Psychiatric Times

Septermber, 2022: As Suicide Prevention Month continues, we take a look at the mental health
of a group constantly caring for others: first responders.

As September is National Suicide Prevention Awareness Month, this article focuses on the
exposure and affect regarding those who have been charged with protecting the population’s
health and preserving a community’s population—namely, first responders.
In 2022, the world has been challenged by several unprecedented large-scale crisis events
such as increases in mass shootings, increases in violence, and pernicious natural disasters.
Although first responders have been trained to engage in extreme conditions amid rapid onset
of change circumstances, such trainings do not comprehensively address or provide resources
for the post-response mental health needs of these professionals. In fact, because of the
pandemic, alongside a host of other various social ingressions like public insurrections and
aggressive social discord over the past 2 years, the mental health needs of first responders
have gained more attention. In this, a larger scope of questions predominates, such as: What
happens to those same professionals who continuously endure the gross impact of such
phenomena beyond their psychological and physical capabilities? Additionally, what is being
done to assist first responders regarding assessment and remediation of mental health issues?
Finally, how prevalent are things like posttraumatic stress disorder (PTSD) and other
pathologies that may result from being a first responder?
Definitive trends also underscore these kinds of questions regarding first responders and the
pathos-defined issues that have emerged from studies that depict PTSD, suicide, depression,
alcoholism, and drug abuse as most predominant among this group of professionals.1 Although
this observation was made nearly a decade ago, current research shows these same trends
have negatively increased in 2022.
As well, more sobering statistics from the Centers for Disease Control and Prevention (CDC)
have found that occupational stress in first responders can be associated with increased risk of
serious mental health issues including hopelessness, anxiety, depression, posttraumatic stress,
and suicidal behaviors such as suicidal ideation and actualized attempts.2
The following article presents a purview and inquiry into how society, policy makers, and
government agencies can begin to synthesize the current trends regarding the mental health
issues of first responders, as well as their compromised and vulnerable realities, and emotional
valance. Additionally, this article examines a few of the current promising psychological
preventatives being tested with first-responder populations and the future prospects to be
considered for building mental health resources for this group.
The Role of the First Responder
To more clearly define “first responders,” one must consider the cross-segment of industry
categorized as helping professionals, where the primary role is first-line contact in any
emergency situation. For the purposes of this article, the author will refer to such a role primarily
as “first responder”; however, this reference can be somewhat arbitrary, and first responders
may also be characterized as “emergency response providers” or “public health workers.” Either
way, first responders are those who must meet the challenging demands of their front-line status
within roles that represent a collection of various helping professions.
Under the umbrella of those considered first responders are police officers, firefighters, and
emergency medical technicians (EMTs). Given their occupational demands, these helping
professionals are the ones who are also the most chronically exposed to stress and traumatic
scenes in the line of duty on a daily basis. To expand on this, according to Title VI from the
Domestic Security of the US Code, the term “emergency response providers” might also include
federal, state, and local governmental and nongovernmental emergency public safety, fire, law
enforcement, emergency response, emergency medical (including hospital emergency
facilities), and related personnel, agencies, and authorities.3
The next section provides a look at some of the emergent literature that has been documented
concerning the mental health sequelae of first responders and the psychopathology that may
perseverate. This may include the artifacts of depression, anxiety, suicidal ideation, and a host
of other variants.
Statistics on First-Response Personnel
Some statistics provided on first responders and their mental health have been documented by
the US Department of Healthin a supplement from the Substance Abuse and Mental Health
Administration Help for Heroes Program.4 The statistics reveal the following associated with
firefighters, police officers, and EMS professionals5-7:
“It is estimated that 30 percent of first responders develop behavioral health conditions
including, but not limited to, depression and [PTSD], as compared with 20% in the general
population. In a study about suicidality, firefighters were reported to have higher attempt and
ideation rates than the general population. In law enforcement, the estimates suggest between
125 and 300 police officers commit suicide every year.”
