Vision for a Comprehensive Mental Health Support

Vision for a Comprehensive Mental Health Support System for First Responders and Military Members

Manuela Joannou M.D. CCFP(EM)FCFP
Medical Director, Service Injury Support Centre
Founder, Project Trauma Support

 

Military Members for a variety of reasons, which is resulting in an increased number of insurance claims for psychological injuries and prolonged absences from work. This is unsustainable, both in financial terms and in terms of the quality of emergency service available to society. But the real cost is to the affected first responders, who may have their lives ravaged as a cost of being in service. This document will summarize opportunities for improved working conditions and points of intervention where psychological injury claims and absences are decreased, and overall service, career satisfaction and longevity is increased. We propose that more can be done to improve emergency service workers’ and military member’s resilience, and that leadership skill and sensitivity in addressing mental health of their members can be enhanced. There needs to be more recognition that Moral Injury very often causes the burden of suffering and needs to be addressed. Peer resilience coaches can be selected and trained to provide skillful, timely and cost -effective support and early intervention. Likewise, special teams of physicians and other allied health professionals with emergency experience can be trained to provide specialized care with improved cost and effectiveness.

IMPROVEMENT OF THE SETTING:

In assessing the challenges of improving mental health within the emergency first responder services, it is apparent that stigma is a significant obstacle. Emergency Services and Defense organizations must incorporate educational programming for their command staff, new recruits and seasoned serving members to help them better understand the psychological impacts of their operations. This would include education on importance of sleep and healthy lifestyle to counter the effects of shift work and overtime hours necessitated by difficult calls. The concept of potentially psychologically and morally injurious incidents should be explored, and members should be supported in developing their own personal resilience philosophies and strengthening their own healthy coping mechanisms.

Command Staff should be given education on how to be more sensitive to the needs of their members who might be dealing with some psychological as well as physical impacts of their work. Leaders should make a point of getting to know their members well, so that they can notice early signs of difficulty. They should be especially tuned in to recognize that some behaviours that could lead to disciplinary measures could be early signs of PTSD, depression, substance abuse or other signs of mental health impairment. In addition, command staff should have a forum where they can be free to seek help and peer support for themselves without suffering any career repercussions.

The overall culture should be one of support, camaraderie and compassion, reflected through attitudes that foster improved morale, dedication and career satisfaction.

IMPROVEMENT OF THE MINDSET

Members and supervisors alike should get regular training in improving their own mental resilience and should be made to feel comfortable coming forth when they are noticing the early signs of stress.

Their first line of resources should ideally come from their own Family Physician, but they should also have access to carefully selected and trained peer Resilience Coaches, who are colleagues that have lived experience on the job but have had extra training in helping others to examine their own attitudes and thought patterns that can lead to increased psychological distress.

Members should feel comfortable speaking with their immediate supervisors, knowing that their requests for help or special considerations will be met with kindness and compassion. Every effort should be made to give members the accommodations that they need in order to get them back to being fully operational as soon as they are able.

Members should be encouraged to check in with their physicians on regular, at least yearly intervals, and have physical as well as psychological assessments done. If it is felt that members need more extensive psychological care than what the family physician or resilience coach can provide, they should be referred to a dedicated mental health professional.

There should be a team of specially trained mental health clinicians available to work with emergency service personnel. These should have either some personal experience working in emergency fields themselves or have taken it upon themselves to learn as much as they can about the culture of the emergency services, the types of critical incidents first responders may have to attend, and the impacts of such exposures.

Family members of first responders should also have access to educational programs that allow them to be alerted to the first subtle signs of operational stress, and what resources are available to help their loved ones. Many social workers and psychologists are trained in family therapy and can offer good supports to spouses and children of first responders who might be impacted vicariously by a first responder’s work stress.

 

PREVENTION OF OPERATIONAL STRESS INJURIES

If the above measures are in place, much will be done to address the cumulative stress of front- line service. However, the nature of emergency service work means that there will be many critical incidents that could potentially be psychologically or morally injurious. Early intervention with defusing or debriefing can be skillfully provided by trained resilience coaches who have themselves dealt with similar incidents and are trained to recognize the potentially maladaptive thinking patterns that can lead to increased and prolonged distress. This can be done in a group setting, but in some instances, it may be necessary to offer the debriefing in a one-on-one format.

