A firefighter / paramedic (EMT) in Maine answers an emergency call. He grabs his equipment and does a job he knows well. The next day, he discovers that the person he helped has tested positive for COVID-19. He immediately worries not only about himself, but also about his wife and small child, who have breathing problems.
Amy Davenport Dakin, a licensed clinical advisor in Maine and a licensed clinical mental health advisor in New Hampshire, has worked with this firefighter / EMT for several years. Prior to the incident, he had struggled with anxiety, depression, suicide, and post-traumatic stress disorder (PTSD), but successfully solved many of these problems with Dakin's help. This recent experience of being exposed to the virus that causes COVID-19 adds another layer of stress and anxiety that could spoil its previous advances, Dakin says.
As the name suggests, first aiders such as rescue workers, police officers, firefighters, paramedics, dispatchers and other trained specialists are the first to respond in emergency situations. If people do not get into an emergency themselves, this service is often taken for granted, and little is generally thought about the accumulated mental health burden of first responders.
This requires a reality check. "Our worst days are first aiders every day," emphasizes Drew Prochniak, a licensed professional counselor (LPC) and licensed psychosocial counselor (LMHC) in private practice in Portland, Oregon ]. "Your days are full of accidents, pain, grief, loss and trauma."
According to a supplementary research report from the Disaster Technical Assistance Center of the Authority for Drug Abuse and Mental Health in 2018, about 30% of first aiders are affected by depression and PTSD. In addition, 37% of fire and rescue workers have considered suicide, which is almost ten times the rate of American adults in general. In fact, more firefighters die of suicide than fires in the United States, Dakin notes.
It is easy to suspect that this population could benefit from therapeutic interventions, but its members are often the last to ask for help. By getting to know the community of first responders and adapting approaches to this population, counselors can remove some of the obstacles that prevent these heroes from prioritizing their sanity.
Getting to know culture
Dakin, a member of the American Counseling Association, admits that it can be difficult for counselors who are new to first-aiders to get a foot in the door of the church. Someone initially referred a fireman to Dakin for advice, and the experience sparked their interest in working more with first responders. But first she had to earn her trust.
For approximately seven years, she attended union meetings, gave training and presentations, answered calls with first responders, and hung out at her stations. This notoriety enabled her to build relationships and trust within the first aid community and helped her determine that it was a population that she wanted to work full-time with. Today she owns New Perceptions Inc. in Kingston, New Hampshire, a private practice that focuses on the treatment of trauma and mental health care for first responders.
Prochniak, a former search and rescue professional and author of the book Addiction & Recovery for First Responders, agrees to build a relationship with a first aider Department or agency is an important step in overcoming community members' belief that clinicians do not understand their culture. "There is this mystery among clinicians that we only talk about emotions and want to get into people's heads," says Prochniak. Building relationships with first aiders outside of counseling sessions will show them that therapists are just normal people, he says.
Prochniak, who specializes in the education, training and treatment of first aiders, says that there is a personality type that goes hand in hand with being a clinician who works with this population ]. Consultants must be able to hear about grotesque experiences and show respect for the work of first aiders, he explains. For law enforcement clients, this often means that counselors must be comfortable with clients who have weapons in the session, he adds.
Prochniak warns advisors not to ask first responders about the worst, what they saw, what type of weapon they were carrying, or whether they had ever shot anyone. Instead, consultants should be curious about them as people: how long have they been doing this work? What made you decide to enter this industry? How does your work affect your family? What kind of social network do you have? Do they only hang out with people from the first aid community? What else do you do outside of work?
Consultants must also be able to tolerate a dark, almost pathological sense of humor, since first-aiders often use this as a coping mechanism. “Among other things, we deal with humor with trauma. And it can be very annoying for people who don't experience [what first responders do]”notes Carrie Whittaker, LPC and LMHC in New York and Connecticut.
