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Beyond Debriefing: How to Address Responders’ Emotional Health

First responders need time with colleagues to decompress after responding to an incident.

On Christmas Day 2011, a 9-year-old girl was killed when a tree fell through her family’s moving car on Whidbey Island in Washington state. Firefighter and EMT Rob Harrison was among the first on the scene. He knew the girl. He looked into her mother’s eyes. He said he did something a first responder will rarely admit to. “I broke down and cried on the scene.”

Despite professional training, traumatic events take their toll on first responders. Children’s deaths hit particularly hard, leaving psychological scars that can have a devastating impact in the short and long terms.

As many as 37 percent of firefighters meet criteria for a diagnosis of post-traumatic stress disorder (PTSD), according to the journal Fire Engineering. A decade after 9/11, about 1,000 of 5,000 Long Island first responders still showed symptoms of PTSD. After the Newtown, Conn., massacre, as many as seven police officers — more than 16 percent of the local 43-member force — were out at one time with PTSD issues, according to Police Chief Michael Kehoe.

The emergency management community has taken some steps to address the emotional needs of those who rush to a disaster scene. But experts say there’s much more that could (and should) be done.

Addressing Emotional Needs

The question of emotional health among first responders has been getting more attention lately. After the Boston Marathon bombings, for instance, Police Commissioner Ed Davis took the unusual step of calling for large-scale counseling efforts. “Officers that I have talked to have been extremely traumatized and saw things that you would see on a battlefield. We are extremely concerned about that,” Davis told The Wall Street Journal.

In recent years, the standard answer to first responders’ emotional needs has been the critical incident stress debriefing, an often mandatory gathering of those hit hardest by the trauma of disaster. Authoritative voices, however, say these interventions are insufficient.

The World Health Organization, for instance, says a psychological debriefing “should not be used for people exposed recently to a traumatic event,” and may do more harm than good.

While such debriefings have been common practice for first responders, the value hasn’t been scientifically demonstrated, said Kathleen Tierney, sociology professor and director of the Natural Hazards Center at the University of Colorado, Boulder. “This is something that doesn’t have much science behind it,” she said. The largest drawback: Debriefings are simply too generic. “One-size-fits-all debriefings are not appropriate.”

Yet the need for some intervention is indisputable.

“First responders in disaster situations and other kinds of major emergencies are confronted with things that can be psychologically very disturbing,” Tierney said. “The sight of dead bodies, people who lost limbs, people who are trapped, seeing children who have been killed or injured.”

The lasting effects of such exposure can include depression, anxiety and withdrawal. If generic debriefings aren’t the answer, what else can emergency managers do to ensure that responders
are properly cared for?

Lay the Groundwork

As with so many aspects of emergency management, post-trauma care often comes down to planning, said Jeff Upperman, director of the Trauma Program and the Pediatric Disaster Resources and Training Center at Children’s Hospital Los Angeles.

Knowing that medical personnel will be among the first to confront the human toll of a disaster, Upperman looks to ensure that proper support mechanisms are in place long before any event. “As a Level 1 trauma center, we have exercises on an annual and semiannual basis,” he said. “We have an active committee to talk about plans and preparations.”

Those plans include building networks with local schools and churches where personnel may turn for help. “You’re part of that community; you’re not isolated from that,” he said. Pre-planning for community support therefore can be a major benefit.

Front-line managers must be trained to recognize signs of stress and shown how to act appropriately. “Leadership is going to have to be ready to make some just-in-time decisions,” Upperman said. Likewise, personal communications networks should be designated in advance. “We ask explicitly, ‘do you know how to text?’ Because texting will not tie up the phone lines like a phone call, and will allow people to talk to family as soon as they need to.”

Containing Hours

Before considering further solutions, it may be useful to delve deeper into the problem. While a disaster can be traumatic, the impact often is worsened by the management of first responders, especially when it comes to time in the field.

The dictum that rescuers need to go home after 12 hours is too often ignored.

The impulse to stay in the field is built into the first responder psyche, Tierney said. “They don’t know when to stop, and they don’t want to stop. Twelve hours on is hard enough already, but often it is very difficult to get people to stop working. Unless management takes a strong stand, things can get out of hand. There has to be the enforcement of hours, so people don’t exhaust themselves working overtime.”

