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What First Responders Teach Us About Cumulative Stress

A firefighter/EMS individual I recently saw reported that he had been on the job since he was 18 years old. He recognized that over time and relatively immediately that his cumulative stress impaired his relationships and ability to relate to others. He was having a challenging time maintaining a long-term intimate relationship because he would waver between being irritable and aggressive and becoming cut off and emotionally distant. He described being one of the first on the scene of two car accidents which I was familiar with where children were sadly killed. Just listening to his story brought up profoundly sad visceral feelings within me. I could only imagine how it impacted him over time.

When I asked him (and other first responders I see) why he didn’t seek treatment all along and especially following the circumstances that “haunted” him where he was shot, stabbed, fell through a roof and received 722 stitches, witnessed horrific scenes of children, among other devastating circumstances that he was witness to and experienced, he responded that he thought that he would be perceived as weak, could handle it on his own, and didn’t have the time to be bothered. For others, they explained that no one else that they knew sought help, it wasn’t directly encouraged by superiors, and they were fearful that they would lose their jobs.

First responders cumulative stress is a work hazard. The situations they are generally faced with are inherently challenging, complex, and dangerous. They are typically the first to arrive on the scene of events involving injuries and loss of life, are confronted with circumstances where their lives are seriously threatened and provide emotional as well as physical support to traumatized survivors.

According to Blue H.E.L.P, a nonprofit that works to reduce the stigma around mental health issues in law enforcement, 228 current or former officers died by suicide last year, compared with 172 in 2018. Also in 2019, 114 fire fighters and 19 EMS died by suicide with an estimated 55-60% reporting rate. Through January, there had been 15 officer suicides in 2020, according to the group.

A white paper commissioned by the Ruderman Foundation revealed that first responders, including policemen and firefighters, are more likely to die by suicide than in the line of duty. In 2017, there were at least 103 firefighter suicides and 140 police officer suicides. In contrast, 93 firefighters and 129 police officers died in the line of duty.

It is estimated that 30 percent of first responders develop behavioral health conditions including, but not limited to, depression and post-traumatic stress disorder (PTSD), as compared with 20 percent in the general population. In a study about suicidality, firefighters were reported to have higher attempt and ideation rates than the general population.

First responders have many vulnerabilities because of their constant exposure to death and destruction. There are other risk factors for them and others who are experiencing cumulative stress that put them at higher risk for Post-Traumatic Stress Disorder (PTSD). Those vulnerable to PTSD are individuals who have experienced prior trauma, are exposed to trauma as children, are female, experienced a high level of physical and psychological hyper-arousal in the period immediately following a traumatic event, had dissociative symptoms and psychic numbing at the time of a traumatic event, presented with depressive symptoms in the initial weeks after the traumatic event, and had Acute Stress Disorder.

First responders must continue to respond despite their level of disturbance, even after concerted effort is put in where they may have “failed” or achieved “unsuccessful” results. Some even witness their friends and colleagues being hurt or killed after working in similar ways and situations that they personally do. Further, they can have embedded sensory stimuli through incomprehensible images, sounds, and smells that can evoke flashbacks or an emotional experience of a traumatic memory. These harrowing exposures and experiences are repeated over many years of service.

Stress varies from person to person. All the symptoms related to stress carry the connotation of unreasonable demands being placed on the individual psychologically, emotionally, and/or physiologically. Stressors can be physical, emotional or both.

Physical and emotional stress often elicits physiological responses that are mediated through the autonomic nervous system. Stress is present in individuals in two major ways through momentary stress and cumulative stress. Momentary stress appears regularly in everyday life. The prolonged accumulation of momentary stress leads to an increase in long-term cumulative stress and impact on overall health. It is now widely accepted in the scientific and medical communities that chronic stress can have a detrimental effect on mental and physical well-being.

There are also some events that are considered high stress (e.g., death of a spouse or child, divorce, victim of a violent attack, major medical challenges, losing a job, etc.), medium stress (e.g., getting bullied, issues in a marriage, pregnancy, financial difficulties, changing jobs, a child going off to college, moving, etc.) and low stress (e.g., problems with a boss, trouble sleeping, gaining weight, changing schools, etc.).

If an individual is experiencing a combination of high, medium, and low stress events in succession over a number of years it puts them more at risk for anxiety, a somatization of symptoms in their body, and it negatively impacting on their overall coping and functioning. When a person experiences overlapping stress, their mind and body don’t have a chance to recover before they must go into overdrive to deal with the next challenge.

Many individuals are expected to quickly move on without an impairment to their functioning. For first responders who especially need to have precise reaction time, problem-solving skills, agility/mobility, and communication skills, this can be daunting.

There are 50 common signs and symptoms of stress some which include frequent headaches, insomnia, difficulty concentrating, irritability, gastroenterological issues, social withdrawal, etc. According to the American Psychological Association, stress also profoundly effects the mind and body. It’s known from research that prolonged chronic stress leads to memory losspromotes spread of cancer through the lymphatic system, promotes premature aging, can lead to changes in personalityweight gain, increased risk for cardiovascular events, such as heart attack and stroke, and mental health disorders such as depression and anxiety, and in many other significant ways.

The Code Green Campaign, a first responder oriented mental health advocacy and education non-profit organization identifies activating healthy coping strategies to ease the cumulative effects of stress such as creating a daily routine to help regain a sense of control, exercising, developing a self-care plan, seeking mental health support, etc. Firefighter Behavioral Health Alliance (FBHA) directly educates firefighters/Emergency Medical Services (EMS) personnel and their families about behavioral health issues such as depression, PTSD, anxiety and addictions, as well as firefighter suicides.

The US Department of Health & Human Services and Substance Abuse and Mental Health Services Administration (SAMHSA) wrote an extensive report on First Responders: Behavioral Health Concerns, Emergency Response, and Trauma.

The extent of cumulative stress is not limited to first responders but extends to all of us. I have seen a patient where in a relatively short period of time, her mother, twin sister, and college-age daughter all died which made up all the formative women in her life. There are many who are experiencing a combination of stressors and are struggling silently and devastatingly. We see the direct result of that from the significant increase in suicide rates among our youth and first responders.

There’s a lot of stigma and shame attached to seeking and accepting help. We have to systemically get better at acculturating our youth at schools and at home with social-emotional, coping, emotional regulation, and communication skills so they feel open and entitled to explore and work through their physiological, psychological, and social needs.

For first responders or any individual that is experiencing cumulative stress, if left untreated, the symptomology often becomes unwieldy. The level of psychological distress can destroy relationships, detrimentally affect personal health and mental health, and deprive a person of living a fulfilling life. I have seen my share of individuals who finally make their way in once they find themselves in extreme pain and despair. Don’t deny yourself and seek to help others get the support that is needed and deserved.

Blog posted Psych Central.

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