We must accept finite disappointment, but never lose infinite hope.
— MARTIN LUTHER KING JR.
Officer Taylor called in sick for the fifth day in a row. She hadn’t gotten out of bed in those five days other than to go to the bathroom or to scrounge up something to eat. She lay in bed staring outside as the world went by, oblivious to the emotional pain she was trying to endure.
Taylor had once been an enthusiastic officer who loved going to work every day. Now, eight years later, she didn’t understand what had happened to her. She couldn’t remember the last time she really enjoyed anything. She was unable to connect with her family and now avoided her friends, fearing they would think she was losing her mind. She hated the thought of going in to work.
Officer Taylor had become calloused, unable to feel anything for anyone. The only thing she felt now was the emptiness and helplessness inside her. The pain in her spirit was overpowering and absolute; it felt like a sword had pierced her soul. Her heart ached beyond description. She felt hopeless, unable to cope with the prospect of continuing on in her depression.
That’s when Taylor saw her service handgun on the counter in the other room. She realized that the only way she could end her emotional suffering was to end her life. She walked over to the counter and stared at her gun belt. As she slowly wrapped her trembling fingers around the butt of her handgun, she felt some comfort. That weapon had kept her safe for eight years; now it would give her peace. She removed the handgun and walked back to her bed, passing a photo in the hallway of herself smiling as an officer newly graduated from the police academy.
Taylor sat in bed, holding the gun in her right hand and resting it on her lap. Tears began to roll down her cheeks as she lifted the barrel of the gun toward her open mouth. At that moment, her cat jumped up on the bed, purring and rubbing his face against her thigh. Taylor had the immediate thought that after she killed herself, no one would take care of her cat. Her love for her cat caused her to come out of her trance and begin thinking about how she might keep living. She was able to pull herself together and seek the help she needed through the police psychologist and the peer-support team. She had had no idea that she’d been suffering from intense PTSD, and she soon realized she wasn’t losing her mind but had suffered a serious injury to her mind and spirit. After only a few sessions of an extremely effective treatment for PTSD called EMDR (eye movement desensitization and reprocessing), she began to recover. Officer Taylor is now doing well.
Because a career as an emergency first responder inherently exposes us to repeated and significant traumatic incidents and acute stress, it is impossible for us to avoid events that can cause acute stress disorder (ASD) or post-traumatic stress disorder (PTSD). For this reason, it’s essential for you to learn how to prepare yourself to constructively process the repeated trauma of your profession.
It is estimated that hundreds of thousands of current and former emergency first responders are suffering from PTSD and ASD. Just one major traumatic incident or the cumulative effects of repeated stressful situations can cause acute, debilitating stress, or acute stress disorder. If this condition continues unrelieved and becomes further aggravated, it can potentially develop into PTSD, which is actually an injury to the brain’s ability to process a critical incident or acute stress, and may result in several seriously debilitating symptoms.
Acute stress disorder causes many of the same symptoms as PTSD, just to a lesser extent. PTSD is brought about by continued exposure to psychological trauma causing intense fear, horror, or helplessness. Every emergency first responder is susceptible to these potentially debilitating injuries to the mind and spirit, but there are ways to prepare for and process trauma that can significantly reduce the intensity and duration of symptoms.
It is important to understand the development of PTSD from a psychological perspective. PTSD tends to develop after a critical incident in which an emergency first responder has been exposed to trauma that concerned actual or threatened death or grave harm. It can also develop over time, after a person has endured repeated, significantly stressful and intensely dangerous situations. The typical emotions experienced during such incidents include extreme fear, helplessness, and alarm. During or after the incident, you may experience emotional numbing, the inability to recall information or details related to the incident, the feeling of being in a fog, depression, and a repeated sense of watching yourself from a distance.
Well after the incident is over, PTSD sufferers may reexperience the trauma through flashbacks, night terrors, or illusions. Physical symptoms of PTSD may include an extremely heightened sense of hypervigilance along with an inability to relax, extreme anxiety, serious difficulty sleeping, and intense agitation. You may also try to avoid any reminder of the critical incident by staying clear of certain people or locations, switching your shift, or not coming to work. You may even experience inadvertent incidents of dereliction of duty. Other potential symptoms include significant mood disturbances, which may result in feeling disconnected from others and an inability to express feelings in the way you did previously. The emergency first responder suffering from PTSD may also experience intrusive thoughts, angry rages, the inability to concentrate or focus, an exaggerated startle response, continued depression, uncontrollable emotions, and the inability to stop mentally replaying the traumatic event over and over again.
