Category: News

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

Summary: There are increasing work stresses on our First Responders and 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 comfort 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 life 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 incorporating educational programming for their command staff, new recruits and seasoned serving members will help all to 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 could be given more 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 who make a point of getting to know their members well 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 could be offered 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 or psychologist, but they would also have access to carefully selected and trained peer resilience life 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 life 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 life 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 or nurse practitioners 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.

Addressing moral injury together

Project Trauma Support is one resource for first responders focused on “deep, personal connection,” peer group support and utilizing physicians with lived experience.

Project Trauma Support is an organization located in Perth, Ont., offering a six-day retreat for first responders, military members and veterans. Photo: Project Trauma Support

When it comes to post-traumatic stress disorder (PTSD) in Canadian first responder services, things don’t have to be the way they are.

That’s the opinion of Dr. Manuela Joannou, the medical director of Project Trauma Support, which is an organization located in Perth, Ont. Launched in 2016, it offers a six-day retreat for first responders, military members and veterans.

Many police services are working short staffed and underserviced because they have an inordinate number of officers off work or on accommodated duty due to psychological injuries such as PTSD, anxiety and depression. We hear some services are squeaking by with up to 30 per cent of their force missing from action.

“Police officers are very reluctant to put up their hand to ask for time off, for a break, or some other consideration when the demands and the stresses of being on the job are getting to be too much,” Joannou says. She goes on to note there are several reasons for this.

Stigma is the big reason. Members of society expect our emergency responders to be larger than life, somewhat like the heroes in the comic books they grew up with. Their emergency services and supervisors hold them to very high standards, but the officers also hold themselves to impossibly high standards, which very often is where the problem lies.

Project Trauma Support is working in partnership with the Mood Disorders Society of Canada and with research teams at Queen’s University and the University of Alberta to gather evidence that their model can lessen the symptoms of PTSD, and in some cases even promote post-traumatic growth.
Photo: Project Trauma Support

Stigma comes in at many levels. The first level is self-stigma, where an officer will refuse to admit that they could be having some issues with the demands of the job because they equate this to being somehow weak or inadequate and the idea of this is too unacceptable to entertain. Often an officer who is finally getting to the point where he or she just cannot go on feels that they are letting their entire platoon down and this creates a sense of shame. The next level of stigma comes from the service itself.

Supervisors trying to fill the shifts are often exasperated when yet another officer is asking for time off. Other members of the team are irritated when they can’t get the holidays they want, they must work overtime, or they feel they are put in unnecessary danger when they are working short staffed because so many others are off.

Although there is currently a significant effort being made to minimize the stigma that surrounds asking for help, many officers still feel that admitting any sort of “weakness” is akin to committing career suicide. Someone who has worked very hard to gain a desirable assignment or rank, or is looking to be promoted, often feels that they can kiss their achievements goodbye if they come forth indicating that they are struggling emotionally or psychologically.

All these levels of stigma are significant barriers that keep any officer who might be noticing the first signs of stress from asking for help.

Many provinces now have presumptive legislation whereby if an officer is diagnosed with PTSD, it is presumed that the condition was caused by one or more critical incidents occurring on the job. To be formally diagnosed with PTSD, one must have borne witness to (or repeatedly examined the facts pertaining to) a critical incident or incidents involving loss of life, threatened loss of life, or severe sexual trauma. These are almost a given in the working life of a police officer.

They must also be harbouring symptoms that span four main categories1 summarized by intrusive thoughts involving reliving the event(s) and/or nightmares, avoidant behaviour where one stays away from people, places or things that could be reminders of the trauma; numbing of emotions so that one is mentally “checked out” and does not have to deal with uncomfortable feelings; and hypervigilance, where one is constantly scanning their environment for possible threats. There must be significant mental distress and/or distortions of thinking caused by these symptoms, and the symptoms must be present for one month or more.

The symptoms must be prolonged before a diagnosis can be made, because very often a person will be able to find the right way to process or make peace with an incident within a few weeks after it happens, so that they will never go on to develop PTSD. This offers a window of opportunity after a traumatic event where an officer can be helped to find and use healthy coping strategies, psychological defense mechanisms and perceptions so they remain resilient.

Most times, when an officer finally is unable to continue working because their stress injury is too great, they will have been suffering from symptoms for years and often decades. It is arguable that any officer who has spent a few years on the job is likely impacted by some degree of post-traumatic stress. It makes sense that we should be trying to identify and strengthen the coping mechanisms that can promote resilience to the job-related stress.

What is resilience? One definition is the ability to bounce back, resist, or even thrive in the face of adversity. How advantageous would it be if every time an officer faced a critical incident, instead of having adverse symptoms as a consequence, they were able to process the event in a way that could improve their coping mechanisms?

Project Trauma Support is working in partnership with the Mood Disorders Society of Canada and with research teams at Queen’s University and the University of Alberta to gather evidence that their model can lessen the symptoms of PTSD, and in some cases even promote post-traumatic growth.

Moreover, one of the main focusses of the program is addressing what is known as moral injury.

“Moral injury is just beginning to be recognized as an important component of Operational Stress Injuries (OSIs). In many cases we feel it is moral injury that causes the burden of suffering,” Joannou states. “Moral injury is an affront to the very being of a person, what one might describe as an injury to one’s heart and soul.”

Although there is not yet a consensus on a definition for moral injury, according to Joannou, they have a working definition that seems appropriate.

“A moral injury might result from having done something you wish you hadn’t, or not having done something you wish you had, and this resulted in dire consequences. Moral injury can also come from witnessing something that you feel is just plain wrong.”