That enforcement starts with training, educating first responders about the physical impact of overwork and teaching them to recognize signs of mental and physical fatigue. “This kind of information needs to be part of that training,” Tierney said. “That you have to take breaks, and you have to leave at the end of your shift.”

Sometimes the strongest way to make that case is to remind first responders that taking a break is critical to doing their job well. “After a couple of days, people just won’t be working as effectively, whether it’s decision-making or the physical component. You need rest; you need downtime,” said Dave Neal, professor of political science, a sociologist and a member of the fire and emergency management program at Oklahoma State University.

This issue of managing hours extends beyond the responders themselves, Neal said. Those who rush to help emergency workers cope also must be strictly observed and regulated by emergency managers overseeing events.

“There is a tendency for everyone and everything to show up in the first couple of days, which often comes from too much self-dispatching,” Neal said. That includes psychologists, clergy and well-meaning laymen. “They may be really good people, but maybe it makes more sense for them to wait two or three days until after that first wave, when the mental and emotional stress starts to take place. That means emergency coordinators need to have a system in place.”

How to Help

What forms of assistance can help first responders? EMT Harrison said the critical incident stress debriefing wasn’t the answer. “It was the only tool we had at the time, but for me it didn’t work.”

Since the 2011 incident, Harrison’s community has developed another option — developing the voluntary response network Whidbey CareNet, founded by Petra Martin. Through this network, a broad range of local care providers step up during crises to help comfort those on the front lines.

Those services run the gamut, with counselors, massage therapists, even pedicurists and chefs volunteering to help ease the pain. Volunteers in the mostly rural area of Whidbey provide a cost-effective means of emotional support for those who need it.

The American Group Psychotherapy Association likewise offers a number of best practices for supporting first responders.

  • Self Care — Make sure first responders are meeting their own basic needs as an incident unfolds: sleeping, eating, hydrating and taking downtime for activities such as music, exercise and prayer.
  • The Walk-Around — Someone needs to be on the ground offering a supportive presence and monitoring responders’ emotional state. This may be a peer, chaplain or officially sanctioned service member. Eyes and ears on the ground can make a difference.
  • Buddy Care — With their “Band of Brothers” mentality, first responders may likeliest
    respond to an informal inquiry about how their buddies are doing. They may be more open to sharing with one another and more attuned than an outsider to their peers’ emotional state.
Chaplains and counselors also form a vital link in the chain of immediate support personnel. This is what they’re trained to do, and their early presence on the scene can help contain the long-term negative effects of an event.

Make Connections

As the issue of first responder care has gained momentum in recent years, experts say coordinated partnerships have emerged as one of the most effective tools.

Neal points to the example of the Murrah Federal Building, site of the Oklahoma City bombing that killed 168 people in 1995. In that instance, the American Red Cross teamed with the American Psychological Association to rapidly identify qualified support personnel and get them on the scene. This helped contain a hodgepodge of self-selected, would-be caregivers, according to Neal. “They had a lot of mental health workers showing up, from highly trained psychiatrists to lay preachers with an eighth-grade education.”

By working in tandem, the national organizations were able to implement some order and put qualified professionals in place.

The partnership model can be seen in Philadelphia’s First Responders Addiction Treatment (FRAT) Program, which addresses alcoholism or other dependencies that may accompany the emotional trauma of first responder work. In that case, the organization works with the local area medical community to ensure that emergency personnel get proper support.

While formal arrangements are crucial, there’s much to be said for less formal support. On 9/11, for instance, volunteers from all walks set up tents to offer support to first responders. “They created a respite center, a place to rest,” Tierney said. “All the volunteers did was sit and talk to people, hold their hand if they wanted to, just provide some human contact.”

Finally, and crucially, in the first responder culture, rescuers are most likely to talk to those within their own ranks. A firefighter who avoids a counselor might share more openly with a peer in uniform. Emergency planners must create the time and space for front-liners to hang out and decompress, both just after and in the weeks following an event.

This speaks to what is perhaps the greatest challenge in caring for the caregivers: the macho culture that drives the first responder mindset. Emergency managers looking to ease the pain must always be mindful that “tough guys don’t cry.” Providing appropriate care means finding a way over, through or around this fundamental sticking point. Mental health professionals can help emergency managers craft plans that address emotional needs while still treading thoughtfully on this delicate ground.

Adam Stone is a contributing writer for Government Technology magazine.