By Kendall Pfeffer, Sam Buser, Ph.D.; and Jana Tran, Ph.D.
As evidenced by the 2017 Atlantic hurricane season, natural disasters are relatively commonplace events which are potentially traumatic for many of the individuals caught in their wake.
While the human suffering and losses suffered by affected communities are widely reported, the consequences of these events on the men and women who bear the burden of search and rescue is understudied and underreported.
No one who witnesses a disaster is untouched by it, and first responders are uniquely impacted.
Following what has been one of most aggressive and destructive hurricane seasons on record, it is crucial that we reflect on what we know about mental health consequences for first responders and how we might improve disaster mental health efforts moving forward.
How do natural disasters impact first responder mental health?
Research has identified seven phases of a disaster:
- Pre-disaster (warning or threat),
- Impact,
- Heroic,
- Honeymoon,
- Inventory,
- Disillusionment, and
- Recovery.
In the initial weeks following a disaster (i.e., the honeymoon phase), community cohesion is at its peak, altruism is prominent and many survivors experience optimism as the community bands together.
Expressions of gratitude for first responders’ selfless acts of heroism are abundant; however, as the community returns to normal, recognition subsides.
During the inventory and disillusionment phases, optimism often gives way to discouragement or despondency. First responders may feel abandoned or resentful, and signs of burnout and compassion fatigue become more evident.
These feelings are exacerbated for those struggling with wage or benefit issues.
Finally, in the recovery phase, emotional resources and social support may wear thin for those who continue to struggle.
Each disaster has intrinsically unique factors which influence the nature, intensity and duration of post-disaster stress, including:
- Control – While hurricanes and natural disasters are beyond human control and absent of evil intent, flooding and other negative consequences may be exacerbated due to human factors. Many first responders experience anger and frustration directed at their command staff; and local, state and national government agencies for failing to properly staff certain areas or appropriately allocate resources. Additionally, the random, uncontrollable nature of the event may cause feelings of helplessness and heightened anxiety.
- Exposure – First responders may be victims themselves, even while they are trying to help others. Those who have lost their homes or witnessed destruction and loss within their families or neighborhoods experience a combination of grief and trauma that may extend the duration of recovery. High exposure survivors tend to experience more anxiety, sadness, post-trauma symptoms, physical or somatic symptoms and alcohol use.
- Scale and scope – Harvey was the wettest tropical hurricane on record in the contiguous U.S. and caused catastrophic flooding and property damage in the Houston-area. Irma brought intense wind and rainfall for 37 consecutive hours resulting in 132 deaths. Maria devastated the entire island of Puerto Rico, leaving residents without power, water or access to medical care. When entire communities are impacted to this degree, survivors can become disoriented. Social support that maintains a sense of community and occurs in familiar settings is critical. Fortunately, the first responder community binds together to help their brothers and sisters in times of crisis such as these.
- Active Incident – For most citizens, after the storm passes, the disaster threat is over, and the recovery and rebuilding process can begin. For first responders, the end point is ambiguous. Hurricanes and floods often remain an “active incident” as they continue to make related calls (e.g., recovering bodies) over a period of weeks.
- Recurrence – We know that anniversaries of critical incidents can trigger post-traumatic stress symptoms. Because hurricanes follow a seasonal pattern, survivors may be concerned that a storm will hit again before the season ends or again next hurricane season. At the one-year anniversary, reminders that we are potentially at-risk can reignite disaster stress and hypervigilance.
Unique characteristics of first responders
First responders are generally altruistic, fearless and intrinsically motivated individuals who may occasionally struggle to identify when it is time to take a break for self-care.
They experience compounded demands to meet the needs of survivors and the community, all while coping with anxiety about the safety and well-being of their own families.
This unique position of being both rescuer and victim frequently results in ethical dilemmas. They may experience overwhelming feelings of helplessness as their professional duty to serve their community comes into direct conflict with personal commitments to protect loved ones.
Many first responders recover dead bodies, and some may respond to civilians who have chosen to commit suicide as a result of the disaster. This degree of exposure to human tragedy, coupled with higher levels of pre-trauma exposure and chronic occupational stress, means first responders will be uniquely vulnerable to adverse stress reactions.
The majority of survivors are resilient and will integrate their disaster experience, process their loss and move forward over time.
However, first responders who have significant pre-existing physical, behavioral or mental health issues are at greater risk for depression, anxiety and post-traumatic stress disorder.
Those who have experienced recent or concurrent losses or other stressors (e.g., the death of a loved one, divorce or marital distress, financial strain, illness) are also at greater risk of delayed recovery.
Additionally, overwork and sleep disruption during initial operations compound risk for PTSD.
Depression and PTSD may be manifested in physical complaints, as well as behavioral and emotional reactions, particularly prominent among those less able to experience and express emotions directly. Emotional reactions will oscillate between numbness and intense expression (i.e., anger or irritability).