These are staggering results compared to those in other professions. If one reflects on the
nature of each of these roles and what they are called to do to preserve life and community, the
possibility of such tremendous role strain will always have some psychological implications. In
looking at the work of firefighters, for example, these professionals are often the first on the
scene in an emergency response call. “The nature of their work, including repeated exposure to
painful and provocative experiences, and erratic sleep schedules, can impose significant risks to
their mental health.”8 Thus, repeated exposure to hard circumstances that arise from crises are,
by nature, psychically scarring and elevate the risk for future traumatic sequelae. To this end,
one may add yet another insidious element of risk to be considered: intrinsic barriers that bar
them from seeking help because of stigma, diminished capacity on the job, informal codes of
silence, and treatment costs.
As with most exposure to extreme stressors, the elevated risk of things like anxiety, suicidal
ideation, PTSD symptomology, and other issues may become more acute. Using the following
example, according to research by Stanley et al, “over 50% of firefighter deaths are due to
stress and extreme exhaustion.”8 In addition, “the suicidality of firefighters in yet another study
revealed markedly greater elevated levels of posttraumatic stress from the profession, while
career firefighters reported higher levels of PTSD.”8
In turn, according to Bentley et al, an estimated 69% of EMS providers report not having enough
recovery time between traumatic incidents.9 As most EMS providers are expected to be on duty
for strenuous amounts of time—up to and beyond 24 hours—the duration and intensity of being
on-call, engaging in extremely stressful situations, and having little opportunity for rest in
between incidents becomes an unbalanced centrifuge of extraordinary circumstances to
contend with that can lead to negative outcomes for the individual. Also, EMS workers typically
experience greater noted degrees of problematic alcohol and drug use—more so than the
general population.6 Like firefighters and police officers, most EMS personnel are reluctant to
seek care due to fears of stigma, irrational codes of silence, and fear of possible disciplinary
action such as being put on leave or desk duty indefinitely.10
In a number of studies, first responders showed disturbingly clear outcomes in reference to
suicidal ideation. According to the studies, there was a 28% lifetime prevalence rate of feeling
as though life was not worth living, 10.4% had more extreme instances of suicidal ideation, and
3.1% revealed past suicide attempts. As well, 37% of the first responders surveyed for 2 primary
studies had contemplated suicide nearly 10 times more than the typical American adult. The
lifetime prevalence of suicidal ideation among police officers was revealed to be 25% in female
officers and 23% for male officers. Suicide attempt rates among police officers ranged from
0.7% to 55% in studies based on extensive literature reviews.11 As well, international analysis
concerning suicides among law enforcement and their proportionate mortality ratios (PMRs)—or
more so, the ratio of death count for this occupation compared to the expected number of
deaths in all occupations combined—appeared significantly higher for all races and sexes
combined (all law enforcement PMR equals 169%).12
In the wake of the pandemic, the volatility and precarious nature of widescale crises only added
to the extreme pressures of first responders. As we begin to uncover more data and evidence
from the impact of the pandemic, much more will be learned about just how devastating and
long-lasting those impacts have become. In the following section we look at some of the current
resources being developed and implemented to address the needs of these professionals.
What Is Being Done
Part of the issue concerns the gap in research concerning a more comprehensive
understanding of first-responder suicides. However, there have been several initiatives
underway to help close this gap so that more enhanced resourcing is prevalent. One of the first
steps was the construction of an interagency team of researchers composed from the National
Highway Traffic Safety Administration (NHTSA) and the CDC’s National Center for Injury
Prevention and Control (NCIPC), alongside the National Institute for Occupational Safety and
Health (NIOSH).2
This aggregated team of researchers is now analyzing and gathering more data around suicides
of first responders using data from the most recent 3 years abstracted from the National Violent
Death Reporting System (NVDRS). It is the only state-based surveillance system that
aggregates data on the various types of violent deaths that include suicides. But why would
suicides among first responders be an important data point to explore? Such specific data will
actually help provide clarity around the circumstances of suicides among first responders.