The importance of restorative sleep after critical incidents must be stressed, and it is important to have physicians available who are capable of prescribing sleep medications if necessary. The physicians may also order time off work as indicated in order to prevent long term absences later. Accommodated positions may be necessary for a short term to allow members to recover from difficult calls. If there are disciplinary measures, professional conduct charges, criminal charges or investigations into operations, more psychological support, time off or accommodation may be needed.

MORE DEFINITIVE MENTAL HEALTH INTERVENTIONS

Although implementing all the cultural changes, building resilient teams and providing effective early intervention strategies will go a long way to preventing lasting psychological injury and prolonged absences from work, there will be times when specialized, more definitive care is indicated.

Addiction to drugs and/or alcohol presents a special situation, where a secure, residential facility should be considered. Ideally, there would be a facility available where only first responders attend. In this way, the addiction and any psychological injuries sustained from service can be addressed simultaneously, and participants can feel free to talk about any work-related traumas.

Post Traumatic Stress Disorder and Moral injury can cause significant disability, and when it becomes apparent that short term absence or accommodation is not beneficial, then a more intense program should be considered. We have found that our six day Project Trauma Support residential experiential program offered at the right time can be effective in either keeping a member operational or helping them return to work. Many times, the hurdle that needs to be overcome falls into the category of Moral Injury or Institutional (“Sanctuary”) Trauma, and our program specifically addresses these, as well as PTSD and other Operational Stress Injuries.

Day programming that offers group psychotherapy can be effective and can be combined with a residential program, either before or after.

Longer term in -patient hospitalizations should be reserved for members who are showing signs of severe psychiatric illness, or when there is a need for diagnostic clarity or optimization of the medication regimen.

In special circumstances, where there are refractory cases of PTSD, depression or suicidal ideation, it might make sense to consider some of the emerging therapies with ketamine or Psychedelic Assisted psychotherapy.

SUCCESSFUL REINTEGRATION

Return to work after absence, accommodation or more definitive treatment should be approached strategically with sensitivity to the potential psychologic impacts. Return to work is in effect exposure therapy itself. There should be the availability of resilience life coaches, kind and compassionate leaders, and support from colleagues and peers. There should be regular, ongoing one-on-one sessions with a trusted clinician who can monitor sleep, anxiety levels, effects of any medication, stress tolerance, adaptability, concentration and overall psychological and physical health. Peer support should be made available, preferably through collaboration between the professional association and the employer. Linking with outside agencies and members from other emergency services can often be beneficial. This provides additional supports and the validation that work in the emergency services extracts a toll on the very humanity of an individual. The training, instruments, weapons and uniforms may be different, but the psychological impacts are the same.

Recharge and Re-Engage

Special Service PTS Cohort # 66

Project Trauma Support is grateful to have received a grant from the J.P. Bicknell Foundation which allows us to offer this special program for First Responders and Military Members who are staying on the job in spite of significant operational stress.

Rainbow over a treeWith increasing challenges faced by those who are the first and last defense of our communities and our country, it is imperative that we develop and implement responsive programming that can assist those who hold the lines in a timely and effective manner. Project Trauma Support has developed a novel residential, experiential curriculum that has shown success in helping first responders process their difficult calls so that they can continue to serve solidly with pride.

Since 2016, we have had over 800 first responders, military members/veterans and front-line medical professionals complete our programs.

FRIDAY DECEMBER 1st to WEDNESDAY
DECEMBER 6TH, PERTH, ONTARIO

“YOU DID NOT GO THROUGH ALL THIS FOR NOTHING
and….
YOUR STORY IS NOT OVER YET”

For more Information, see www.projectraumasupport.com or email us
at [email protected]

The way of the Samurai

Hey guys,

While I was under the Ketamine, I saw a Samurai.

