
The Problem
When it comes to the mental health of emergency medical services (EMS) workers, you are deluding yourself if you think it is “OK not to be not OK.” We have made progress, but not nearly enough. The EMS frontline is paying a heavy price in disability and death. Our families—biological and occupational—are collateral damage.
Findings by researchers reveal that of responders considering disclosing their mental health status, 55% say supervisors would treat them differently, 45% say co-workers would think them weak, and 34% believe they will not get promotions.1 If we openly seek to preserve our own mental health and life, we may not be allowed to continue our work saving others.
I wish I could tell those entering the field that it is recognized as a strength to be open about mental health. Unfortunately, it is a risk for those in EMS to say they are not OK or are OK but were not at one point—especially to present or potential employers.
I have been outspoken about mental health. I have disclosed in writings and presentations that I have anxiety, depression, and posttraumatic stress disorder (PTSD). I have felt the pull of suicidal ideation, and talk openly of my wife, brother, and co-workers—all of whom died by suicide.
Related
- Psychological Trauma: The Silent Stalker
- Post-Traumatic Stress Disorder Comparison Between Fire and EMS Personnel
- First Responders and PTSD: A Literature Review
- Toward a Better Understanding of Post-Traumatic Stress Disorder (PTSD)
My disclosures have made me the target of discrimination and other unsavory actions, but also make me a safe person to approach. I am honored I can lend a caring ear but disheartened by the stories. I am sometimes tired and downtrodden, sometimes downright angry, and always focused on honoring those who have died and those who are alive and struggling. I am weary—no, sick and tired—of those among us in EMS who “talk the talk,” but do not “walk the walk.” Would-be helpers often silently watch. As a holocaust survivor, Elie Wiesel said, “Neutrality helps the oppressor, never the victim.”
Real-Life Examples
There are too many stories to relay without writing a novel. I have selected two of the more poignant ones and my own. Names have been changed to protect the innocent and not-so-innocent.
Sara, a colleague, was a finalist at a fire department and then rejected because the psychologist conducting her pre-hire assessment advised against hiring. The reason? During the assessment, Sara revealed that she had been abused as a child and had been successfully treated for PTSD. In the psychologist’s written opinion, Sara was at too much of a risk of being psychologically traumatized. So, the person who arguably would be the most empathetic and helpful on abuse-related calls was denied the opportunity to use the trauma she successfully recovered from to help others. Sara was essentially re-victimized. The message to everyone applying to that department is, “Whatever you do, do not disclose that you were abused.” So much for victims’ rights.
Listening to Sara’s story, I could not help but reflect on Barb, a former student. It was 2014 and Barb had been in EMS for several years. By all accounts, Barb was an exemplary student and an accomplished paramedic. Barb moved out of state and sought EMS credentials in the new state. On the application, was a question about mental health and Barb disclosed that she had been treated for depression and PTSD. The result was a denial of her application. Barb emailed asking if I could send a letter of support to the State. Ultimately, Barb did prevail, but not without a lot of effort and stress. I found the letter and would like to share it here.
I am writing on behalf of Barb Smith, who was enrolled in our paramedic program and successfully completed her coursework in 2005. While at our college, Barb was an exemplary student and performed well both in the classroom and in her clinical/field experiences.
I am aware that Barb has suffered from depression, and I understand that she has been treated successfully with medication. I have observed no indications that Barb is unable to carry out the duties and responsibilities inherent to working as a paramedic.
I would like to point out that according to the Centers for Disease Control (CDC) 50% of Americans have a diagnosable mental disorder and an estimated 19 million people suffer from depression. The National Alliance for the Mentally Ill (NAMI) reports that treatment available today is highly effective with a 70-90% success rate, which is better than treatment success rates for many other common diseases. Through advances in medicine, we now realize that depression is caused by a chemical imbalance in the brain and that this illness is fundamentally no different that asthma, diabetes, or heart disease.
As a long-time paramedic and educator who has been diagnosed and treated for posttraumatic stress disorder (PTSD), I can assure you it is possible to serve as a proficient clinician and to even excel in the field of emergency medical services. The stigma of having a mental health issue has long been a barrier to otherwise successful and productive members of my profession and society in general. I urge you not to let this stigma continue to be perpetuated and prevent qualified and able people, such as Barb, to be barred from a profession they have a drive and passion to thrive in.
Fast forward back to today. A paramedic colleague of mine, John, suffers from PTSD, major depressive disorder and generalized anxiety. After years of struggling and at the urging of his wife, John sought help and took leave under the Family Medical Leave Act (FMLA). At the 12-week point, John asked for more time while actively engaging in treatment.
Under FMLA,2 the employer no longer had to guarantee employment or a similar job after 12 weeks. John learned that his position had been posted and was told he could apply for any job he was qualified for later. John’s mental health provider canceled his appointments until he could prove he had health insurance or private pay. John’s former employer offered insurance continuation under the Consolidated Omnibus Budget Reconciliation Act (COBRA), but the program is costly, and he is now out of a primary job, with a family to support. John is with in the process of wading through mounds of paperwork, which is daunting given his health.
