Early intervention via therapy is vital to ensuring emergency workers are able to psychologically adjust to their experiences and maintain their health and wellbeing. (Photo by John Cetrino.)
Therapy (also known as counseling or talking therapy) is a vital component for full recovery from disaster and trauma, ensuring that frontline and emergency workers “psychologically adjust” to emotionally difficult experiences. Let’s examine why therapy is sometimes necessary for emergency workers and what therapy might involve for those who choose to reach out for professional support.
Helping Individuals via the Community
The impact of disaster and crises, whether natural or manmade, affects communities, families, and individuals, exposing those affected to medium to long-term physiological and mental health issues. The need to provide support and care to those who are injured, lose loved ones, or suffer significant property loss has long been recognized. More recently, however, the impact on frontline emergency response personnel has gained recognition. Since the World Trade Center attacks in 2001, Hurricane Katrina in 2005, and more recently after natural disasters in New Zealand and Japan, significant research has been undertaken into the impact of disasters on first responders such as firefighters, police, and paramedics. From this research, it has become clear that early intervention, via therapy, is vital to ensuring emergency workers are able to psychologically adjust to their experiences and maintain their health and well-being.
Recovery from disaster has evolved from a position of almost wishful thinking and hope for a return to normalcy to an understanding that recovery must be an integrated, whole systems approach. The approach, taken post-Hurricane Katrina in the United States and in countries prone to recurrent natural disasters such as New Zealand, has viewed recovery as one part of a multifaceted, community-wide approach. Other elements include risk reduction, building community resilience, and improved response plans. Recovery is not considered an entity in itself under these models but rather has subsets that include components addressing the physical environment, infrastructure, psychosocial dimensions, attributes of community, and economy.1
In New Zealand, significant work has been undertaken on developing a holistic approach to recovery following the Christchurch earthquakes. It has been found that recovery interventions must encompass everything from immediate actions to meet a community’s basic living needs to long-term interventions for those who suffer physically or mentally.
The psychosocial elements of this holistic approach look at meeting the immediate, medium, and long-term needs of individuals, families, and communities while building capacity and well-being. It requires partnerships between various people within the community, from health professionals to urban planners and economists. It is within this framework of recovery that therapy is considered essential for total community rehabilitation. Indeed, individual recovery is considered to be integrated into community recovery and vice versa.2
Different Degrees of Trauma
Most people will recover from trauma with little or no professional intervention; however, each individual will interpret and understand traumatic events differently. Various forms of therapy can assist individuals to come to terms with the meaning of their experience; how they are affected by it; and, ultimately, how to move on from it. Support and treatment, whether short- or long-term, will vary depending on the needs of the individual. Victims are often classified by degree of impact, with primary and secondary survivors being those who are directly affected by the disaster and those who may be grieving for those most affected. Emergency support workers and primary caregivers are considered third-level survivors, with fourth and fifth level being those who have witnessed or been indirectly affected by the events, as well as affected members of the general community.3
Many people will avoid experiencing any form of acute stress or trauma throughout their lives. In the case of emergency workers and frontline staff, however, trauma can be a daily part of their job. For these individuals, their work requires them to be responsive to natural and manmade disasters and crises that require them to care for the needs and welfare of others. The very nature of their employment exposes them to direct risk and subsequent direct and indirect stress and trauma. For frontline and emergency workers, their ability to process the events they witness and maintain a healthy sense of well-being is essential.
Despite a significant body of research that shows the efficacy of early access to quality psychosocial therapy and support, there is still a strong stigma surrounding mental-health issues. It has long been established that negative attitudes toward mental health inhibit an individual’s ability and willingness to seek help. It is also well understood that the sooner help and treatment are sought, the more effective that treatment will be.
Many emergency workers choose their careers based on a strong desire to make a difference and help people. These roles generally attract people who believe they are resilient and able to manage their personal feelings. The culture of many emergency response workplaces therefore reinforces the sense of tough people doing tough jobs. Generally, the belief that emergency workers are trained to stoically deal with trauma implies that trauma does not have the same effect on them as it does on the general public. Being trained and potentially prepared for trauma does not necessarily protect from its severe effects, however, especially when the scope of the disaster is enormous.
The reality is that in cases of extreme disaster, frontline workers have been found to have significantly higher risk of post-traumatic stress disorder (PTSD) than other populations. For example, 12 percent of firefighters who responded to the 9/11 World Trade Center disaster showed PTSD symptoms two and a half years after the event,4 and the symptoms were still prevalent nine years after the event.5 Similar results were found in police, paramedics, and volunteer responders. In addition to PTSD, emergency response workers may suffer from higher than average levels of anxiety, depression, and substance abuse. Often, more than one of these will occur concurrently.
Seeking Professional Support
Most employers offer counseling support services through in-house counseling or outsourced employee assistance programs, but using internal resources can create further fear and apprehension. Seeking help for emotional issues as a result of trauma may be impeded by anticipated stigma from work colleagues, family, friends, and even the broader community. There may be a concern that security of employment might be jeopardized when admitting the need to get help. Other barriers include concerns about the cost, whether the right therapy is available, and even whether it would be effective.