In the jobs we all did we were brainwashed into thinking that in order to do this we had to be a certain way, follow made up codes and heaven forbid if you screwed up……

The Samurai was one of the most brainwashed professions of all; so many rules and traditions they had to follow.

If they messed up, they had to fall on their sword…. in other words, kill themselves.

I don’t doubt that many of us have found themselves in a state where at one time or another, because of the job we were doing, ending it all made sense. I now I thought about it every day.

If the Samurai refused to fall on their sword but to walk away instead, they were stripped of the title and “honor “. They were then called a “Ronin”.

The Ronin, as you can imagine, had a stigma attached to them, much like us with PTSD.

But when you think about it, the Ronin walked away from a life of violence and obeying a master that only used them. But remember, just because they left didn’t mean they couldn’t still do the things they had been trained to do.

A Ronin took everything he learned and everything he was trained to do out into the world and made it his own.

I got a RONIN tattoo to remind myself of this, and when I look at it I will also remember the 3 days I spent with you guys.

P.S. by walking away the Ronin lived 30 to 40 more years.

Ketamine: The Psychedelic Journey

Ketamine, like all psychedelics, is a vehicle that allows us to face our suffering and change our relationship to it.

It can transport a person’s consciousness to another, more mystical realm where more liberal possibilities and perspectives are revealed. The constraints imposed by one’s ego are lifted. The usual defenses and paradigms are brushed aside and more vulnerable parts of one’s personality are allowed to emerge.

The stimulation of oxytocin receptors that allows for deep interpersonal connection can flood a person’s consciousness with a sense of understanding, empathy, and forgiveness. This allows a more generous reassessment of other’s offensive past behaviours and intentions.

Ketamine can remove doubts and enforce determination and resolve. It can make a person much less self-conscious, and less influenced by the judgements of others.

Not infrequently, a psychedelic experience can bring a person face to face with some consciously or unconsciously suppressed memories or demons that have been haunting them. While this can be quite disconcerting and even terrifying, the altered state also provides some new psychological resources that give the opportunity for new processing and resolution.

The psychedelic journey can allow a person to take back their power to make the necessary changes that lead to more successful endeavours, more satisfying relationships, and improved overall life fulfilment.

What Veterans have taught me about love

It has been said that soldiers fight mostly for love of their comrades in arms. As both a civilian and military physician, over the last 34 years I have heard hundreds of stories from the people who serve our country. The following is an attempt to give a voice to those whom I have had the privilege to serve and to showcase the valuable lessons they have taught me on the subject of love.

Dr. Markus Besemann just retired as Head of Rehabilitation Medicine for the Canadian Armed Forces. He is one of our Project Trauma Support physicians. This is an article he had published in the Atlas Journal. The “Atlas” was previously known as the “Centre for Excellence for PTSD”

In October 1991, I was posted to the National Defence Medical Centre (NDMC) in Ottawa. We were told to stand by for the admission of some of the survivors of the ill-fated Hercules 130322 Boxtop 22 crash, just kilometres away from Canadian Forces Station Alert. As those requiring medical care were admitted, we heard stories of the courageous pilot Captain John Couch, who gave up his own cold-weather clothing so that others would live. This selfless gesture led to his own death from exposure just hours before the search and rescue team reached the scene. This moment marked the beginning of my understanding of the depth of self-sacrifice that military personnel and Veterans are no strangers to. In my young officer’s mind, this was nothing short of Biblical love.

Several years later, I was walking alongside a senior submariner who, with tears in his eyes, told me all about the Chicoutimi submarine disaster and how with few exceptions, those who saved the day were some of the less polished “bad apples.” Their rough and ready backgrounds had inadvertently prepared them for the unexpected. In other words, what caused them and others distress in peacetime served them very well when catastrophe hit. Another lesson on love: Don’t judge a book by its cover. It is what is hidden inside a man or woman that really counts, no matter how this strength of character is acquired.