To add insult to injury, John’s co-workers said they had been told not to contact him during leave because it was “none of their business.” I cannot imagine an employer telling co-workers of a person recovering from a heart attack or struggling with cancer, “It is none of your business.” The moral of this story is, “If you get to 12 weeks FMLA, come back and fake it in hopes you make it.”
The last example is my own. In 2019, a new fire chief who rose through the ranks, Don, attempted to put my mental health on a performance review. In the preceding 25 years, I had all positive reviews, a long list of accomplishments, and no discipline or patient complaints. The first statement Don made was to the effect of, “You know I have to find something you need to do better on, right?” Don told me that I needed to work on conflict management skills. Unfortunately, Don was unable or unwilling to share any details about the statement. Feeling pressured, Don finally said, “People talk” and “We were really worried about your mental health.” When asked when, Don said, “About six months ago” and then said, “The younger medics think you are stuck in your ways.” Again, no examples were given. After declining to sign the review without a satisfactory explanation, Don struck the comment from the review, and I gave him something legitimate to write. Later, Don would deny he said such a thing and an EMS commander would say, “I know you believe that happened” and invoked the word, “paranoid.” By virtue of having a mental health diagnosis, what I said did not matter because any complaint I made—no matter how legitimate—would be dismissed as the result of mental illness altering my perception. Using this line of logic, one can do just about anything to an employee and get away with it so long as there are no witnesses.
Two days after I filed a formal complaint against Don, an anonymous and confidential complaint was lodged against me. This complaint was held out as evidence that I did have a problem with conflict management. Without knowing what the complaint could be about, I lost a fair amount of sleep thinking about it. My anxiety was heightened, and depression set back in.
The public safety director/police chief, Eric, would later say in an e-mail, that the review was “professional, productive, and not adversarial.” Don later wrote in an e-mail to human resources, “The conversation was very light; the mood was good” and “It was a very calm and professional meeting.” Later, the City’s legal response claimed I had an “exaggerated and hostile reaction to the suggestion that anyone could have said anything even remotely critical about him.”
To make a complicated story short, I resigned from my position in 2021 after two years of fighting. My dead wife and brother were referred to as a source of my problems and the reason people were to be warry about my mental health. My family became stressed, and I became physically ill when approaching the main station, so avoided it and worked at a remote station—one silver lining of the pandemic. I filed a First Report of Injury Report because, on principle, the least that could be done was to cover medication and therapy co-pays.
Despite the PTSD law in my state, I was still denied my claim by the League of Minnesota Cities (LMC). The psychologist hired by the LMC wrote that I had achieved the maximum recovery expected and met no criteria for psychiatric diagnoses. I was disregarded because I had mental illnesses. Now I was told I did not have any. Apparently, the status of one’s mental health is determined by whatever best serves to avoid a compensation claim or culpability for discrimination and harassment. I can only image how many other people have gone through the same hardship as myself while trying to receive the benefits they deserve.
The psychologist further wrote that no trauma was caused by my work as a paramedic. This despite diagnoses from other professionals, medication regimens, eye-movement desensitization, and reprocessing treatment, and multiple assessments and therapy sessions. One would think more weight would be put on the findings of therapists I had seen for years over one assessment the LMC paid for on behalf of an insured employer.
State Law
This section is devoted to Minnesota law; however, many other states have similar laws. There are likely discrepancies in your own state, and I urge you to investigate.
The presumptive PTSD bill that was established to protect us in EMS has a loophole that specifically omits PTSD arising from the way an agency “in good faith” treats—or victimizes (my words) their employees.3 An agency can make life rough for a responder, exacerbate their PTSD, and force a resignation because it was an employer-amplified trauma, not a continued response to calls. Of course, the responses do have a role. Like cancer and heart disease, it is generally naïve to think chronic maladies are caused by one factor. The bill is silent on cumulative trauma and requires the employee to report a single incident causing PTSD and receive a diagnosis from a psychiatrist or psychologist.
The diagnoses cannot come from other qualified licensed professionals, such as licensed clinical social workers or licensed professional clinical counselors. The statute rules that trauma of other origins cannot exist for a claim, and those diagnoses must follow the current Diagnostic and Statistical Manual (DSM). The DSM states that PTSD can occur from several factors, not just a single incident.4 These conflicting statements and cherry-picking of the DSM favor the employer to the detriment of the EMS worker. Many of us have experienced other forms of traumatic experiences in our lives that are non-occupational—both before and after exposure at work. Most of us with PTSD would be disqualified from a claim before even filing for one.
In Minnesota, a firefighter’s death is a line of duty-death if they die of a cardiac event within 24 hours of a response or training. Questions about smoking history, diet, exercise, genetics, or even past heart history are absent in both the statute6 and the Death Benefit Application from the State.7 There is clearly a double standard when it comes to mental health. Does the State believe PTSD is only valid if it comes from something on-the-job you can point at, or not? The statute is a start, but it does too little, does not favor the employee, and is blind to scientific evidence.