Although it can only provide a basic understanding of first-responder suicides, the information
will be a significant start in the right direction for helping understand how first responders are
dealing with extreme stress issues.
However, there are still inherent missing data elements that will need to be addressed to fill the
voids in information and data collected. As a result, in 2020 the United States House and
Senate had approved funding for this very need known as the Helping Emergency Responders
Overcome (HERO) Act.2 This has led to legislation that directly incorporates the CDC to initiate
a “public safety officer suicide reporting system” that will help increase and gather important and
sometimes nuanced details around such events.2 Such legislation actually opens the door to
promote research that will be targeted and directed toward helping first responders understand
and hopefully circumvent negative outcomes in the future. These are the first in a series of
promising steps.
Progressive Interventions
With the number of mass shootings that have taken place over the years and the experience of
first responders arriving at such scenes of mass destruction (which often are compared to war
zones), investigators are starting to explore those effects most recently in regard to police,
EMTs, and firefighters who attempt to control and manage real-time atrocities. Some studies
have revealed distinct derivative similarities regarding military soldiers engaged in war and
those who are repeatedly exposed to “warlike” environments, such as those in which first
responders must work.
IOPs. As part of progressive steps to help first responders navigate the negative effects of the
role, more and more clinics are using intensive outpatient programs (IOPs) as an avenue of
hope. IOPs provide a more aggressive intervention path for first responders to be treated, which
is being proposed and implemented as a possible conduit to regulating trauma symptomology.
IOPs are designed to deliver treatment in a more rapid fashion, establishing rigorous
psychosocial supports for participants and addressing relapse anchors while enhancing an
individual’s coping skills.13 The IOP outpatient setting also provides clinicians the opportunity to
work intensively with patients daily for an extended amount of time.
Deborah Beidel, a professor of psychology and medical education at the University of Central
Florida, and her colleague, Amie Newins, an assistant professor of psychology at the same
institution, are using IOPs as a way to help first responders. Both have been studying the effects
of an empirically tested PTSD treatment program utilizing the IOP protocols that were originally
developed for treating military veterans in trauma management therapy. They have begun
modifying this particular treatment over time to adjust for first responders. This program relies on
some aspects of exposure therapy that offer a homeopathic opportunity that does not abruptly
attempt to challenge fears, but rather, allows the individual the opportunity to gradually explore
and diminish feelings in tandem with measured exposure to simulations that might create
anxious states.13 As a result, when those first responders treated begin to understand that their
reactions and feelings are not applicable to all situations, their fears—for instance, of large-scale
benign events like concerts or meetings that may feel similar to a former mass crisis they may
have worked in—may begin to lessen. In the results of their intensive outpatient program, Beidel
and Newins found that about 70% of first responders who participated and demonstrated signs
of PTSD no longer met the criteria after completing the program.13 Such experimental therapies
like this one are beginning to show great promise, but more resources like this are still needed.
Peer to peer. Utilizing peer-to-peer sessions as a way to become more dialogic in
communicating and processing various traumata is also finding its way into resourcing for first
responders. Jeffrey Brown, PsyD, a private practitioner and assistant clinical professor in the
Department of Psychiatry at Harvard Medical School, and Beth Meister, EdD, a private
practitioner and also a clinical instructor at Harvard Medical School, were at the forefront of the
very traumatic Boston Marathon bombing. At the time, both were working on the ground in a
makeshift tent to help victims. As first responders at such a crisis-level event, both professionals
were asked in interviews following the incident about their own self-care. Here is what they
said14:
Brown: “I’ve been practicing what I preach: focusing on healthy eating, regular exercise, and a
routine that includes ample sleep. While I’ve processed the event many times with patients
who’ve brought their own experiences into therapy, I’ve also participated in a team support
session and other meetings focused on shared experiences and support for medical team
members directly exposed.”