Another story that deeply affected me came from a combat medic in Afghanistan who was tasked with carrying a casualty on his shoulders during an ambush in the darkness of night. Given the load he was carrying, he lost sight of his platoon. Bewildered and lost, he searched for direction, until he eventually saw another brother in arms at the end of the road pointing the way home. He successfully reunited with his unit, only to find out later that the brother pointing the way had been killed earlier that evening in a firefight in another village. Soldiers do not desert their comrades, even after they die.

“And though they did hurt me so bad…You did not desert me My brothers in arms.”

Brothers in Arms, Dire Straits

Stories such as these are not uncommon in the context of war. They have been well described in the diaries of soldiers from previous conflicts. They help illustrate the extreme paradox that is present on the battlefields of life. Despite the horrific destruction and death, love persists and rises above it all.  As a medical doctor, I have personally heard countless such stories over the years and I have been drawn to ask myself, who am I to question these lived experiences and the messages they convey?

Many military personnel appear to know from a very young age that they wish to serve. This may be the result of a dream passed on by military Families or one borne out of a sense of somehow feeling that they were called to be the protectors of society. The dedication with which service personnel pursue this life calling never ceases to amaze me.  It is the deepest form of love. The conflicting tragedy and beauty of this incarnation, which benefits many of the more privileged in society, is that it comes at a tremendous cost to the Veteran. Many Veterans elected to put on the uniform and swear an oath to make the world a better place. This however can often leave them with many unanswered questions and harsh self-judgment for choices made or not made.

Veterans have taught me that self-love is one of the hardest “missions” they have ever undertaken and that this can be a long soul-searching and sometimes gut-wrenching journey. Given that the definition of mission success is expressed in extraordinary acts of bravery, it is often difficult for Veterans to put themselves first and love themselves unconditionally because of the morally conflicting decisions they have had to make in the line of duty. The challenge over the long term for the Veteran is to realize that this acquired identity does not define them. One of the greatest obstacles for Veterans in their healing journey is to learn to embrace their authentic self despite the possibility that this process might lead to a completely different narrative about who they are and how others might view them. Only when they can reconcile their identity as a soldier and their true essence as a human being can they begin the journey towards forgiveness. It has been said that true forgiveness occurs when you finally realize that there was nothing to forgive in the first place.

Love is often difficult for Veterans to demonstrate. Sometimes their love is shown when they volunteer to take another’s place on patrol or lay out a comrade’s air mattress at 3 a.m. because their fire team partner is still on sentry duty. Veterans’ expressions of love can be rough around the edges and displayed in brutal honesty and dark humour. The tough love they express for their comrades and their steadfast commitment to their core beliefs and values often goes unrecognized by many civilians and is often misunderstood. It is the deepest form of love I have ever had the privilege to witness. In its sheer rawness, it shaves away all the fluff we so often mistakenly take for signs of love, but that in reality is so far removed from what love actually is. Ultimately, what unites us all —whether civilian or military — are our individual struggles with loving and forgiving ourselves unconditionally, understanding that we all at some point in our lives fall short of our idealistic expectations, but that we restore balance by expressing compassion to ourselves and to others.

This is amongst the most important lessons learned, that despite the suffering Veterans have endured and continue to endure, there is value and a purpose to all of it. If embraced, it can teach us all more about how to love and be loved. If I were to try and summarize as succinctly as possible the essence of what it is that I am trying to convey in the name of those who have sacrificed so much, it would be the notion of embracing the paradox of life. The world our Veterans have seen and experienced is as horrific as it is beautiful. At the end of the day, they have shown us and continue to show us that ALL of it is love in its various manifestations.

LCol (Ret’d) Markus Besemann CD, BSc, MD, FRCP(C), Dip. Sport Med. (CASEM)

Learn more about moral injury, the impact of events or acts that a person performs, witnesses or fails to prevent, which conflict with one’s own deeply held moral beliefs and values.


Dr. Markus Besemann just retired as Head of Rehabilitation Medicine for the Canadian Armed Forces. He is one of our Project Trauma Support physicians. This is an article he had published in the Atlas Journal. The “Atlas” was previously known as the “Centre for Excellence for PTSD”