Guidelines for Working with First Responders (Firefighters,Police, Emergency Medical Service and Military) in the Aftermath of Disaster

Suzanne B. Phillips Psy.D.,ABPP, CGP
Dianne Kane DSW,CGP

As witnessed in response to the Oklahoma Bombing, 9/11, The California Fires, The Tsunami, Hurricane Katrina, Hurricane Rita, Firefighters, Emergency Medical Services, Law Enforcement and the military (enlisted, reserve and National Guard) are the First Responders in the face of natural and man-made disasters. Often their response reflects a commitment to help in addition to the

Characteristics of First Responders

• First Responders have a “Mission First” perspective. Any support or response offered to these groups must recognize the importance of the mission.

• Intervention and support is only viable if it is perceived as  “added value” toward achieving the goals of the mission.

• First Responders have a different perspective on traumatic events than civilians. They enter into and expect to remain in dangerous, life threatening situations to accomplish their mission. Their threshold for the intense fear, horror or helplessness associated with traumatic situations is different than civilians.

• Given their training, skills, personal and professional identities, First Responders have considerable resilience to function despite personal hardship. In most cases they return to and maintain prior levels of functioning.

• First Responders have a Band of Brothers mentality. Their code of “ Leave

no man behind” is reflected in courageous loyalty, as well as possible self-blame  for the injury or loss of others.

• First Responders expect not to get injured and not to feel stress. Their attitude is – “Don’t get hurt, don’t feel and don’t get off the line.” Personal injury is often experienced as personal failure.

• First Responders have an insider-outsider mentality. The expectation is that outsiders will not understand and should not be told. This often applies to partners who may feel the strain but at times feel like outsiders.

• It is difficult for First Responders to recognize the cumulative stress associated with their work as well as the fact that some catastrophes are so great and disasters so extensive, that no one is spared the hyperarousal, numbing and intrusive symptoms attendant to trauma. ( For example, it is beyond what could ever be imagined for FDNY to lose 343 brothers in  9/11, for Reservists to look for bodies in the aftermath of the Tsunami or for Police in New Orleans to be caught between disaster and disorder.)

• First Responders come to understand that central to resilience is the ability to manage stress and distress.

• The group resilience of a firehouse, military unit, or EMS team can often serve as a buffer for cumulative stress. The shared experience of trauma often contains and reduces the degree of traumatic impact- they are not alone with the memory.

• In First Responders there is often a “ functional” delay in symptoms ( anxiety, depression, PTSD) until the mission is over. Occurring months even years later this can be alarming to them and their families.

•  In many of the services, the major barrier to seeking care for mental health issues is the stigma associated with mental health problems as a “ career killer. ” While this has lessened somewhat with firefighters in New York, given the recognized traumatic grief and need for help by so many, it remains a conflict for many who identify themselves with their work and fear jeopardizing it in any way.

• Peer Counselors and Chaplains are the most trusted resources used by most First Responders.

Interventions with First Responders

• Support the Mission- Crucial to your overall support of the mission is your understanding of the command structure and the role you are assigned by the service you are identified with  be it an Office of Emergency Management , a medical unit, a volunteer agency,  a disaster team, one of the Uniformed Services etc. )  In the aftermath of disaster, coordination of role and service is essential.

• Psychological First Aid (PFA)-  This is considered  “ best practice” for intervention with First Responders in the aftermath of disaster ( Everly & Flynn,2005; Institute of Medicine,2003;Litz, Gray & Adler, 2004) The goal is the support of resiliency and continued functioning. Psychological First Aid involves a variety of responses including care for basic needs, empathic listening, normalizing of symptoms and expected responses, psycho-education for stress reduction and coping skills, on-going assessment and referrals for higher levels of care. Given that First Responders have a strong sense of group cohesion ( which command personnel seek to maintain and promote) and often share similar trauma and loss, Group Psychological First Aid( Group –PFA), which utilizes the elements of Psychological First Aid in a group setting, may be particularly useful (Everly, Phillips, Kane& Feldman, 2005).

Many of the following responses could be subsumed under the heading of Psychological First Aid.

•  “ Self Care” – Crucial to the functioning of First Responders  is care of their own basic needs. Reminders of and re-enforcement of self care ( sleep, eating, hydrating, down time- music, exercise, prayer etc.) are important. Self-Care is generally underscored by officers in the service who remind their personnel to take care of themselves, but it is very difficult for First Responders to come off the line in the face of disaster. Your role whether you are handing out water, identifying a safe place for resting, or empathically listening as you hand out blankets is to add value to their functioning by being a support to their care. 