Prochniak points out that advisors must also be smart when dealing with double relationships. He is not only a resident clinician, but also a trainer and educator. At the beginning of every new customer relationship with a first aider, he prepares them for the opportunity to meet him during training courses, briefings, meetings or carpooling opportunities. He makes it clear to these customers that under such circumstances he will not recognize them out of respect for their confidentiality. "A wrong mistake in confirming that you see someone [in counseling] or that you know someone else could cost you a customer," he explains.
In addition, consultants need to be flexible when working with first responders because they have irregular schedules, Dakin says. This may mean that you have telemedicine sessions or need to meet with these customers outside of the typical 9 to 5 work day. There will also be short-term cancellations, she emphasizes. Dakin usually has a 24-hour cancellation fee, but refrains from first aiders who are stuck at work or otherwise have a good reason not to schedule their appointments.
In many ways, counselors may need to be willing to work with first responders, says Dakin. If there is an emergency such as a death on duty or an explosion, Dakin must be willing to drop everything, including her current number of cases for that day, to respond. And if a client who works as a first aider has a bad call on a Sunday, she works on that Sunday too. Although it rarely happened, the union or customers didn't even call until 10 p.m. because of an emergency.
Prochniak and Dakin both emphasize the importance of being humble with this population. "Even though you are the mental health specialist, you are not the specialist in your field," explains Prochniak. "Just because you know a trauma or just because you know stress doesn't mean that you know this population. It turns out to be very different … because it's a unique culture. So get to know the culture. Spend time with it. "
No shame in need of help
The biggest obstacle for first-aiders looking for help is the associated stigma – a false belief that when they need advice, they are weak or unable to do their job, Dakin says.
People often assume that first-aiders who have registered for the job are ready to deal with the associated trauma. But that's not how the brain works, Dakin emphasizes. "The brain can only be exposed to so many traumatic images before it is overloaded," she says.
Joel Smith, an LPC in private practice in Denver, agrees that we as a society do relatively little to recognize proxy first aid trauma. Although these professionals generally have improved skills in dealing with trauma, they are still prone to burnout, he says. Smith tries to normalize this reality for first-aid customers by asking, “Has your stress built up for a while? Does it explode? How do you deal with your stress? "
Whittaker, an ACA member who has a private practice in Manhattan and Westchester, New York, puts this idea of being "hard enough to deal with" into context for her first aid customers. She explains that being hard doesn't mean that they never get upset or that nothing disturbs them. It means processing those feelings to help yourself do your job better.
"It is important that advisors remind them that it doesn’t mean being tough enough to handle it." That doesn't mean that sometimes you don't break down and cry, ”she says.
First aiders also tend not to want to burden others with what they have experienced. Some of Dakin's customers have said to her, "It's a really bad call, and I don't know if I want to put those thoughts in your head."
Doctors must assure these clients that counseling is a safe place to talk about their problems and experiences. When consultants hear difficult stories, consultants shouldn't sound alarmed and say, "I can't believe this happened!" That must have been terrible. "
"While [that statement] is validated and has the best intentions, these people don't want to hear that," says Dakin. "You basically want to talk. They want to tell their story. “Consultants can confirm that the client's experience was difficult without being overly reactionary, she says, and that mostly involves careful listening.
Consultants should also be aware of their facial expressions, Whittaker adds. If advisors look shocked or scared, these clients will notice and are more likely to close.
Smith, Therapist at Jefferson Center (a community-based mental health and substance use service in Colorado) and an employee at Look Inside Counseling finds motivational interviews an effective technique when first-aiders are reluctant to accept help from others. For example, says Smith, counselors can ask these clients, "How can you get help yourself?" or "How can you model how you get help?" Technology enables first-aiders to develop healthy discomfort because they are also heroes who help others and people who need help with their own problems, explains Smith.
"One of the best ways to help yourself is to feel like you're helping someone else," Smith continues. This is one of the reasons why he encourages first-aiders who have benefited from counseling to tell colleagues how they have helped them.
These clients could share an effective coping skill they learned in counseling with the rest of their team, or model self-care at work. "When you see someone fighting, it's one thing. But when you see them fight and overcome it, the idea arises that it is possible [for you too]," notes Smith.
