RESPONDER MENTAL HEALTHJamie Temple BA, NRP, CCP

EXPECTED OUTCOMES

• Review stress and its accompanying symptoms.

• Discuss why Emergency Responders are at risk for PTSD.

• Uncover coping strategies to mitigate the effects of stress.

• Realize what it means to be resilient.

• Increase your ability to recognize some of the warning signs of a Provider who may be contemplating suicide.

• Identify available resources to assist in stress mitigation.

DO WE HAVE ANY STRESS?

911World

EVERYDAY• Stress is an unavoidable part of our lives.

• Stress can lead to:• Hypertension

• tachycardia

• Ulcers

• General irritability

• Poor performance ( all arenas)

• Now add your everyday stress to the JOB stress!

WE ARE TRYING TO AVOID…

POTENTIALLY CRITICAL INCIDENTS

• MVC involving death / severe injury

• MCI

• Staff assault

• Line of duty death / injury

• Injury / death of a child

• Suicide of co-worker

• Identify with victim

• School shooting

• Hostage situation

• Terrorist action

• Unexpected death of co-worker

• Any event with strong sense stimulation:

• Visual, smell, auditory

• Known victim

BEHAVIORAL COGNITIVE

• Changes in activity

• Withdrawal

• Increase /decrease eating

• Increase smoking

• Increase alcohol use

• Excessive humor

• Confusion

• Lowered attention span

• Memory problems

• Poor concentration

• Disruption of logical thinking

• Distressing dreams

• Recurring flashbacks

PHYSICAL EMOTIONAL

• N / V

• Profuse sweating

• Diarrhea

• Tachycardia / HTN

• Dry mouth

• Fatigue

• Feeling uncoordinated

• Denial

• Fear

• Survivor guilt

• Depression

• Wanting to die / hide

• Anger

• Identifying with victim

• Feeling hopeless / helpless

IF YOU EXPERIENCE ANY OF THESE, SEEK MEDICAL ATTENTION

IMMEDIATELY!• Chest Pain / Dyspnea

• Hypertension

• Cardiac Arrythmias

• Sx of shock

• Dehydration / syncope

• Vertigo

• Bloody Stools

• Disorientation

• Problems with familiar items, people

• Change in speech patterns

• Inappropriate emotions

• Panic Reactions

• Difficulty making decisions

PTSD ISN’T ABOUT WHAT’S WRONG WITH YOU, IT’S

ABOUT WHAT HAPPENED TO YOU.

PERSONAL SAFETY

UNDER PRESSURE

•“pucker-factor” increases, along with

•Pulse

•B/P

•Heat production

•All the other “fight or flight responses

•And…

AUGUST 5, 1949MANN GULCH – CENTRAL MONTANA

PANIC!

•Reduces awareness to only the essential facts, or most basic instincts.

•Being chased by fire, your only thought is “run from the fire”

•FEAR

•Perceptual Narrowing…

HOW IN THE …

•Wag realized his first emotion, FEAR, had outlived its usefulness!

•Turned on his conscious mind,

•(autopilot – off).

•Rational brain could expand the list of options

EMS APPLICATION

PROCEDURAL MEMORY

•Skill / task memory

•Learned, perfected

•Cognitive toolbox that contains a recipe for a successful event

•Outside conscious control

EXPLICIT MEMORY

•Supports our ability to reason on the spot or recall exact details.

WORKING MEMORY

•Our ability to hold information short-term.

•Protect that memory briefly,

•While doing something else!

•Major predictor of IQ and intelligence

HOW DO YOU HANDLE THE UNEXPECTED, ON THE SPOT

QUESTION OR DECISION?

STRATEGY

•Relax, regroup, maybe even pause briefly if the situation involves a high working memory task.

•Would this strategy work for a task which requires procedural memory?

DUNCKER'S CANDLE PROBLEM

•Using only the objects shown in the picture, mount the candle to the wall.

PRE-FRONTAL CORTEX

•Increased PFC activity (working memory) leads to less space available on the “mental scratch-Pad.