Meister: “I attended a support session for race volunteers 2 weeks after the event, which was
helpful. Although I felt no prominent after-effects, I tried to talk to family and friends about the
experience when they asked and when I felt it would be helpful for me to talk. My initial anger at
the loss of life, injury, destruction, and disruption of a sense of security has been replaced by a
feeling of sadness when my mind goes to that day. I have found cognitive strategies helpful in
dealing with the memories, just as I teach them to my patients.”
Peer support programs are being implemented both in the United States, Canada, and other
countries across the world. They are steadily becoming part of frontline responder programs,
such as police officer peer-support programs. One of the main goals of such programs is to
help, for instance, police officers handle the exposure of daily stressors and traumatic material
by being able to process it with a peer. The emergence of such programs evidenced greater
proliferation during the 9/11 terrorist attacks in New York, where “a peer-based assistant
program was found to be extremely beneficial in screening for stress-related symptoms amongst
police officers, as well as helping them to process the aftermath of exposure to the 9/11 terrorist
attacks in New York.”15
State-based programs. The rise of more “state-based programs similar to the program
sponsored by the University of Texas Health Science Center at Houston have worked toward
designing and implementing short continuing education (CE) virtual training programs
specifically for first responders, describing how to recognize mental health and substance use
issues in oneself or one’s peers. They have also established a statewide, completely
confidential toll-free helpline (1-833-EMS-IN-TX) to provide screening, brief interventions,
motivational interviewing, and other resources for first responders. Other states have formed
similar programs.16 The hope is that more state agencies begin addressing the mental health
needs of first responders as programs like this begin seeing results.
Marketing the right approach. Finally, another idea comes from the prospect of how such
resources are marketed to both first responders and their agencies. Those working as mental
health professionals need to find more creative ways to market the potential of counseling and
therapy to first responders who might be hesitant to engage otherwise. Therapists can conduct
agency trainings for first responders, volunteer for ride-alongs, or participate in community
events with police officers, firefighters, and EMTs as first steps to initiating a mental health
dialogue. A psychotherapeutic approach where first responders engage in counseling shows
promise, with group therapy leading the way forward from the work of researcher Vallejo.17 In
this particular study, first responders participated in psychoanalytically oriented group
psychotherapy practice twice per week over a 3-month period. Utilizing a group of police officers
(n = 8) from Colombia who had been previously diagnosed with PTSD symptomology, the
results of the study showed that posttraumatic stress symptomatology had improved in the trial
sample after group psychotherapy was completed.
In a similar study, a randomized clinical trial (n = 42) of Dutch police officers were sampled and
divided into 2 distinct groups: an experimental group and a control group.18 In this study, the
experimental group was given a combination of cognitive-behavioral and psychodynamic
treatments for 16 weekly sessions. The findings of this study indicate that officers who attended
psychotherapy for PTSD produced more significant improvements in altering their PTSD
symptomatology compared with officers in the control group.18 Such results are again promising
for the future of treatment possibilities for first responders.
Concluding Thoughts
The potential challenges faced by first responders have grown exponentially. As the nation
counts on the heroic efforts displayed by these individuals daily in their line of work, policies and
supplemental resourcing need to be modified to address the ever-burgeoning needs of this
group. Some strategies, however, are beginning to take shape and show efficacious promise in
fighting the deleterious effects that first responders might internally battle. More data is needed,
though, to help understand the areas of opportunity available for continued research. As natural
environmental impacts and socioeconomic issues continue to grow, so too must the efforts of
research and policy to help sustain and treat the mental health needs of those we count on daily
to arrive at and treat the victims of torrential situations. It is no longer a hope but an imperative
that we address and help fortify one of the most valued and critical areas of professional
avocation—namely, first responders.
Dr Luster is senior director of research strategy, innovation, and development in the College of
Doctoral Studies at the University of Phoenix, in addition to running his own private practice
called Inspirethought Counseling.