Tailor-made advice for first aiders
Prochniak, the psychiatrist for American Medical Response in the Portland / Vancouver metropolitan region, notes that mindfulness, targeted breathing and meditation techniques work well to reduce anxiety and stress levels for first aiders and to increase their resistance to stress. However, sometimes these clients may hesitate to try out such techniques, either because they perceive a stigma associated with the techniques, or because the consultants present them.
One approach that can help overcome this hesitation is to find concrete ways to translate clinical language into the everyday language of first aiders, says Prochniak. For example, if he works with a paramedic, he will discuss how mindfulness techniques strengthen the parasympathetic nervous system. If he works with a law enforcement client, he will refer to combat breathing. This is how these experts describe the use of deep breaths to calm or reduce stress.
Dakin often persuades first responders to try mindfulness and yoga by explaining the science behind the exercises. She often compares how the brain processes trauma to what happens to diabetes: just as increased glucose levels in the body deteriorate when the pancreas does not function properly, too much trauma leads to an overload of chemicals in the brain . Then the brain responds by releasing cortisol. Breathing and mindfulness exercises help reduce this reaction and regulate the chemical level.
Similarly, the traditional way of presenting and explaining yoga does not match the culture of the first aider, Dakin notes. When she first encourages these clients to try yoga, the answer is usually, "I don't go to a studio with spandex and meditate."
To counteract this negative perception, Dakin recommends a yoga program that was specially developed for first aiders (Yogaforfirstresponders.org). The program adapts its language to the culture, she says. For example, the child pose is renamed a warrior pose, which is a more strength-based term. Dakin now knows some first aiders who practice yoga at work to regulate their breathing and avoid switching to combat or flight mode as quickly.
Smith found that some of his customers find it helpful to design grounding techniques as training. They have an "earth buddy" and together they work on their awareness, he says.
Dakin also uses a familiar language to help first-aiders become familiar with mindfulness. For example, instead of using a numerical scale to describe how upset they are, firefighters use the fire hazard warning scale, which estimates the existing and expected fire risk for an area. The scale is color-coded and changes from red (extreme danger) to green (low danger).
When a customer says he is in the red, Dakin lets him take a deep breath as he imagines his arrow is moving to a safer level. She explains how every breath soothes her nervous system. This ability has become a special language that she shares with her customers. A customer can start a session by saying, "I was in the red a couple of times this week, but I was breathing and at least plunging into the yellow."
Dakin also explains to his customers that mindfulness need not be limited to sitting still and breathing deeply. It can take the form of something that they usually like to do, such as fishing, walking, kayaking, or hiking, as long as they do it carefully.
Dealing with Anxiety
First aiders are often afraid of what their day might bring. "Schedule and routine are the enemy of fear," says Smith, who specializes in trauma, mood management, addiction, and LGBTQ-specific needs . First aiders can include calming activities such as walking their dog or calling a family member at certain times of the day. "This kind of life expectancy leaves less room for fear," he explains.
He encourages his customers to make earthing part of their daily routine. They can ground themselves when they wake up, shower, or go to bed. You can also settle on the way to work, Smith emphasizes. They take a few minutes when they are at a red light and notice what is going on around them: “I'm stuck in traffic. A child is riding a bicycle next to me. It's raining. A song that I like is played on the radio. "
Smith advises customers to set phone reminders to ground themselves. Even if you cannot check your phones at this minute, you will be reminded later. Then it can take two minutes before going back to work to breathe and become aware of how your body feels, your surroundings and your emotions.
Grounding can also be a preventive measure, Smith adds. "If you're in an emergency and you're already grounded, you're better off at the back of the emergency," he says.
As customers improve their grounding skills, Smith asks them to imagine grounding during an emergency at work. This includes visualizing the person in front of them who has the emergency, as well as all the chaos and turbulence that is developing around them while at the same time perceiving their body and role in the situation.
"It doesn't sound intuitive if you imagine the chaos, but first responders will experience it during their day and then ground themselves in the midst of that chaos," says Smith. This is an advanced grounding ability and is not suitable for first aiders who have just started therapy, he emphasizes.