These symptoms tend to have a profound negative effect on work performance and one’s overall quality of life. They often lead to poor coping skills or to risk-taking behaviors, such as excessive drinking, drug use (legal and illegal), promiscuity and affairs, and various addictions, such as gambling, pornography, and others. Other signs of maladaptive coping include difficulties in family relationships and an excessive desire to isolate yourself.
It is key for you to realize that all these symptoms are a natural, normal physiological reaction as the mind attempts to process trauma, since the brain’s normal processing ability has been injured. You may experience these symptoms to a greater or lesser degree than someone else, but every emergency first responder is susceptible to undergoing a PTSD injury and symptoms. The most important thing for you to remember is that if you are experiencing any of these symptoms, it is critical to seek help.
Struggling to resist or hide the symptoms can inadvertently cause symptoms of ASD to worsen and become PTSD, or can cause the more severe symptoms of PTSD to become seriously life altering. These symptoms do not typically just suddenly go away. You need to be trained in advance to deal with them, or helped through the experience, so that your mind can positively and effectively place the traumatic event in the proper perspective and, by doing so, alleviate the symptoms.
There is never any shame in needing or seeking help; it is normal. In fact, as a matter of emotional survival and wellness, you should see a therapist annually who is experienced in PTSD and in treating first responders as part of a regular pattern of prevention and wellness maintenance — even if you are not experiencing any symptoms. The only shame is not doing everything you can to be well; to enjoy life, family, and work; and to move forward. It would be a tragedy to choose to suffer through something that reduces the quality of your life when there is assistance available that has been proven effective. PTSD is not about what’s wrong with you — it is about what happened to you.
To limit the intensity of PTSD symptoms and to constructively process trauma, preparation is critical. You will need to be both mentally and physically prepared in order to provide yourself with the best chance for surviving emotionally. In addition to the spiritual wellness practices described in chapter 2 — which inherently fortify the mind, spirit, and emotions, enabling them to deal with a traumatic incident once it happens — the following wellness methods, too, will assist you in preparing for and mitigating the effects of ASD and PTSD.
Develop a trusted support system made up of family and friends. Discuss with them what to expect, how you are likely to behave after a critical incident — either after a traumatic event or after consistent exposures to significant stress — and how they can best support and most effectively help you. Remember, your physical, mental, and emotional health and well-being, as well as the quality of your life, all depend on your level of preparedness and the development of an effective support system.
As a form of prevention and wellness maintenance, consult with a psychologist specializing in treating emergency first responders and trauma to determine if you are being adversely affected by past trauma and to gain insight into how to deal with trauma and stress more effectively.
The idea behind an annual checkup like this is not that “something is wrong.” Something may or may not be affecting you, but the emphasis is on getting a wellness check and discussing the previous year — both professionally and personally — regardless, as a preventative and wellness-maintenance measure. This is similar as going to a physician each year for a physical checkup. The goal is to accomplish several different things:
1. Discuss issues that are currently concerning you; talk about how things have gone professionally and personally over the preceding year.
2. Explore the past year in general and look for areas of concern or in which you might wish to make changes.
3. Examine the coping skills and resiliency you have exhibited during previous stressful and traumatic events. Discuss what your coping mechanisms are. Are they healthy? How might you improve on them?
4. Set goals for the next year.
5. Become comfortable talking with a therapist who is an expert in dealing with trauma, PTSD, and first responders. That way, you’ll be more comfortable seeking assistance if you ever feel it is needed in the future.
Work at developing a mind-set that recognizes that you will eventually experience a significant traumatic incident, and that you will survive. Envision how you will handle such an experience both during and after the fact, and what would help you process the trauma and place it in its proper perspective. Mental rehearsal and visualization — seeing yourself experience a traumatic incident and coming through it all right — is essential.