On the other hand, the Minnesota Hometown Heroes Assistance Program provides funds to assist firefighters (non-fire EMS is excluded) in several facets of their health if they experience cancer, heart disease, or psychological trauma.5
The ADA and EEOC
The Americans with Disabilities Amendment Act (ADAA) was enacted to prevent discrimination based on disabilities—actual or perceived, including depression and PTSD.8 The Equal Employment Opportunity Commission (EEOC) investigates and enforces ADAA violations.
After trying to negotiate for change unsuccessfully, I filed an EEOC complaint for discrimination. Employers get a “pass” if they have no knowledge of disability, and Don and Eric feigned ignorance. It was a weak argument, given Don himself had been to my presentations, and the department subscribed to journals where I disclosed my disabilities in writing.
A filing was made with the EEOC, that included direct and documented contradictions within the city’s own statements. I was warned the EEOC would not review the documentation thoroughly, or take it seriously because I was not seeking money. Sure enough, the EEOC found insufficient evidence for ruling one way or the other. The complaint was withdrawn so others would not be aware. I have a 180-day period to file a lawsuit. Unfortunately, the city has taxpayer-funded legal defenses and has outspent me. Justice, it appears, is for sale to the side with the deepest pockets.
Call to Action
Researchers conducting an analysis of studies found that among EMS providers, an estimated 11% suffered from PTSD, 15% from depression, and 27% from general psychological distress.9 My research reveals that EMS personnel have high levels of suicidal ideation, suicide plans, suicide attempts, and suicide deaths when compared to the public.10,11
I was able to put up resistance, but what about the next responder? What is the value we place on even one responder’s life? I must do what I can, even if I cannot afford the legal battle. To do anything else would be tantamount to spitting on the graves of those who lost their mental health battle and thumbing my nose at those who suffer now.
Here are helpful things you can do.
- Advocate for and support colleagues. It is difficult to file paperwork, seek assistance, or complain of unfair treatment when one is in psychological distress.
- Sponsor education on mental health and other disabilities among ourselves and our patients.
- Be intolerant of discrimination, including about mental health. How we treat each other is how we care for our patients.
- Draft policies and procedures that treat mental health and physical health maladies similarly.
- Foster a culture of doing the ethical thing rather than complying with the minimal legal obligation.
- Research. How frequently does this occur? What are the root causes?
- Urge politicians to clean up existing laws and pressure the EEOC and equivalent organizations to do a thorough job.
We are in a war against death and disability. If you fall, I will come back to carry you out. Will you do the same for your partners, or leave them dying on the field of battle?
Editor’s note: This piece has been updated to clarify a misrepresentation of the Minnesota Hometown Heroes Assistance Program unintentionally created by the author during the editing process.
References
- University of Phoenix (2017). Majority of first responders face mental health challenges in the workplace. Retrieved from http://www.phoenix.edu/about_us/media-center/news/uopx-releases-first-responder-mental-heal th-survey-results.html
- Family Medical Leave Act of 1993, 29 U.S.C. § 630.1703(a) et seq. (1993). https://www.dol.gov/agencies/whd/laws-and-regulations/laws/fmla
- Minnesota Workers Compensation, Minn. Stat 176.011 § (2021). https://www.revisor.mn.gov/statutes/cite/176.011
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author.
- Minnesota Hometown Heroes Act, Minn. Stat 299A.477 § (2021). https://www.revisor.mn.gov/statutes/2021/cite/299A.477
- Minnesota Public Safety Officer’s Benefit Account, Minn. Stat. 299A.41-46 § (1990). https://www.revisor.mn.gov/statutes/cite/299A.42
- Minnesota Department of Public Safety. (n.d.). Public safety officer benefit programs. Retrieved from https://dps.mn.gov/divisions/co/programs/public-safety-officer-benefit-program/Pages/default.aspx
- Americans with Disabilities Amendment Act of 2008, 42 U.S.C. § 12102 et seq. (2008). https://www.ada.gov/pubs/adastatute08.htm#12101note
- Petrie, Milligan-Saville, J., Gayed, A., Deady, M., Phelps, A., Dell, L., Forbes, D., Bryant, R. A., Calvo, R. A., Glozier, N., & Harvey, S. B. (2018). Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis. Social Psychiatry and Psychiatric Epidemiology, 53(9), 897–909.
- Caulkins, C. G. & Wolman, D. (2020). Emergency responder suicidality: An analysis by field and emergency medical services credential. Journal of Forensic Brain and Neurological Disorders, 2(1), 1-10.
- Caulkins, C. G. (2018). Suicide among emergency responders in Minnesota: The role of education (doctoral dissertation). Retrieved from https://repository.stcloudstate.edu/hied_etds/28