Processing the trauma
Trauma is no stranger to first-aiders. They watch people die and watch people suffer while they work long hours. And they often feel unable or powerless to help, says Smith.
Some first-aiders also struggle with guilt over decisions they made during an emergency. "If you have to make a decision in a split second, it can be really daunting. It could mean saving your life or saving someone else's life, but sacrificing something or someone else," says Whittaker, who deals with trauma has specialized.
"Trauma makes us think terrible things about ourselves and our own abilities," says Smith. For example, a highly qualified emergency room nurse can suddenly doubt her skills if several people die during her shift for a week. The nurse may suddenly feel out of control or feel useless.
Smith finds trauma-treating therapies such as desensitization and reprocessing of eye movements (EMDR) and trauma-focused cognitive behavioral therapy in first-aid populations are effective. These therapies help clients process their feelings about the trauma while learning to part with unhealthy thinking.
Because emergency situations are chaotic and unpredictable, it is often difficult for first responders to slow down and think about what they can realistically control, says Smith. He often has customer journals on what they can and cannot control.
“You can have control over your own beliefs about yourself and your purpose. And that can be extremely helpful in a trauma environment, ”says Smith. With EMDR, customers can view a task that frightens them, reduce that fear, and feel more confident about performing the task, he adds.
Behavioral patterns can be meaningful
Dakin often recognizes PTSD and emotional problems by looking for behavior changes or irregular behavior patterns with first aiders. For example, a first responder who has been working in the department without problems for 20 years can suddenly start yelling at the fire chief and refusing to follow rules. In this case, the Dakin union often asks to do an assessment to find out what may be going on.
Consultants should also be aware of the behavioral pattern in connection with substance use. "There is a large juxtaposition of substance abuse and trauma," says Smith. "So if you work in an environment where you will see and experience trauma, then … you're more likely to develop a drug problem."
First aiders may not necessarily fight long-term addiction or participate in alcohol excesses, says Prochniak. Perhaps they spend their free days drinking casually every week because they find their private lives less exciting than their working lives, he notes.
Both Prochniak and Smith encourage consultants who work with first responders to ask about their substance use, including quantity, frequency, and changes over time. "If this is a problem, it is usually helpful to manage drug abuse habits before working on trauma," Smith advises.
Prochniak also encourages customers to notice when they feel itchy, drink or take drugs, and think about what that itch (substance use) is trying to scratch. Are you scared, bored, unsettled? Together, they then work out a plan to address the underlying problem. "It can be helpful to break it down into this smaller view of what's behind drinking [or substance use]," he notes.
Development of transition plans
All of the stress and trauma of the job can affect the personal relationships of first responders. "People who go through trauma can go up and down emotionally, so a first-aider can sometimes be angry or irritated, if not explosive," says Smith. "Maybe they'll cry a lot or be very scared and can't really be in a room with [family or friends] because they have pent-up energy."
First aiders often need help learning the transition from work to home, where the rules can vary, says Prochniak. For example, if a fireman works a 24-hour shift (followed by a 48-hour break), his partner is responsible for the 24-hour period for the house. When the fireman returns home, he may be upset because he expects the house to be clean and organized as it is at work.
Prochniak and Smith help these customers develop transition plans to better manage the boundaries between work and home. Smith encourages his customers to self-check before they go home from work. You may ask yourself, "Where am I right now? How do I feel (angry, sad, scared)? What do I need before I go home? “His customers often find that they need 30 minutes for themselves. You can run, sit in the car and listen to music, read a book, or eat something before they are ready to meet the demands of the home.
Prochniak recommends first aiders to use the following transition strategies:
If you had a hard day's work, send a text message or call your partner to create a heads-up.
Take 30 minutes to exercise either in a gym or on devices that you keep in your garage to process the cortisol and neurotransmitters that have accumulated over the course of your shift.
Change your clothes at work so that you don't wear your uniform at home. Prochniak often advises customers to look at the shoes they wear. When they wear their official or work boots, they are at work. If not, they are at home. This serves as a reminder of the role in which they play and their expectations.
