to realign.
    • If you are creative, express yourself through art, music, or dance. This can be a meaningful way to process emotions.
    • Request a follow up or outcome report from calls that stay present in your mind. This may help to tie up loose ends about the unknown aspects of the call after care was transferred. 

Completing the Process

  • Establish a boundary around what you will and will not carry forward emotionally.
  • Develop an “honor and release” system that works best for you:
    • Write the person’s name on a stone and toss it into a body of water in a natural setting that you find comforting.
    • Write their name on a piece of paper, roll it up, and burn it in a ceremonial manner.
    • Say a prayer for them.
    • Mentally honor and release the memory.
  • Focus on what you know, not what you imagine:
    • Acknowledge that the patient died; they had a specific injury or illness.
    • You don’t know what the patient felt, whether they experienced pain, or how the family will move forward. Avoid getting stuck reliving unknown scenarios.
  • Set a timeline:
    • Allow yourself a designated time to feel sad and awful, then commit to wrapping it up.
    • If you struggle to adhere to this timeline or if grief persists for more than a week and interferes with your life or job performance, it’s time to seek therapy (EMDR, Brainspotting or CBT) from a professional.
    • Don’t suffer! The longer you wait, the more it can become “stuck,” requiring more work to “unstick” it. Early intervention is key.

What is a Self-Assessment and Why Is It Important to Assess Yourself Regularly?

Self-assessment is the process of checking in with our bodies and minds to gauge our emotional and physical well-being. It’s crucial to perform regular self-assessments because we can become accustomed to “numbing” ourselves to fulfill our job responsibilities. This protective mechanism often carries over to our personal lives and can make it difficult to recognize when something feels off.

Performing a self-assessment and conducting a body scan can provide insights that might otherwise remain inaccessible. A body scan can be done while sitting or lying in a quiet location where you won’t be disturbed. Start at your toes and slowly mentally scan up each area of your body, taking note of any pain, discomfort, or tension. Continue this process all the way up to the top of your head. This heightened awareness can help identify where you hold tension during times of stress. It’s also beneficial to reassess after doing grounding and resiliency exercises to determine their effectiveness.

Engaging in a resiliency practice whenever you feel a stress response activate, can help bring that stress to “completion.” While it’s understood that a call is not the appropriate time to do this, it is important to complete the stress response afterward using whatever technique works best for you.

Listen to your body and mind. To grow and thrive, you must be present in your body and emotions. Growth often occurs outside of our comfort zones, so be prepared for this process to feel uncomfortable and challenging. Remember, the uncomfortable phase is temporary and can lead to healing on many levels; ultimately supporting a healthy, satisfying, and fulfilling life and career.

Be mindful of unhealthy coping mechanisms such as alcohol, substances, and high-risk behaviors. While these may numb emotions temporarily, they often have more severe consequences for your body and mind. When the “high” wears off, the underlying grief remains. Consider these unhealthy coping strategies as temporary fixes to long-term problems.

Negative Consequences of Burying Grief

Burying grief can lead to several negative consequences, including:

  • Burnout and Depression
  • Loss of Joy in Work
  • Difficulty Connecting with Others
  • Chronic Complaining –
    As human beings, we naturally want to feel empathy for the heartbreaking situations we have witnessed. However, when we have “stuck” unexpressed emotions, we may find ourselves becoming chronic complainers. This behavior can be an attempt to elicit the empathy and compassion we crave in response to minor annoyances. The last thing we want is to push others away.
  • The Tough Shell Persona –
    It’s easy to develop a tough outer shell when we struggle to express emotions vulnerably. While a tough and gruff exterior can serve as a protective mechanism, it can also mask the pain we carry inside. This may manifest as minimizing the pain and suffering of others, being unapproachable, or finding it difficult to express or feel empathy. Having someone you trust and feel safe with to open up to is essential for emotional healing.

It is important to note that, in addition to caring for ourselves, we are also responsible for observing changes in our peers and subordinates that may indicate underlying issues. Approaching these situations with confidentiality and compassion is paramount. Some indicators to watch for include sudden or gradual changes in behavior, such as:

  • Increased absenteeism or calling off work more frequently.
  • Uncharacteristic isolation from the shift.
  • Signs of irritability or anger.

As a supervisor, fostering an open-door policy and building established trust within your team is essential. Ultimately, the individual must be willing to engage in conversation; however, expressing that they are a valued member of the team and that their well-being matters can be a helpful way to initiate dialogue. Discreetly communicate that you’ve noticed some changes and that resources are available should they choose to seek them out.