• The Walk Around- Walking around during the acute and sub-acute stages of disaster offers a non-intrusive supportive presence to assess self-care, listen, normalize, provide information (if asked), and informally assess the need for higher levels of care.  The Walk Around brings the support services to the First Responders. It was used by the Military at the Pentagon after 9/11, in New York after 9/11 and after the Oklahoma Bombing. The Walk Around should always be an officially sanctioned intervention and is most effectively done with a peer counselor from the service, a member of the service or a Chaplain – If you are not part of the culture or already known to the service, their presence lends you credibility.

• “  Buddy Care”- Given the Band of Brothers mentality, First Responders are more likely to respond to an informal inquiry as to how their buddies are doing  than a focus on themselves. This often provides an opportunity for sharing information on signs of stress, normalizing of symptoms, coping skills, referrals for higher levels of care etc.  First Responders know each other. They know when the talker stops talking or the joker is withdrawn.    

•  Importance of Chaplains – It is important to recognize the need and facilitate  the use of Chaplains when appropriate.  In the military, chaplains are the only members of the military with confidentiality. Their role is important because disaster brings with it loss, grieving, burial rites and an assault of belief systems.

• Inclusion and Collaboration with Peers. One of the lessons learned in the aftermath of previous disasters is that  close collaboration with peer counselors from within the identified culture is a viable way to reduce barriers to mental health care. Understanding their important contribution and respecting the different skills that peers and professions bring to those affected maximizes the help offered. Pre and post event training of peers is essential and such training sessions in and of themselves serve as an intervention that reduces the impact of trauma of those being trained ( Castellano, 2005; Haley,2005).

• Don’t Deploy Alone – Don’t Go it Alone. Working with First Responders is both a challenge and a privilege. Given that First Responders are usually the front line of response in the aftermath of disaster it is important for you to be part of an identified group or agency in your response to them. This enhances your credibility, effectiveness and support by others. In this regard coordination with others, co-leadership, peer group and supervision buffers the countertransference impact of disaster work and restores resiliency.

Resources:

Emergency Medical Services

The “ On site Academy”-residential facility in Massachusetts open to Emergency Medical Services recovering from PTSD. Phone 978 632-3518

Sister Program

“West Coast Post-Trauma Retreat”  www.WCPR2001.org

Police

Police Organization Providing Peer Assistance (POPPA) Programs as the Police Organization Providing Peer Assistance (POPPA) in NY and the Cop 2 Cop program in New Jersey offer confidential counseling and/or 24/7 hot line support that eliminates the fear of stigma or consequence. ( Poppa – About Us)www.poppanewyork.org

Cop 2 Cop Program Confidential Helpline for new Jersey Law Enforcement 1-866-Cop2Cop Helpline http://ubhc.umdnj.edu/Cop2Cop/main.htm

Firefighters

Fire Department of the City of New York- Counseling Service Unit [email protected]

Military

National Center for PTSD: Resources for U.S. Soldiers Returning from Deployment ( Website offers information and resources)

http://www.ptsd.va.gov

References:

Castellano, C. (2003). Large group crisis intervention for law enforcement in response to the September 11 World Trade Center mass disaster.International Journal of Emergency Mental Health, Vol. 5, No. 1.

 Cozza, S., Huleatt,W., and James,L. (2002).Walter Reed Army Medical Center’s mental health response to the Pentagon attack. Military Medicine, Vol. 167, Suppl. 4:12, pp. 12-14. 

Department of Veterans’ Affairs, Department of Defense (2004). VA/DoD Guidelines for the management of posttraumatic stress. Washington, D.C.

Everly, G.S., Jr. & Flynn, B.W. (2005). Principles and practice of acute psychological first aid after disasters. In G.S. Everly, Jr. & C.L. Parkers (Eds). Mental health aspects of disasters: Public health preparedness and response, Vol. I. Baltimore: Johns Hopkins Center for Public Health Preparedness. 

Everly,G.S., Phillips,S., Kane,D., and Feldman,D. (2005) “ Principles and practices of group psychological first aid ( Group-PFA). Manuscript submitted for publication.

Haley, M. (2005, February 19).” An immunization against stress…pre-incident education.” ICIF. 8^th World Congress on Stress, Trauma, and Coping,Baltimore, MD.

Halloway, J. (2004). Psychologists help reduce stress in the military. Monitor, APA, Vol. 35, No. 2, Feb. 2004.

Hoge, C., Castro, C., Messer, S., McGurk, D., Cotting, D. and Koffman, R. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, Vol. 351, pp. 13-22.

Institute of Medicine (2003). Preparing for the Psychological Consequences of Terrorism. Washington D.C.: National Academy Press.

Karam, J. (2002). Into the breach: a year of life and death with EMS. New York: St. Martin’s Press.

 Kates, A. R. (2001). Copshock: Surviving posttraumatic stress disorder (PTSD). Tuscan: Hillbrook Street Press.