Professional help should be sought if the individual starts to feel isolated; has trouble sleeping or increased nightmares; experiences sudden unexpected bursts of fear, anger, or irritability; finds himself withdrawing from family and friends; or if there is an increase in the use of substances such as alcohol and drugs to avoid negative feelings.
When considering the provision of support to frontline and emergency response staff from a psychosocial approach, the need for an inclusive, whole-of-community approach is important. The tendency of some workers to deny the need for help and remain separate and isolated from their colleagues, family, and friends for fear of judgment, stigma, or other negative consequences is the most detrimental approach to take.
Recognizing that most people will recover with limited intervention, education and discussions surrounding unique trauma responses should be undertaken both at the training stage, before disasters occur, and soon after a traumatic event. This can be effectively achieved in the workplace and can remove some of the stigma around seeking help. Affected workers and workplaces can create support groups, group discussions, and counseling either formally or informally since peer support is essential.
For workplaces that are, by their nature, regularly exposed to traumatic events, such as the emergency services, internal peer support programs are emerging as effective strategies. An effective peer support program will have professionally trained and accredited peer supporters overseen by a skilled mental health professional. The peer supporters are integrated into the workforce and are accessible for both day-to-day support as well as during and after major disasters or traumatic events. Peer support programs will have clearly articulated and agreed-on goals, provide informal monitoring of peers within the workplace, and have clear evaluation criteria.
The power of the community should not be underestimated in supporting the individual’s recovery. Community events that encourage social integration, open communication, and community support should be organized and engaged in. The sense of belonging and family that is often found in emergency service workplaces is well placed to create these whole-of-community support services.
Through this process, those who require intensive formal counseling and professional therapy can be supported by accessing the necessary services. For the small but significant group that faces long-term mental health issues, professional counseling will be essential. The earlier this need is identified and implemented, the more successful the long-term health and well-being outcomes will be. This integrated, layered approach to community and individual recovery is considered to build resilience and responsiveness to future trauma.
Once it is determined that professional help is required, a tailored, personalized treatment plan will be developed in consultation with all relevant practitioners and the individual receiving care. Most interventions are either psychological or pharmacological. Treatment will generally be undertaken in outpatient or community programs unless there is a concern for the well-being of the patient, such as the risk of self-harm, in which case inpatient care may be recommended.
Types of Therapy
Psychological therapy often takes the form of group therapy or cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing. CBT is based on the understanding that behavior is driven by the individual’s understanding: his thoughts. This therapy aims to change the underlying perceptions shaping the behavior through a series of exercises aimed at reeducation. The emergency worker is supported in confronting his memory of the trauma and processing it. Generally, CBT will be short-term therapy.
Eye movement desensitization and reprocessing works on the basis that memory of the trauma is stored in an unprocessed manner, resulting in an inability to move past the event. The therapy requires the emergency worker to focus on the memories of the trauma while following the therapist’s moving finger. This is believed to allow the processing of the trauma while supported by the therapist.
Pharmacological therapy is predominantly based on the prescription of anti-depression medication. Generally, this approach is recommended concurrently with psychological therapies or as a precursor to these treatments.
In conclusion, disaster; crises; and the consequential loss, damage, and trauma can occur at any time. Effective preparedness and planning can help minimize the impact of a disaster. Those affected will, to varying degrees, require short- to long-term support to recover from the traumatic event and rebuild mental and physical well-being. An integrated, layered, and personalized psychosocial approach to recovery can help communities and individuals recover more effectively than a less coordinated approach. Special attention needs to be paid to those who are most affected by the traumatic event and those who come to their aid. Early intervention of group support, counseling, and professional therapy will assist in ensuring the best possible outcomes for the long-term health and well-being of those affected, including emergency response and frontline crises workers.
1. Mitchell, James K, “The Primacy of Partnership: Scoping a New National Disaster Recovery Policy,” The ANNALS of the American Academy of Political and Social Science (2006), 604; 228.
2. Mooney, Maureen F, et al, “Psychosocial Recovery from Disasters: A Framework Informed by Evidence,” New Zealand Journal of Psychology, Vol. 40, No. 4, 2011.
3. Cohen, Raquel E, “Mental Health Services for Victims of Disaster,” World Psychiatry, 2002 Oct; 1(3): 149-152.
4. Corrigan M, McWilliams R, Kelly K, et al, “A Computerized Self-Administered Questionnaire to Evaluate Posttraumatic Stress in Firefighters after the WTC Collapse,” American Journal of Public Health, Suppl 3: S702-9, 2009.
5. Soo J, Webber MP, Gustave J et al, “Trends in Probable PTSD in Firefighters Exposed to the World Trade Center Disaster, 2001-2010,” Disaster Medicine Public Health Preparedness, 5 Suppl 2: S197-203, 2011.
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