If you or someone you know is contemplating suicide, please consider calling the following numbers for the National Suicide Hotline
- 988
- National Suicide Hotline: 1-800-273-8255
Some say, “Emergency medical services work is stressful. It can make you crazy.”
That sounds laughably obvious, but it is an undeniable truth that a portion of EMS providers will develop post-traumatic stress disorder (PTSD), depression and substance abuse problems. Even more seriously, for multiple reasons both subtle and obvious, EMS has a higher than average suicide rate.1
Therefore, some EMS providers will take their own life, and the number will be a higher percentage than the public at large. And that, of course, is no laughing matter. There is a program in New York to recognize this reality, address it and work to reduce these problems. As part of this initiative, Drew Anderson, psychologist university professor, and volunteer fire fighter and EMT with 12 years-experience has given a widely shared, easily available presentation on understanding and addressing these mental health risks.
The presentation, entitled “Mental Health & Well-Being in Emergency Services & Corrections,” is now included on nycaresup.com, the website of NYCARESUP. NYCARESUP is run by the Suicide Prevention Center of New York, a division of the New York State Office of Mental Health, as well as on YouTube.
When asked about the effectiveness of using YouTube as a medium for getting important information to EMS providers, Jenna Heise, one of the spokespeople for the NYCARESUP program said that the pros of using YouTube were convenience and cost-effectiveness, while the con was tracking viewing of the presentations. “Viewers can watch the presentation at their convenience, pause and review sections as needed,” she said. “Distributing content via YouTube is relatively inexpensive compared to in-person seminars or workshops offered in the workplace.”
We spoke to Anderson recently about this program and related issues. While an earlier article focused on the inherent risks and mental health problems of EMS, this article focuses on reducing, addressing, and treating the mental health hazards of EMS.
“We should acknowledge mental health and behavioral health issues on the job are not a sign of weakness. Instead, they are an occupational hazard,” said Anderson in the presentation. “It is guaranteed, considering what we do, that a certain percentage of us will experience these problems. There’s no way around it.”
Aside from the obvious stressor of stressful, dangerous, and disturbing emergency calls, Anderson began with a list of other risk factors and stressors inherent to EMS. While admitting that many were “normal life stuff” and largely self-explanatory, they are an important part of understanding the problem of mental health risks to first responders. These were:
- Shift work
- Sleep deprivation
- Low pay / financial stress
- Relationship / family stress caused by time away from work or having to provide support and understanding to someone who works in a field that at times is difficult to understand or hear about
- Loss
In this context, Anderson explained that loss as a stressor does not just mean death, but any kind of loss including a friend, respected colleague, or mentor leaving the agency, moving away, or retiring. These all add stress to the life of an EMS service provider and increase susceptibility to the inherent mental health risks of the profession.
He acknowledged that most of these are systemic and not easily changeable.
“Low pay. Shift work. I can’t fix that.” While he admitted it would be great if there were a way to triple everyone’s pay, as there was no real way to do that, instead, he said, he would focus on what was achievable.
“There really are things you can do about it [the situation]. . . . start with focus on yourself. Individual things you can do to focus on lowering your risk.”
Project Yourself
“Physical health is the foundation. You cannot out-psychologize biology,” said Anderson, emphasizing the need for self-care and maintaining one’s physical health as an important factor in maintaining mental health. “If you haven’t slept for 36 hours, I have nothing for you. These physical factors really are the foundation for the whole thing.”
The first protective measure was sleep and the importance of getting enough sleep. This was emphasized at several points in the presentation and in different ways. In our interview, Anderson emphasized that getting sufficient sleep was the most important thing that a first responder should do to preserve their physical and mental health.
Studies have directly shown links between insufficient sleep and higher rates of PTSD and suicide among first responders. People who have had sufficient levels of sleep before a traumatic incident show much lower rates for developing PTSD than those who were sleep deprived.
Anderson said that people who do shift work, are sleep deprived, and then go out on a traumatic call are setting themselves up for failure. There is also a direct correlation between suicides and suicidality and sleep deprivation. “On the other hand, good sleep is a protective factor. Sleep makes it easier to handle all the ups and downs of life.”
“If you have to focus on one thing physically, it’s take care that you are getting enough sleep. Other reasons not on here. It [sleep deprivation] makes you worse at your job. It may increase your chance of cancer. . . I could go on for an hour on this.”