The Centre for Addiction and Mental Health (CAMH) describes moral injury as “a loss injury; a disruption in our trust that occurs within our moral values and beliefs. Any events, action or inaction transgressing our moral/ethical beliefs, expectations and standards can set the stage for moral injury.”

The symptoms of moral injury include shame and guilt, or overwhelming sadness. There is also often what is known as “Sanctuary Trauma” or “Institutional Trauma.” This occurs when a person feels that the very institution for which they served with great pride, effort and personal risk does not come to their rescue when they experience hardship, but instead acts in such a way to make matters worse. Leadership failure and the feeling that one has been scapegoated, ostracized or unfairly punished all lead to feelings of anger, betrayal or a sense of injustice.

“There are some myths surrounding PTSD and moral injury that we feel need to be exposed,” Joannou says. “The idea that only weak people get these injuries is totally false. We have run our program a total of 33 times so far, with 334 participants and those who come to us are anything but weak.”

These are the “bravest members of our warrior class who have put themselves out in a way that most people could not imagine,” she continues. “It does not matter how well-trained, brave, well-intentioned or experienced someone is, there is a limit to what a human can withstand… Instead of this being a sign of weakness, this injury should be a testament to the degree of courage, critical difficulty and personal hardship they have been exposed to. If this is recognized early, there is every reason to hope that the right types of support can be put into place to help build resilience and resistance.”

The current culture in policing — with the stigma surrounding psychological trauma symptoms — poses a detrimental barrier to implementing procedures to intervene at opportune points. There needs to be more awareness on the part of supervisors and command staff so that critical incidents and emotional and psychological impact can be recognized early and dealt with in a helpful rather than inadvertently harmful way.

“We feel that specially trained peers with lived experience can act as resilience ‘life coaches’ for officers on the job,” Joannou says.

Currently, by the time an officer finally admits that they need to go off work, sees a psychiatrist or psychologist, gets a diagnosis and has an insurance claim approved for therapy, valuable time has passed where some effective interventions could have been deployed. The more time that passes without any help, the harder it is to keep a person on the job.

The Project Trauma Support model involves physicians with lived experience supervising peer mentors who drive the program. These mentors learn to identify common faulty thinking patterns that promote increased psychological distress and can point these out to those trying to process their difficult incidents.

A police officer with a municipal force in Ontario for more than 20 years, Sgt. Mike Richardson also previously served in the Canadian Forces for 14 years. He is currently off work with an OSI from a traumatic work event and was diagnosed with post-traumatic stress in 2017. He says Project Trauma Support has been a “gamechanger” for his wellness thanks to the team environment it champions and the resources it raises awareness about.

“Sure, there are days I feel lonely from symptoms of PTS but now I am never alone,” he tells Blue Line in an email. “When we have PTSD, we want to isolate ourselves… The team from Project Trauma Support, my wife and my cohort brothers continue to provide me with unending support, 24/7 — whether it’s a text, phone call or even a visit. I just can’t say enough about this Project, as it’s such an important and integral part of my support system, my tool box.”

Another common myth, according to Joannou, is that once someone is diagnosed with PTSD, they will just have to learn to live with the symptoms.

“This makes me so sad,” she says. “I think it is a terrible thing to take away someone’s hope. We have seen many come through our program who have been able to process their experiences in a new way and they feel that they come out stronger than they ever were. This often involves doing some soul searching and finding where they may have been psychologically underdefended or may have been personally affected through some link with early life experiences. We also help people find meaning in their experiences, which gives them new resolve and often reminds them of why they signed up to serve in the first place.”

Joannou states that although psychiatric medications are often prescribed for sleep difficulties and mood disturbances that accompany PTSD, medication has its limitations in treating this condition — especially when it comes to addressing moral injury. Receiving support from a peer group is invaluable.

“We find that the group processes we use help to validate our participants’ experiences and allows them to process the resulting emotions. Very often trust issues and feelings of shame and guilt will make a person with an OSI want to isolate, but that is the worst thing you can do. There is no better way to work through pain and negative emotions than to sit with someone who knows exactly what you went through and how you feel, who tells you, ‘I sure get it. It was awful, I had to do the same thing. You were just doing your job.’”

Richardson says when he attends the Project, he feels “instantly accepted and there is no judgement. The doctors, the mentors and all involved understand us and get what we are going through… They just get it.”

Joannou adds she finds it advantageous to bring military members/veterans and first responders together in the group experience.

“When you take off the uniforms, you have the opportunity to work where we all intersect as human beings, and that is where the healing happens. There is a mutual respect between the different members. The details of their stories might be a little different, but the emotional fallout is the same. Deep personal connection seems to be the ingredient that is necessary. Throughout human history, we have come together as community, as neighbours and as tribe to make us feel safe and to work through our struggles, our tragedies and natural disasters. Somehow we seem to have lost sight of how important this is and how to do it.”

The Project Trauma retreat centre is a stigma-free, judgement-free zone, she states, echoing Richardson.

“I am really hoping that we can come to look at post-traumatic stress as a normal response to the first responder experience, and that we can continue to train more clinicians and peers in effective ways to help… I tell all of the participants in our program ‘you did not go through all this for nothing, and your story is not over yet.’”

For more information on Project Trauma Support, visit www.projecttraumasupport.com, or email [email protected].

Footnote

*The DSM-5symptom groups are intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity.

Disclaimer
Blue Line is providing this content for general information only. Mental health conditions are complex, people differ widely in their conditions and responses. Information provided is not a substitute for professional advice. If you feel that you may need medical advice, please consult a qualified health care professional.

Source: The Blue Line Magazine