Conclusion

First responders cannot avoid exposure to traumatic and stressful events; however, we can mitigate the cumulative effects of these experiences through regular mental hygiene and resiliency practices. Departments and employers play a crucial role in supporting this effort by providing ongoing training and fostering open dialogue about mental health and healthy coping strategies throughout our careers and into retirement.

Having a robust and trusted peer support network is essential. The struggles and hardships encountered as first responders can serve as opportunities for growth and deeper self-understanding.

Stress can drive personal development. You don’t have to only survive a career as a First Responder; you can thrive.

Definitions

Duty-Bound Grief: A unique form of grief experienced by first responders, characterized by the cumulative emotional toll of repeated exposure to traumatic events, combined with the need to suppress natural emotional responses in order to perform critical duties. Duty-bound grief encompasses elements of disenfranchised grief, as it is often unrecognized and unsupported by society; cumulative grief, resulting from continuous exposure to suffering and loss; and delayed grief, due to the necessity of maintaining composure in the face of intense situations. This compounded grief is intrinsic to the role of first responders and requires specialized understanding and coping strategies to address its impact on mental health and resilience.

Recommendations

Searches to identify existing research or studies relating to this specific type of grief have been unsuccessful. My hypothesis is that duty-bound grief, when gone unrecognized, can become a large branch of the Tree that is PTSD. Further investigation is necessary to delineate the scope and impact of duty-bound grief, including:

Identifying Risk Factors: Understanding which individuals are most vulnerable to duty-bound grief can help develop targeted preventative measures.

Characterizing Symptoms: Clarifying the distinct emotional and psychological manifestations of duty-bound grief will aid in diagnosing and distinguishing it from other forms of trauma.

Developing Specialized Coping Strategies: Investigating coping strategies tailored to this grief type will allow mental health professionals to provide more effective support to first responders, thereby enhancing their resilience and long-term mental health.

This research will contribute valuable insights to the fields of trauma and grief studies, facilitate more effective interventions, and ultimately foster better mental health outcomes for those who serve on society’s frontlines.

Improved Access:  Create a network of certified therapists trained in the most up-to-date and effective modalities to treat trauma. Clinicians must utilize a trauma informed approach and must be educated on the unique experiences of First Responders in order to best serve this community. This specific network must be readily accessed by First Responders in crisis, and those simply reaching out for care. Eliminating any hoops in accessing the most effective, appropriate and expediate care is crucial.

About the Author

Rachael Belcher is a paramedic with the Baltimore County (MD) Fire Department. With over 20 years of experience in EMS, and as a former 911 operator and police dispatcher, she brings a wealth of firsthand knowledge to her advocacy for the mental health and well-being of first responders. Driven by her dedication to the field, Rachael raises awareness of the unique challenges faced by those on the frontlines, emphasizing the need for specialized support and resilience-building resources.

References

  1. Romero, Kai MD. (2020, May 22). Work grief: A primer for emergency medicine providers. Academic Life in Emergency Medicine. https://www.aliem.com/work-grief-primer/
  2. Jabr, Alexandra. (2019, October). It’s complicated: Grief and the first responder. EMSWorld. https://www.hmpgloballearningnetwork.com/site/emsworld/article/1223276/its-complicated-grief-and-first-responder
  3. First responder mental health and suicide: An evidence-based approach. (2021, Fall). EMS.gov. https://www.ems.gov/first-responder-mental-health-and-suicide-an-evidence-based-approach
  4. Mendoza, M. (2024, September 28). Grief and the first responder: How denying grief can affect the first responder. Psychology Today. https://www.psychologytoday.com/us/blog/understanding-grief/202409/grief-and-the-first-responder
  5. Yunitri, N., Chu, H., Kang, X., Wiratama, B. S., Lee, T. Y., Chang, L. I., Liu, D., Kustanti, C. Y., Chiang, K. Y., & Chen, R. C. (2023). Comparative effectiveness of psychotherapies in adults with posttraumatic stress disorder: A network meta-analysis of randomised controlled trials. Psychological Medicine, 53(13). https://www.cambridge.org/core/journals/psychological-medicine/article/comparative-effectiveness-of-psychotherapies-in-adults-with-posttraumatic-stress-disorder-a-network-metaanalysis-of-randomised-controlled-trials/9A085844AD2E80CE7B5AE0520F0E648D

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