As for solutions to sleep deprivation, Anderson recommends prioritizing sleep over other forms of stress relief such as socializing,
Try to work around shift work in order to catch up on sleep. Schedule naps.
As for determining the best ways to nap, Anderson’s research has provided insight. Due to the way sleep works and the way the human brain cycles through four stages of sleep, people often awake from naps feeling “a sleep hangover” and groggy. To avoid this, he says, the ideal lengths for a nap are either 20 minutes or 90 minutes. He also advocates “coffee naps.”
“I’ve tried this, and it works, coffee naps. Did you hear about this? Nappuccino? You basically slam a cup of coffee and then take a 20 minute nap.” Anderson explains that caffeine takes about 30 minutes to metabolize and just as the coffee is kicking in, you wake up and are not just rested but also boosted by the caffeine. “It works pretty well.”
Diet, of course, is an important part of maintaining one’s health. Simply enough, Anderson advocates reducing processed foods and increasing one’s intake of fruits and vegetables.
While Anderson’s presentation advocates physical activity as an important part of maintaining one’s health, this does not necessarily mean participating in sports or being an athlete. He makes it clear that while it’s fine to be an athlete and compete and strive for excellence in a sport, this is a completely separate endeavor from trying to stay healthy.
Instead, he advocates at least 30 minutes of “moderate physical activity” a day, and it does not need to be in a single setting. He smiles when he defines “moderate physical activity” as “walking as if you were late for an appointment.”
Unfortunately, one way some people deal with stress and depression is avoidance, and this can lead to a reduction in physical activity and exercise. It can also lead to a reduction in social support. It is important to recognize when this is happening and take important steps to address it to reduce or overcome impending problems.
Among other protective factors is social support, both on and off the job including friends both within and without EMS. He mentions that people who don’t do this kind of work often don’t know how to react when told stories about difficult or unusual calls. By contrast, if all your friends are involved in EMS or emergency services work, it is easy, he says, “to get a really skewed view of reality.”
He mentions different classes of social support, such as “casual acquaintances” versus “close friends,” stating that both help provide social support and the kinds of stress relief helpful for reducing the mental health risks of EMS and related professions. He advocates that EMS providers schedule some kind of social activity each week and, like making time or sufficient sleep, make it a priority.
Again, be aware that one sign of depression and other mental health problems is withdrawal from social activities and be aware of it in oneself and others.
“Quality of life” is another goal that should be consciously worked towards in order to reduce PTSD and other mental health risks of serving in EMS. Anderson defines this as not just activities that are fun and joyful, but also activities that give you a feeling of accomplishment and purpose. These can have an immediate and lasting effect on stress. “There’s an entire intervention devoted to this. It’s not easy but it’s simple in this sense.”
He said he uses such things often in his job as a psychotherapist. “It’s doesn’t really feel like therapy,” he said. “It feels like helping people structure their lives and build these things in. Again, scheduling is key.” After one schedules such things, Anderson does a “check in.” “Did you do them? How did they work? Did you feel better afterwards?”
Peer Support
“If you see something, say something.” Although he alludes to 9-11, Drew Anderson makes it clear that he is not asking EMS providers to keep an eye out for terrorists, so much as to keep a caring and well intentioned eye on their colleagues who, like themselves, are working hard under very stressful and difficult situations and might benefit from a bit of help.
He emphasizes that “seeing something” and “saying something” when it comes to mental health concerns are two distinctly different acts, and performing each requires or benefits from a bit of training.
First one has to notice that there is a problem. When in doubt, Anderson recommends asking people. Signs to watch out for, he says, are when people are just not acting like themselves with irritability and withdrawal being common signs.
“We want to empower people to say ‘Hey, are you doing okay? You don’t seem like yourself. You seem a little bit off.’” Anderson emphasizes that just making that connection is important.
“What we see is, particularly with people in crisis, is that people feel like nobody cares about them. There’s a lot of [feelings of] isolation involved.”
“Just talking with each other, chatting, is what humans have been doing with each other for thousands of years. The overwhelming majority of peer support stuff is informal stuff. You don’t have to have any sort of formal process or anything. You just have to notice that someone is struggling or something and go ‘Hey, are you alright?’”