According to Lt. Colonel David Grossman (coauthor of Warrior Mindset and On Combat), tactical breathing has been shown to dramatically help people not only function at the highest levels during a traumatic event but also cope with the aftermath. Essentially, tactical breathing consists of the following: Just before or after a traumatic incident, or while your mind is reliving the event, take a big breath in through your nose, hold it, then breathe out of your mouth slowly for four seconds. Then repeat this several times. This will calm and center the automatic responses of your mind and body to stress.
Participate in a critical-incident stress management debriefing or defusing within a few days of experiencing a critical incident. (These debriefings and defusings are explained later in this chapter.)
Shortly after a serious critical incident, seek assistance from a psychologist who has experience in traumatic events, whether you think you need it or not. Most agencies have a contract with such psychologists (through the Employee Assistance Program) and offer a certain number of confidential visits for free or at a significantly reduced cost. Treatments for ASD and PTSD can be relatively short-term and extremely effective, especially if sought soon after an incident.
Develop the habit of consistently being well hydrated — with water, not energy drinks, coffee, or sports drinks. Maintaining good hydration helps the brain remain alert and able to process trauma more effectively. Good hydration coupled with good sleep management will significantly help you be prepared for trauma and will lessen its effects.
Find understanding people to talk with who will listen without judgment. Peer-support colleagues (see chapter 7) who have experienced traumatic events offer an invaluable, confidential, and trusted resource; they are individuals you can talk with in order to begin to process the trauma.
PTSD is a complex injury to the brain’s coping ability in which the affected person’s memory, emotional responses, intellectual processes, and nervous system have all been disrupted. PTSD can occur immediately or weeks or years after a traumatic critical incident. Approximately 40 percent of those experiencing PTSD symptoms have a delayed onset of symptoms; about 80 percent of people who develop PTSD also develop other serious health issues, such as heart disease, diabetes, and excessive weight gain.
There are several signs that you and your family members should look for that potentially signal the development of PTSD. These signs include the following:
• broken sleep because of nightmares or night terrors
• outbursts of anger over insignificant things or things that normally would never bother you
• withdrawing from interaction with family, friends, and activities
• having difficulty at work
• taking more leave from work than normal
• drinking too much or abusing medications in order to sleep or forget
• becoming anxious, and possibly even vomiting, before going to work
Many times a person suffering from PTSD does not realize what has happened or how they have changed. If family members or coworkers see some of these signs, it is critical for them to ask questions and offer help. Coworkers and family can assist the person in seeking help in a positive way, by supporting and showing genuine concern for the affected person’s well-being without judging, criticizing, or pressuring the person to just “get over it.”
The following nonintrusive, nonjudgmental questions can be used to begin a conversation:
• “The other day I noticed that you weren’t really yourself. Has anything been bothering you?”
• “Do you want to get some coffee to catch up? I’ve noticed over the past few weeks that you haven’t been yourself.”
• “I’m concerned about you — how are you doing? If you ever need to talk or need anything at all, I’m here for you.”
See chapter 8 for detailed information on what a spouse or other family members can do to support their emergency first responder.
There are several effective treatments for PTSD, such as cognitive behavioral therapy, cognitive processing therapy, stress inoculation therapy, and EMDR. All of these are endorsed by the Department of Defense, the Department of Veterans Affairs, the American Psychiatric Association, and the International Society for Traumatic Stress Studies. The rest of this chapter covers two tools that many first responders find especially effective.
One of the most effective treatments is EMDR. The theory behind it is that traumatic experiences upset the biochemical balance of the brain. EMDR is a form of accelerated information processing that tends to unblock the brain’s information-processing system. EMDR seems to allow the brain to complete the processing that was left unfinished after the traumatic event, when the brain’s normal processing was altered as a result of the traumatic incident.
The purpose of EMDR is to enable a mental restructuring of information about the traumatic event that has not been resolved and normally processed. It helps eliminate the surge of emotion that an individual experiences when thinking about or talking about the event. Traumas that have not been mentally resolved are associated with negative perspectives on issues of self-control, which relate to the negative images manifesting themselves in many forms throughout a person’s life.
Traumatic events that have been completely processed and resolved by means of EMDR appear to accelerate the process necessary to allow assimilation of the trauma into previously held views and norms.
Using a three-pronged approach, the therapist addresses the original traumatic incident, elicits the present internal and environmental triggers that stimulate poorly adaptive behavior, and installs a desired behavioral response that then becomes natural. The following story, written by a fire captain from an agency in Southern California, is a great example of how effective EMDR can be.