Help first aiders support themselves
First aiders work in a close community. "They protect each other, but don't know what to do [to help one another]," says Dakin. She remembers a customer who found his colleague's behavior problematic, but he wasn't sure how to help because he didn't want to get his friend in trouble or make his friend angry with him.
One of the best things counselors can do to support this population is to educate them about healthy ways to help each other. Dakin works with a program (offered by the International Association of Firefighters and the Professional Firefighters of Maine) that trains firefighters to look for warning signals that indicate that an employee is having problems and to intervene before it leads to a mental crisis is coming.
According to Whittaker, peer support for this population often works better than group therapy. Group therapy puts people who have been taught to swallow their emotions and simply "handle" them in an environment where they may fear what a therapist demands from them and how their colleagues react, she explains.
Peer support, on the other hand, "takes the therapist out of the room," says Whittaker. “It is run by people who have gone through it and people who can find these things in common. It feels less like therapy than people just hanging out and talking, which is a much safer experience for them. "
Dakin recently helped some firefighters / rescue workers set up a peer support recovery group. Even when she is present in the group, she lets the first aider lead. She is not there as a consultant, but as moral support, she says. When the group asks for their clinical advice, they give a brief overview of how the brain works or give tips on how to sleep better. She then takes a back seat and lets the group take control again. The goal, she says, is that first aiders support each other.
Answers during COVID-19
The "invisible threat" of COVID-19 is currently threatening first responders, says Prochniak. If they are on site or respond to a call, they no longer know what to expect. They have to assume that everyone is sick or symptomatic, so wear protective clothing and exercise physical distance as best they can while they are still doing their job.
Customers have informed Prochniak that although the number of emergency calls has decreased, the overall intensity of these calls has increased. Weitere Anrufe wurden im Zusammenhang mit Selbstmord und häuslicher Gewalt getätigt.
Die meisten Ersthelfer sind besorgt über die Zukunft, sagt Dakin. Sie sorgen sich um die Gesundheit ihrer Familien und Mitarbeiter und um ihre eigene Gesundheit. Sie sind besorgt über Menschen in der Gemeinde, die häufig auf ihre Dienste angewiesen sind und derzeit nicht anrufen. Und sie sind besorgt über die Arten von Anrufen, die sie erhalten, wenn sich das Anrufvolumen wieder normalisiert.
Prochniak hilft seinen Ersthelfer-Kunden, ihre Angst vor der COVID-19-Pandemie zu bewältigen, indem sie sich auf das konzentrieren, was unter ihrer Kontrolle steht. Sie sind möglicherweise nicht in der Lage, die Gefahr einer Exposition gegenüber dem Virus zu verringern, können jedoch einen Plan entwickeln, was sie tun würden, wenn sie exponiert wären. Würden sie in der Garage, in einem Zelt im Hinterhof, in einem Hotel wohnen? Wie würden sie mit der Kinderbetreuung umgehen?
Whittaker gibt zu, dass es schwierig sein kann, den Erfahrungen der Ersthelfer zuzuhören, aber sie weiß auch zu schätzen, dass sie bereit sind, etwas so Persönliches mit ihr zu teilen. Sie legt Wert darauf, jede Sitzung mit einer erhebenden Note zu beenden. Sie könnten darüber sprechen, wie der Klient Mut bewiesen hat, wie sehr sich der Klient im Umgang mit einer bestimmten Beratungskompetenz verbessert hat oder wie eine Erfahrung besser ausfiel als vom Klienten erwartet.
"Wenn Sie Veränderungen in jemandes Leben sehen", sagt Whittaker, "ist es einfacher, diese schwierigen Geschichten zu hören, weil Sie eine Rolle dabei spielen, sie für sie ein wenig besser zu machen."
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Lindsey Phillips ist Autorin von Counseling Today und UX-Content-Strategin. Kontaktieren Sie sie unter [email protected] oder über ihre Website unter lindseynphillips.com.
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