•Less work space leads to decreased ability

•Right PFC (spatial relationships)…visual cues / ability

•Right PFC is very important to “flight / fight” response

•Sadness, fear, increased vigilance

•Good for most tasks and survival, but…

•Body shunts blood to R PFC, thus away from L PFC (verbal / reasoning)

NOW THAT YOU ARE STRESSED OUT, NOW WHAT?

•Research shows that the activity in the R PFC even after a stressful situation is resolved is latently increased.

•Things like negative emotions and heightened attention!

LESSONS FROM THE SECRET SERVICE

DIVE OR THRIVE UNDER PRESSURE?

EMS APPLICATION

“FIGHT THE FIGHT, NOT THE PLAN”

PLAN

PATIENT ADVOCACY

•Focus on something other than yourself and your feelings / anxiety.

•Remember the patient, who needs your best effort each and every time out of the gate.

•“When you are focused outward, you cannot focus inward on your emotions”.

PRESSURE COOKER

•Pressure causes a breakdown of communication between different areas of the brain.

Norman - 1996

VandeVelde - 1999

Nate Kaeding – 2010 (missed 3

FGA)

Yankees / Red Sox 2004 ALCS

MOST STRESSFUL JOBS IN US:

MOST STRESSFUL JOBS IN US:

1. Firefighter (71.59)2. Enlisted military personnel (70.78)

3. Military General (63.11)4. Commercial Airline Pilot (60.46)5. Police Officer (50.82)

6. Actor (50.33)7. Broadcaster (50.30)8. Event Coordinator (49.93)

9. Photojournalist (49.22)10.Newspaper Reporter (48.76)

Careercast.com 2015/Forbes magazine 2015

FL - SUPERMAN

PTSD for Firefighters is real. If your loved one is

experiencing signs get them help quickly. 27 years of deaths

and babies dying in your hands is a memory that you will

never get rid of ... My love to my crews. Be safe, take care. I

love you all."

SUICIDE AMONG FIREFIGHTERS/EMTS

• No comprehensive data available

• Some believe rate is high

• FF/EMS represent the highest risk population:

• 72% suicides: white males

• 90% suicides: white males + females

• Age 18 – 29 most common for suicides

• FF 96% male, 85% white,young

• Medics 69% male, 93% white, young

IMPORTANT QUESTIONS

• Have you thought about killing yourself?

• When did you last think of suicide?

• Have you ever attempted suicide?

• Has any family member attempted/committed suicide?

• Do you have a plan?

• Do you have the means?

• How specific is your plan?

RISK FACTORS• Sex (male)

• Race (white)

• Age (15 to 34) and (65+)

• Hx Depression

• Previous suicide exposure (self or family)

• Loss of hope/rational thinking

• Means and plan

• No spouse or significant other

• Illness

THE FIREFIGHTER BEHAVIORAL HEALTH ALLIANCE ESTIMATES ABOUT

30 PERCENT OF THE NATION'S 1.3 MILLION CAREER AND VOLUNTEER

FIREFIGHTERS SUFFER FROM PTSD, WITH 132 SUICIDES BY ACTIVE AND

FORMER U.S. FIREFIGHTERS AND PARAMEDICS REPORTED LAST YEAR.

A “YES” ANSWER TO SIX OF THE 10 FOLLOWING QUESTIONS NECESSITATES A REFERRAL TO A MENTAL

HEALTH CARE PROFESSIONAL. IT DOES NOT, HOWEVER, CONSTITUTE A DIAGNOSIS.

• Do upsetting thoughts or memories about the event come into your mind against your will?

• Having upsetting dreams about the event?

• Acting or feeling as though the event was happening again?

• Feeling upset by reminders of the event?

• Do you have bodily reactions (such as fast heartbeat, sweatiness, dizziness, stomach pains) when reminded of the event?

• Difficulty sleeping?

• Irritability or outbursts of anger?

• Difficulty concentrating?

• Heightened awareness of potential dangers to yourself and others?