As a fire captain, I, along with my colleagues, have responded to hundreds of auto accidents, including many disturbing fatalities. One crash initially seemed like all the rest. An innocent victim, no known name, only the unmistakable image of a lifeless face staring into the far-off distance. A drunk driver had killed this twenty-six-year-old woman, who had been doing the right thing by acting as the designated driver for her husband on the ride home in the early morning hours.
The scene was as routine as a DUI crash can be: two bloodied bodies lying in spinal stabilization before being loaded into a single ambulance heading to the hospital. One of them was just hearing the news that his young wife was dead, as the other was being informed that he had just killed a woman. Meanwhile, the victim still lay covered on the roadway, her bloodied body staining the sheet, a lifeless corpse who had been a vibrant and beautiful young woman only minutes earlier.
Unfortunately, the scene of mangled vehicles and scattered debris was routine to us. The same old story of tragedy and unnecessary death. But for some reason, this particular young woman’s face was burned into my brain. I couldn’t stop seeing that lifeless face with her wide-open eyes looking right through me. It wasn’t completely out of the ordinary for images of disturbing scenes and tragedy to trouble me for the remainder of a shift. But this incident was different, a totally new and unwelcome experience.
I kept seeing the dead woman’s face — night after night, day after day. There were times I looked at my wife and saw the dead girl gazing back at me. I had a good support system at home, which is crucial, as well as at work; but because I didn’t even know I had a problem, I couldn’t use the support I had in place.
My wake-up call was a terrifying dream I had about a week after the incident. I dreamed that I was back at the scene, smelling leaking gasoline, stepping over tangled debris, while attempting to remove the young woman from the car as a body recovery. In the dream, as had happened in real life, the young woman was obviously dead, with severe trauma to her head. But in the dream, as I grabbed her upper body in an attempt to lift her out of the tangled wreckage, she abruptly opened her eyes and told us that we killed her. I snapped out of my sleep in a cold sweat, trembling. I knew it was time to seek help. I didn’t know what was going on with me, and I wondered if I was starting to lose my mind.
Help came initially from my fire department through the Employee Assistance Program, which set me up with a therapist. Ultimately, this resulted in a treatment that I had never heard of, called EMDR. I was more than willing to try anything that might get these visions and dreams out of my head. Nothing I had tried on my own was working. The more I tried to forget, the clearer the disturbing images became and the more frequently they showed up.
Incredibly, one treatment was all it took as I embraced the process with metaphorical open arms. It was an amazing transformation as I “saw” the treatment work in my own mind and actually found closure to this event. To this day I have no idea why this particular incident had such a dramatic impact on me. I don’t know why I needed treatment for this call more than any other, but I’m thankful that I found it.
To find an EMDR therapist in your area, visit the EMDR International Association website: www.emdria.org.
Critical-incident stress management (CISM) is a proactive, comprehensive approach to mitigating the effects of a potentially debilitating critical incident. It encompasses both prevention and intervention. Prevention involves equipping people with resources before an actual crisis so that they can potentially cope better or even avert the development of ASD or PTSD symptoms. Continued, periodic training is also a component of CISM. This provides education regarding the nature of critical-incident stress, basic stress management strategic coping skills, and resiliency. Establishing realistic expectations regarding the nature of stress reactions can be crucial in combating misconceptions of invulnerability.
Studies and personal experience have shown that a CISM debriefing (typically held one to three days after the event) of people involved in any serious traumatic incident can be extremely beneficial. A CISM debriefing is a structured group discussion with all persons involved in the traumatic incident, including dispatchers and call takers. The structured discussion lasts two to three hours and is facilitated by a mental health practitioner experienced with trauma using the CISM model developed by J. T. Mitchell.
The CISM debriefing is also attended by peer-support team members and, ideally, a department chaplain. Attendance at the facilitated discussion is mandatory for those involved in a traumatic incident, but participants speak voluntarily. Nancy Bohl-Penrod, of the Counseling Team International, has slightly modified the standard seven-phase Mitchell model of CISM to include nine phases. The debriefing allows for both mental and emotional processing of thoughts, feelings, and reactions. It also provides information on stress management and coping strategies. Reasons for a CISM debriefing and its therapeutic effects include the following:
1. Early intervention. Early counseling prevents the crystallization of traumatic memories.
2. Opportunity to verbalize the trauma. Verbally reconstructing and expressing specific traumas, fears, and regrets leads to reduced stress reactions and symptoms and can promote the constructive processing of trauma.
