PTSD: National Center for PTSD

Disaster Rescue and Response Workers

Police, firefighters, emergency medical personnel, National Guardsmen and other rescue workers who respond to disaster and mass violence events face the danger of death or physical injury, the potential loss of their coworkers and friends, and devastating effects on their communities. In addition to physical danger, they may also be at risk for behavioral and emotional readjustment problems (1-7).

What Are the Mental Health Risks of Rescue and Response Work?

Posttraumatic stress disorder (PTSD) and depression have been the most studied mental health outcomes among rescue and response workers, with prevalence of PTSD ranging from 0%-34% and depression from 21%-53% (8). For instance, in post-World Trade Center (WTC) disaster studies, most rescue workers experienced mild and normal stress reactions, but some workers experienced severe stress reactions that led to chronic decrements in functioning, or worsening function over time. Risk factors included Hispanic ethnicity, pre-WTC psychiatric history, greater WTC disaster exposure, greater medical illness burden, life stressors and post-WTC traumas, and maladaptive coping (e.g., substance use, avoidance coping) (2-3).

In other post-disaster settings, rescue workers at greatest risk for the development of ongoing trauma-related symptoms have been those who: had a history of early physical victimization; had a prior psychiatric history; were volunteers; had been exposed to extreme danger, death, bodily injury, or maimed bodies; had experienced loss (of home or valued possessions, neighborhoods and communities); had experienced intense emotional demands, extreme fatigue, or physical stress; had experienced chronic medical illness or psychological disorders, chronic poverty, or recent or subsequent major life stressors; and had reported avoidance coping, lower levels of self-efficacy and lower social acknowledgment (e.g., 1,6,9-12).

What Protective Factors Benefit Rescue and Response Work?

Protective factors for first responders include higher perceived preparedness, greater sense of purpose in life, family support, and positive-approach and emotion-focused coping (e.g., problem solving, positive reframing, acceptance) (5,10,13). Longitudinal studies of disaster responders have identified social support and integration, and a benevolent perception of the world, as potentially buffering factors to developing PTSD (4,14,15). Training and preparedness for specific tasks performed have also been associated with resilience or recovery (5,16).

What Are Some Ways to Manage Work-Related Stress?

Emotional wellness is a growing concern for responder organizations. Responders who have undergone resilience training have displayed improvements in negative affect, depression and stress levels (17). And, unlike psychological debriefing, resilience training does not appear to cause harm in regard to psychological distress measures or memory performance.

Another approach has been to integrate ongoing peer support interventions into first responder culture. This strategy is attractive because first responders have limited opportunities to access formal treatment, as well as concerns about stigma or negative changes in job duties or pay should they in engage in mental health treatment (e.g.,18). The limited research that has been conducted on peer support shows that those who have received early and regular peer support report significant gains on a number of dimensions, including better cognitive functioning, improved social and overall functioning, and decreased psychiatric symptoms (19-21).

The Stress First Aid model is one example of a framework for peer support within the first responder culture. It was based on the same five elements of recovery identified for post-disaster environments (safety, calming, connectedness, self-efficacy, and hope) (22), and has been applied to military, fire and rescue, and law enforcement personnel (23-25).

With regard to treatment, studies using trauma-focused cognitive behavioral approaches and medication with first responders generally show significant treatment effects, particularly among patients who have a good alliance with their therapist. Treatments that prioritize and provide targeted assistance for particular symptoms have also proven effective (7,18,26-28).