RESILIENCE: PSYCH & BEHAVIORAL LINGO

• Resilience = ability to withstand negative pressure • Resilient people experience negative circumstances associated with

poor psychological and social outcomes yet despite odds, they end up healthy & productive:

• Mentally ill or abusive parents

• Deprived social or economic conditions

• Major stressful events

WHAT MAKES SOME PEOPLE RESILIENT AND OTHERS

VULNERABLE TO LIFE STRESSORS?

PERSONAL RESILIENCE RELATED TO:

1. Biology

• temperament, emotions, intelligence, creativity, immune resistance, genetics and physical condition

2. Attachment

• capacity for bonding (forming significant relationships with others), capacity for empathy

3. Control

• mastery over one’s environment, social competence, self-esteem, personal autonomy and sense of purpose

PATHOLOGICAL STRESS• Acute Stress Disorder (ASD):

• Symptoms experienced during or immediately after the trauma, last for at least 2 days, and resolve within 4 weeks.

• Post-Traumatic Stress Disorder (PTSD):

• Symptoms begin within 1 – 3 months after the event, may last months to years.

• Lifetime incidence: 7.8%

• Population prevalence 0.8 – 4%

• Lower incidence in emergency responders

Javidi H, Yadollahie M. Post-traumatic stress disorder. Int J Occup Envir

Med. 2012;3:2-9.

COMPARE FF TO JOHN Q PUBLIC:• Substance use/abuse

• Alcohol, drugs, tobacco

• Sleep disorders

• Depression

• PTSD

• Suicide

• Anger management, violent behavior

• Marital, family, relationship problems

TOBACCO• FF substantially lower smoking rates than military and

civilian populations

• Very high rates of smokeless tobacco use

Product FF Military Civilia

n

MD RN LPN

Cigarett

es

13.6

%

30.5% 23.4% 2% 7% 25%

SLT 21.2

%

15.6% 6.5% - - -

Haddock CK, Jitnarin N, Poston WS, Turley B, Johnke SA. Tobacco use among

firefighters in the Central United States. Am J Indust Med. 2011;54:697-706.

Sarna L, Bialous SA, Nandy K, Antonio AL, Yang Q. Changes in smoking

prevalences among health care professionals from 2003 to 2010. JAMA. 2014;

311:197-199.

ALCOHOL USE AMONG FIREFIGHTERS

• Binge drinking common (56% monthly)

• Chiefs lowest, ff/paramedics highest

• Little difference between career/volunteer

• 10% reported driving after drinking

Haddock CK, Jahnke SA,

Poston WS, Jitnarin N, Kaipust

CM, Tuley B, Hyder ML.

Alcohol use among firefighters

in the Central United States.

Occupational Medicine. 2012;

62:661-664.

PTSD AND FIREFIGHTERS

• Low rates of PTSD among FF (4.2%)

• Wide variations in other studies (6-32%)

• These data comparable or < civilian PTSD

• FF are very resilient

• Alcohol use among FF > civilians

• PTSD risks = lack of support & higher level of life stressors

Meyer EC, Daly E, Zimering R, Knight J, Kamholz BW.

Predictors of postraumatic stress disorder and other

psychological symptoms in trauma-exposed firefighters.

Psychological Services. 2012;9:1-15.

DIVORCE

• Calculating population rateis elusive

• Attorney data suggest firefighters have higher incidence of divorce

• Family, home and relationship issues likely related to work…

WHY NOT TAKE THE HELP?

• Fear of being fired. We’re not allowed CISM at our service."

• "I asked for help and ended up losing my 22-year career."

• "Asked for help and was laughed at."

• "Was told to get back to work. Was told I signed up for it so deal with it."

• "It wasn’t offered even though we all thought it should be. One co-worker stated it didn’t even bother him. A different co-worker who heard about it made comments about me being ‘mentally fit enough to be on a truck’ because the kid’s death bothered me."

40% OF PROVIDERS WHO HAD ACCESS TO

SUPPORT ACTUALLY SOUGHT HELP!