Additionally, first responders who utilize maladaptive coping styles (e.g., avoidance, emotional numbing, drinking to cope) are more vulnerable. Many of these coping strategies are implicated in the development and maintenance of PTSD.
Ironically, the strategies that have assisted first responders in coping with the day-to-day accumulation of occupational stress and frequent exposure to potentially traumatic events may prevent them from effectively processing a natural disaster.
Aspects of EMS culture may impede willingness to seek social support (i.e., a “man up” or “don’t take it home with you” mentality).
EMS agencies are replete with individuals who exhibit a take charge, control-oriented mentality. They are comfortable in the role of rescuer dealing with problems of others. Help seeking behaviors are often interpreted as a sign of weakness. Additionally, stigma and mistrust of outsiders prevent many from seeking mental health services.
On the flip side, extensive social support networks inclusive of crew, department, union and peer-support networks can help to buffer these risk factors. When perceived social support from both their work family and their family at home is high, risk for prolonged stress response lowers.
How to help first responders cope with disaster
Disaster stress reactions are a normal reaction to a difficult and abnormal situation. In the days and weeks immediately following a disaster, they are common and experienced by most.
However, stress reactions that continue into the long-term may be indicative of depression or PTSD and signal that a first responder needs additional support or referral to a mental healthcare provider.
Intervention in the mid- and long-term period following a natural disaster is critical for first responder populations.
1. Implement evidence-based intervention models when possible.
While direct research with first responders in the aftermath of disasters is limited, several crisis intervention models have been well documented and frequently replicated.
Psychological First Aid, originally developed for intervention with civilian populations, has been adapted for first responders [1]. It focuses on stabilization and practical assistance, facilitates normal methods of coping and normalizes emotional responses. Research supports the use PFA in the immediate and mid-term.
Here at the Houston Fire Department, we follow a Critical Incident Stress Management (CISM) model. CISM incorporates multiple intervention components for secondary victims, which cover a range of functions, delivered in different formats, throughout the ongoing phases of crisis/disaster response [2]. The peer-trained model provides the flexibility necessary to respond to unique factors of specific incidents.
2. Use what you’ve got.
Just as each individual survivor has his or her own personal assets that can reduce disaster stress, affected communities often have pre-existing structures for social support and resources for recovery. It’s always recommended to utilize interventions with empirical data supporting their efficacy, but you don’t need to re-invent the wheel.
Use your community, organizational or department resources and customize the intervention model to meet the needs of your first responder community.
3. Consider the fit-ness of your efforts.
When DMH efforts fit the culture of the community being served, service usage increases. First responders are likely to reject outside interference.
Utilize organizational and community mental health providers for consultation, guidance and programmatic planning, and then have trained peer-support teams make initial contacts.
4. Demystify the stress response.
Individuals who believe their traumatic stress symptoms are due to their own weakness, rather than an ordinary response to extraordinary events, are more likely to struggle with traumatic stress symptoms in the long-term [3].
This is particularly true of first responders, given cultural norms of strength and self-sufficiency.
Provide information on common reactions in the short-term; warning signs in the long-term; and, of course, recommendations for healthy coping strategies. De-stigmatization is key.
5. Be persistent and patient.
Go to the survivors. Don’t wait for them to seek out mental health services on their own. Be visible, go from station to station, and provide clear, relevant information.
Because first responders are not accustomed to being the ones in need of assistance, outreach efforts should be nonintrusive and open-ended. Continue to check-in and provide psychoeducation on an ongoing basis, especially around anniversaries.
6. Plan ahead.
Frequently, mental health programs and support networks’ organizational plans are unclear or inadequate immediately following a natural disaster due to rapid mobilization and prioritization of citizen survivor needs.
But it’s never too late to create a functional plan. In the late-term (inventory and disillusionment phases), first responders may be hit particularly hard. Stress reactions become more evident as those around them return to pre-disaster levels of functioning.
Consider implementing a CISM model or some variation of a peer-support network which can also be called upon in the event of a future disaster.
References
1. Ruzek JI, Brymer MJ, Jacobs AK, Layne CM, et al. (2007). Psychological first aid. “Journal Of Mental Health Counseling,” 29(1);17-49.
2. Mitchell JT, Everly GJ. (2000). Critical incident stress management and critical incident stress debriefings: Evolutions, effects and outcomes. In B. Raphael, J. P. Wilson, B. Raphael, J. P. Wilson (Eds.), “Psychological debriefing: Theory, practice and evidence,” (pp. 71-90). New York, NY, US: Cambridge University Press.
3. Ehlers A, Clark DM. (2006). Predictors of chronic posttraumatic stress disorder: Trauma memories and appraisals. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 39-55). New York: Guilford Press.
About the author
Jana K. Tran is staff psychologist for the Houston Fire Department.