References

• Thormar, S. B., Sijbrandij, M., Gersons, B. P. R., Van de Schoot, R., Juen, B., Karlsson, T., & Olff, M. (2016). PTSD symptom trajectories in disaster volunteers: The role of self-efficacy, social acknowledgement, and task carried out. Journal of Traumatic Stress, 29, 1-9. doi:10.1002/jts.22073
• Bromet, E. J., & Luft, B. J. (2015). Consequences of toxic disasters for rescue, recovery, and clean-up workers require integrated mental and physical health monitoring. Social Psychiatry and Psychiatric Epidemiology, 50, 1761-1763. doi:10.1007/s00127-015-1124-0
• Zvolensky, M., J., Farris, S. G., Kotov, R., Schechter, C. B., Bromet, E., Gonzalez, A., Vujanovic, A., Pietrzak, R. H., Crane, M., Kaplan, J., Moline, J., Southwick, S. M., Feder, A., Udasin, I., Reissman, D. B., & Luft, B. J. (2015). World Trade Center disaster sensitization to subsequent life stress: A longitudinal study of disaster responders. Preventive Medicine, 75, 70-74. doi:10.1016/j.ypmed.2015.03.017
• Pietrzak, R. H., Schechter, C. B., Bromet, E. J., Katz, C. L., Reissman, D. B., Ozbay, F., Sharma, V., Crane, M., Harrison, D., Herbert, R., Levin, S. M., Luft, B. J., Moline, J. M., Stellman, J. M., Udasin, I. G., Landrigan, P. J., & Southwick, S. M. (2012). The burden of full and subsyndromal posttraumatic stress disorder among police involved in the World Trade Center rescue and recovery effort.. Journal of Psychiatric Research, 46, 835-842. doi:10.1016/j.jpsychires.2012.03.011
• Pietrzak, R. H., Feder, A., Singh, R., Schechter C. B., Bromet, E. J., Katz, C. L., Reissman, D. B., Ozbay, F., Sharma, V., Crane, M., Harrison, D., Herbert, R., Levin, S,. M., Luft, B. J., Moline, J. M., Stellman, J. M., Udasin, I. G., Landrigan, P. J., & Southwick, S. M. (2014). Trajectories of PTSD risk and resilience in World Trade Center responders: An 8-year prospective cohort study. Psychological Medicine, 44, 205-219. doi:10.1017/S0033291713000597
• Komarovskaya, I., Brown, A. D., Galatzer-Levy, I. R., Madan, A., Henn-Haase, C., Teater, J., Clarke, B. H., Marmar, C. R., & Chemtob, C. M. (2014). Early physical victimization is a risk factor for posttraumatic stress disorder symptoms among Mississippi police and firefighter first responders to Hurricane Katrina. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 92-96. doi:10.1037/a0031600
• Ruggero, C. J., Kotov, R., Callahan, J. L., Kilmer, J. N., Luft, B. J., & Bromet, E. J. (2013). PTSD symptom dimensions and their relationship to functioning in World Trade Center responders. Psychiatry Research, 210, 1049-1055. doi:10.1016/j.psychres.2013.08.052
• Gabern, S. C., Ebbeling, L. G. & Bartel, S. A. (2016). A systematic review of health outcomes among disaster and humanitarian responders. Prehospital and Disaster Medicine, 31, 635-642. doi:10.1017/S1049023X16000832
• Brooks, S. K., Dunn, R., Amlôt, R., Greenberg, N., & Rubin, G. J. (2016). Social and occupational factors associated with psychological distress and disorder among disaster responders: A systematic review. BMC Psychology, 4, 18. doi:10.1186/s40359-016-0120-9
• Arble, E., & Arnetz, B. B. (2016). A model of first-responder coping: An approach/avoidance bifurcation. Stress and Health, 33, 223-232. doi:10.1002/smi.2692
• Thormar, S. B., Gersons, B. P., R., Juen, B., Marschang, A., Djakababa, M. N., & Olff, M. (2010). The mental health impact of volunteering in a disaster setting: A review. The Journal of Nervous and Mental Disease, 198, 529-538. doi:10.1097/NMD.0b013e3181ea1fa9
• Benedek, D. M., Fullerton, C., & Ursao, R. J. (2007). First responders: Mental health consequences of natural and human-made disasters for public health and public safety workers. Annual Review of Public Health, 28, 55-68. doi:10.1146/annurev.publhealth.28.021406.144037
• Feder, A., Mota, N., Salim, R., Rodriguez, J., Singh, R., Schaffer, J., Schechter, C., Cancelmo, L., Bromet, E. J., Katz, C. L., Herbert, R., Levin, S. M., Luft, B. J., Moline, J. M., Stellman, J. M., Udasin, I. G., Landrigan, P. J., Zvolensky, M. J., Yehuda, R., Southwick, S. M., & Pietrzak, R. H. (2016). Risk, coping and PTSD symptom trajectories in World Trade Center responders. Journal of Psychiatric Research, 82, 68-79. doi:10.1016/j.jpsychires.2016.07.003