Even if the problems have nothing to do with EMS, Anderson uses the common but serious and often very distracting issue of divorce or marital problems, such problems can still affect EMS providers ability to do their job in both the short and long term which hurts both the provider and the agency, and a little support and understanding from a peer within this field can go a long way.
“If you have a peer support team, that’s great, but you really don’t need any special skills to do this.”
“Pay attention to changes from the norm,” he advocates. “Every agency has some people who are really good at this. You might be really good at this. But if you are not, I would take a minute and say, ‘Hey, just what should I practice to say?’ Almost like a re-canned statement.” He smiles. “We’re a big fan of pre-plans,” he says, then adds, “The hardest part when we do these trainings is to get people to actually say the words. Just your caring attention is helpful.”
It’s all part of a bigger change, a change towards a healthier, more caring environment. “What we’re really looking at here is changing the department culture. So, it’s OK for anybody to ask anybody else, ‘are you OK? Are you doing alright?’ And it’s not weird. It’s not awkward.”
However, no matter what we do or how well people take care of themselves, there will still be times when first responders and EMS providers end up getting PTSD after an event, they become suicidal. “What if we still have a problem? This will happen. I think we need a plan.”
Anderson says that If a person has been trying everything for approximately eight weeks or more then it is time to assess and think about raising that level of care up. The reddest of the red flags, the most serious, is when one realizes that a person is a danger to themselves or others. But there is no need to wait for things to reach that point if they are having problems functioning and just are not doing their job well, or even just showing signs of extreme stress, depression, distraction, or other signs, symptoms or behaviors associated with possible mental health problems.
If this seems to be the case, Anderson discusses where to go for help, suggesting supervisors, EAP or Employee Assistance Programs, and outside behavioral health professionals. Psychotherapy through telehealth, he says, has been found to be as effective as in-person treatment and mentions that this offers people in need more choices and increased privacy when making appointments.
What to Look for in Intervention and Treatment
Appropriate treatment options depend on the problem or condition.
Depression, says Anderson, is a condition any therapist should be able to treat. There are many types of treatment, including cognitive based therapies. For depression, he advocates one “look for someone you connect with,” saying that almost any therapist should be able to treat depression.
For substance abuse, there are many types of treatment available, both abstinence based and non-abstinence based treatments. The program only touched on these briefly, focusing on recognizing and talking about when to recognize or refer oneself or a colleague to such programs, not so much how to find and select one.
“As for PTSD. Heavy trauma work.” The treatment of PTSD needs a therapist with some specialized training. “You really want to find someone who knows what they are doing for that. It’s not the common cold.”
These treatments or interventions for PTSD include exposure based therapies such as prolonged exposure based therapy, and cognitive processing therapy. According to the American Psychological Association, prolonged exposure therapy works by gradually and carefully having the patient relive or describe the traumatic experiences in a safe setting, and then learning, again gradually and carefully, to respond and react more effectively to the cues, stimuli, or reminders of the incident or incidents that are producing the traumatic, undesired reactions.2
According to the same source, Cognitive Processing therapy focuses on understanding the suffering person’s harmful beliefs about the event and then reinterpreting and correcting them.3 These often lead to improvements within 5 to 6 weeks or in 10 to 12 weeks depending on the type of treatment.
One popular and effective treatment is EMDR or Eye Movement Desensitization and Reprocessing therapy. This involves sessions where the person being treated retells experiencing the traumatizing event, while simultaneously engaging in another task, such as following an object from left to right with their eyes or tapping on the table. While there are some controversies as to why and how it works, it has been found to be an effective treatment of PTSD.
As for what to do when considering a therapist to treat PTSD, Anderson made his views clear. “I would say, ask that therapist if they do an exposure based treatment. They’ll know what you are saying when you say that. You really want to find someone who has the skills and the training to do this kind of work.”
References
1. Haack, J. (2024, October 10). What the Research Tells Us about Mental Health. Journal of Emergency Medical Services (JEMS). Retrieved November 19, 2024, from https://www.jems.com/mental-health-wellness/research-tells-us-about-mental-health/
2. (n.d.). Prolonged Exposure (PE). Apa.org. Retrieved November 19, 2024, from https://www.apa.org/ptsd-guideline/treatments/prolonged-exposure
3. (n.d.). Cognitive Processing Therapy (CPT). Apa.org. Retrieved November 19, 2024, from https://www.apa.org/ptsd-guideline/treatments/cognitive-processing-therapy