3. Group support. The group experience provides numerous healing factors that are intrinsic to the group process, including the validation of thoughts, emotions, and stress reactions.
4. Peer support. Peers can most effectively eradicate the myth that what the traumatized person is experiencing is unique, and they can suggest more appropriate stress-management techniques.
5. Stress education. This allows for a better understanding of the skills that can be learned in order to cope with stressful situations.
6. Follow-up support. People in need of further care can be more readily identified during follow-up sessions.
EXAMPLE OF A CISM DEBRIEFING
In a typical CISM debriefing, the facilitator, the peer-support team members, and the chaplain begin by explaining the process and their roles, and clearing up any initial concerns of those present. The fact phase is next, in which participants describe, from their own perspectives, their involvement in the incident.
The fact phase is followed by the thought phase, in which participants talk about their thoughts associated with the critical incident and immediately afterward. During the reaction phase, participants are encouraged to express any emotions regarding the incident. This phase allows everyone to identify what was, for them, the most traumatic aspect of the incident, along with their associated emotional reactions to the trauma. This is followed by the symptoms phase, in which participants describe any stress-related symptoms experienced since the traumatic event. It also allows an opportunity for peers to validate those symptoms.
The unfinished-business phase allows participants to bring up anything from the present critical incident that reminds them of a past traumatic experience that may still be bothering them. Often, traumatic incidents resurrect memories of and intense emotions related to past traumatic experiences that have never been effectively processed. One such example is an instance when an officer described feeling and thinking he was going to die during the fatal shooting of a suspect. He mentioned that this incident didn’t bother him nearly as much as an incident two years earlier, in which he was suddenly surprised by a man who shoved a loaded gun in his face and the officer had to react with his bare hands to defend himself. This phase was an ideal time for the facilitator to discuss and help the officer process that previous incident.
The goal of the teaching/educational phase is to educate the participants about critical-incident stress and coping tactics, possible symptoms that may be experienced after a delayed onset, and ways to mitigate those potential symptoms. This is followed by the wrap-up phase, in which participants can ask questions. Finally, in the round-robin/reentry phase, the facilitator clarifies any ambiguities, answers final questions, and makes summary statements that return the group to its normal mode of functioning.
CISM debriefings have proven to be highly effective. For the more serious incidents, a secondary CISM debriefing is recommended. The life partners of the first responders who were involved attend this one, without the first responders being present. This meeting provides the family members with invaluable insights, support, and assistance so that they can most effectively support and care for their first-responder mates.
In contrast to a CISM debriefing, a defusing is a group discussion with all employees who were involved in the incident, usually within hours, which allows for an initial processing of the event and a discussion of the participants’ immediate reactions to it. Typically a defusing involves peer-support team members only, without participation of a mental health practitioner. A defusing is informal, a shorter discussion for less serious incidents, but it still addresses the potential for participants to develop debilitating stress reactions. Defusings provide information about coping with stress, normalizing reactions, and assessing potential wellness needs.
Additional information and resources for treating PTSD is available from the National Center for Post-traumatic Stress Disorder, at www.ptsd.va.gov/index.asp, and from the Counseling Team International, at www.thecounselingteam.com.
In what ways do you cope with problems, and what can you do to more wisely and positively deal with them? Do you tend to ignore issues and feelings, or do you handle issues in a positive way as they arise?
Most people tend not to deal with their problems; they simply ignore them. As a first responder, you will find that this can become detrimental to your wellness and your coping ability. It’s imperative to recognize issues and deal with them immediately in a positive, constructive way. Ignored feelings will only intensify. Simply recognizing them and becoming more aware of how they affect you is an important first step.
What gives you hope and why?
When you lose hope, you have nothing. It’s vital to evaluate all the ways you are inspired, motivated, and encouraged and the reasons why those things give you hope. The more you cultivate hope, motivation, and inspiration, the more resilient you will become.