• Schwarzer, R., Bowler, R. M. & Cone, J. E. (2014). Social integration buffers stress in New York police after the 9/11 terrorist attach. Anxiety, Stress, & Coping, 27, 18-26. doi:10.1080/10615806.2013.805552
• Yuan, C., Wang, Z., Inslicht, S. S., McCaslin, S. E., Metzer, T. J., Henn-Haase, C., Apfel, B. A., Tong, H., Neylan, T. C., Fang, Y., & Marmar, C. R. (2011). Protective factors for posttraumatic stress disorder symptoms in a prospective study of police officers. Psychiatry Research, 188, 45-50. doi:10.1016/j.psychres.2010.10.034
• Koçak, H., Çaliskan, C., Kaya, E., Yavuz, Ö., & Altintas, K. H. (2015). Determination of individual preparation behaviors of emergency health services personnel towards disasters. Journal of Acute Disease, 4, 180-185. doi:10.1016/j.joad.2015.04.004
• Varker, T. & Devilly, G. J. (2012). An analogue trial of inoculation/resilience training for emergency services personnel: Proof of concept. Journal of Anxiety Disorders, 26, 696-701. doi:10.1016/j.janxdis.2012.01.009
• Haugen, P. T., Evces, M., & Weiss, D. S. (2012). Treating posttraumatic stress disorder in first responders: A systematic review. Clinical Psychology Review, 32, 370-380. doi:10.1016/j.cpr.2012.04.001
• Jain, S., McLean, C., Adler, E. P., Lindley, S. E., Ruzek, J. I., & Rosen, C. S. (2013). Does the integration of peers into the treatment of adults with posttraumatic stress disorder improve access to mental health care? A literature review and conceptual model. Journal of Traumatic Stress Disorders & Treatment, 2. doi:10.4172/2324-8947.10000109
• Marks, M. R., Bowers, C., DePesa, N. P., Trachik, B., Deavers, F. E., & James, N. T. (2017). REACT: A paraprofessional training program for first responders - A pilot study. Bulletin of the Menninger Clinic, 81, 150-166. doi:10.1521/bumc.2017.81.2.150
• Creamer, M., C., Varker, T., Bisson, J., Darte, K., Greenberg, N., Lau, W., Moreton, G., O’Donnell, M., Richardson, D., Ruzek, J., Watson, P., & Forbes, D. (2012). Guidelines for peer support in high-risk organizations: An international consensus study using the Delphi Method. Journal of Traumatic Stress, 25, 134-141. doi:10.1002/jts.21685
• Hobfall, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M., Gersons, B. P. R., de Jong, J. T. V. M., Layne, C. M., Magues, S>, Neria, Y., Norwood, A. E., Pynoos, R. S., Reissman, D., Juzek, J. I., Shalev, A. Y., Solomon, Z., Steinberg, A M., & Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70, 283-315. doi:10.1521/psyc.2007.70.4.283
• Nash, W. P., Silva, C., & Litz, B. (2009). The historic origins of military and Veteran mental health stigma and the Stress Injury Model as a means to reduce it. Psychiatric Annals, 39, 789-795. doi:10.3928/00485713-20090728-05
• Watson, P., Gist, R., Taylor, V., Evlander, E., Leto, F., Martin, R., Vaught, D., Nash, W. P., Westphal, R., & Litz, B. (2013). Stress First Aid for Firefighters and Emergency Services Personnel. The National Fallen Firefighters Foundation.
• Westphal, R., Watson, P., Gist, R., Taylor, V., Evlander, E., Leto, F., Martin, R., Vaught, D., Nash, W. P., & Litz, B. (2014). Stress First Aid for Law Enforcement Personnel Instructor’s Manual. Oregon Department of Public Safety Standards & Training.
• Haugen, P. T., Werth, A. S., Foster, A. L., & Owen, J. (2016). The role of theory-specific techniques and therapeutic alliance in promoting positive outcomes: Integrative psychotherapy for World Trade Center responders. The Journal of Nervous and Mental Disease, 204, 955-959. doi:10.1097/NMD.0000000000000631
• Jarero, I., Amaya, C., Givaudan, M., & Miranda, A. (2013). EMDR individual protocol for paraprofessional use: A randomized controlled trial with first responders. Journal of EMDR Practice and Research, 7, 55-64. doi:10.1891/1933-3196.7.2.55
• Haugen, P. T., Splaun, A. K., Evces, M. R., & Weiss, D. S. (2013). Integrative approach for the treatment of PTSD in 9/11 first responders: Three core techniques. Psychotherapy (Chic), 50, 336-340. doi:10.1037/a0032526

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