OF COURSE…

AND AGAIN…

WHY WORRY ABOUT IT…

Impacts of Traumatic Stress on an Agency

Besides taking a toll on the individual, traumatic stress

has an impact on the agency. The effects of traumatic

stress on organizations often include:

•Communication breakdowns.

•Decreased morale.

•Deteriorating group cohesiveness.

•Increased absenteeism.

•Increased healthcare costs including increased

worker’s compensation and disability claims.

•Decreased ability to retain effective personnel.

•Decreased employee efficiency and productivity.

ACCORDING TO RESEARCH BY DR. MATTHEW TULL IN “RATES OF PTSD IN FIREFIGHTERS,” YOU

ARE AT GREATER RISK FOR PTSD IF YOU:

•Begin your fire service career at a young age.

•Have underlying mental health issues.

•Were in close proximity to death.

•Hold a supervisory position.

•Experience multiple traumatic events in close

proximity.

•Are unmarried.

•Were previously in treatment for another disorder.

You do not need to fulfill any or all of these factors to

suffer from PTSD.

IDEATIONS

34% of those with ideation form plans.

72% of those with plans proceed to an attempt.

It should be noted, however, that 26% of persons with ideation but no plan proceed to make an unplanned attempt.

Also important, the majority of transitions from ideation to action take place within the first year after onset.

INTERPERSONAL THEORY OF SUICIDE

•Thwarted belongingness

•Perceived Burdensomeness

•Capability for Suicide

THWARTED BELONGINGNESS

the belief that one is alone, without connection or having lost the connections one felt to be essential to meaning, purpose, or sense of self;

the feeling that one is no longer an integral part of family, friends, workplace, or other relevant index groups.

PERCEIVED BURDENSOMENESS

the perception that one’s

continued existence

creates a drain on family, friends,

coworkers, or even society.

Inherent in that belief is the

perception—almost invariably a

misperception—that the world

would be a better

place if one were no longer a

part of it.

CAPABILITY FOR SUICIDE

is found where some combination of experience and disposition

becomes sufficient to overcome one’s natural aversion to pain and

annihilation.

This may result from a learned capacity to ensure or ignore pain

through repeated exposure and/or habituation; progressive

disinhibition through prior attempts, exposure to combat or

violence; the modeling effects of suicide in others; or any of a

number of routes and vectors.

This capability must, however, be present for ideation

to evolve into action. In other words, the power of the suicide taboo weakens.

IS PATH WARM MODEL

Ideation/threatened or communicated

Substance abuse/excessive or communicated

Purposeless/no reason for living

Anxiety, agitation, or insomnia

Trapped

Hopelessness

Withdrawal from friends, family, society

Anger (uncontrolled)/ rage/seeking revenge

Recklessness/risky acts-unthinkingMood changes (dramatic)

PFA – PSYCHOLOGICAL FIRST AID

Three basics of psychic resilience are hardwired into our biological makeup:

1. Sense of safety

2. Meaningful social connections

3. Sense of efficacy

Protect

Direct

Connect

RECREATE SENSE OF SAFETY

• Immediate physical needs (self-care)

• Bathroom, food, fluids, breaks, clothing changes, sleep, time off…

• Protect from onlookers & media

• Walk-Around – supportive presence & monitor well being(chaplain, peer, etc)

Protect

MEANINGFUL SOCIAL CONNECTION

• Help connect with family, friends, children, significant others

• Talking in homogenous groups (ie: firefighters vs. heterogeneous strangers)

• Provide information on normal signs and symptoms including suggestions for what to do

• Educate significant others on s/s and how they can help

Direct

REESTABLISH SENSE OF EFFICACY

• Recognition for job well done

• Encourage normal routines & roles

• Discuss self care strategies to reduce anxiety

• Exercise, rest, relaxation

• Encourage people to support and assist others

• Identify resources that promote effective coping (printed materials)

• Accurate, simple information about plans, schedules, events

• MH follow-up assessment @ 3 months

Connect

RESOURCES

• EAP

• CISM

• Code Green Campaign

• Reviving Responders

• Safe Call Now