Traumas Expose Fire Fighters to Mental Health Problems
Statement of the Problem
First responders are usually the first on the scene to face challenging, dangerous, and draining situations (SAMHSA, 2018). This study hypothesizes repeated exposure to traumatic events both human and naturally caused may result in depression, post-traumatic stress disorder (PTSD) or anxiety in Fire Fighters. Natural traumatic events can be defined as, wild fires, tornadoes, floods or earthquakes. Traumatic events can also be caused by human action such as car accidents, overdosing, mass shootings, terrorism, accidental fires or arson. This study notes limitations and the need to further explore pre-existing mental health conditions in individuals prior to becoming a Fire Fighter.
Justification for and Significance of the Study
According to a National Fire Protection Agency (NFPA) survey in 2016 there were 35,320,000 total Fire Department calls within the United States. NFPA estimates there were approximately 1,056,200 local firefighters in the US in 2017. Of the total number of firefighters 373,600 (35%) were career firefighters and 682,600 (65%) were volunteer firefighters. Considering the link between occupational stress and mental health difficulties, it is not surprising that firefighters are at an elevated risk for a variety of mental disorders (Steinkopf et al., 2016). Understanding the degree to which high-risk job responsibilities contribute to the formation of negative cognitions and depression/PTSD is essential for the development of interventions designed to reduce mental health risks in the workplace (Brondolo et al., 2018). Brondolo et al., (2018) also notes firefighters who face extremely demanding and dangerous job responsibilities may be particularly susceptible to negative cognitions about their overall competence. In contrast, journalists appear to be susceptible to negative cognitions about the world (Brondolo et al., 2018). Occupational response to stress has an individual mental health impact. Brondolo notes as an example, medical examiner (ME) employers are involved in identifying the deceased, determining the cause of death, and communicating this information to relevant parties, including law enforcement, public health authorities, and families of victims. Brondolo hypothesized that (a) greater exposure to disturbing cases and to vicarious trauma would be associated with more intense negative cognitions about alienation and distress intolerance and these cognitions would (b) mediate the relationship of trauma exposure to symptoms of depression and post-traumatic stress, and (c) predict increases in symptoms over time (Brondolo et al., 2018). Another high risk occupation is psychiatric nursing, Hasan, Elsayed, and Tumah (2018) found nursing has been identified as an occupation with high levels of stress, notably in psychiatric settings as the mental health structure and service is very unstable, including high turnover rate and level of psychological wellbeing. Hasan, Elsayed, and Tumah (2018) declares that stress involves an individual’s perception of the demands and the available capacity to handle the stressor. Brondolo et al., (2018) support that pathways linking workplace trauma exposure to mental health symptoms are not understood. Psychological and physical responses to traumatic events vary with the social context of the event, biological and genetic makeup, and past experiences and expectations. These factors interact with the characteristics of the traumatic event to produce psychological and behavioral responses that range from resilience to disability (Benedek, Fullerton, & Ursano, 2007). Fullerton, McCarroll, Ursano, and Wright (1992) point to an example of occupational stress where fire fighters responded to a United Airlines flight carrying 296 passengers and crew that was forced to crash land in Sioux City, Iowa following a midair explosion. Casualties included 112 people who died and 59 who were seriously injured. Fire Fighters primary mission was to fight the fire; however, many people were still strapped in their seats. The occupational stress to witness the trauma, and to respond, while remaining focused to complete their job lead to mental health difficulties. As further stated, Fullerton, et al., (1992) found there were four characteristic responses: identification with the victims and the dead, feelings of hopelessness and guilt, fear of the unknown, and physiological reactions.
Post-Traumatic Stress Disorder in Fire Fighters
The American Psychiatric Association states that post-traumatic stress disorder (PTSD) is a mental health condition that is triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. PTSD affects approximately 3.5 percent of U.S. adults, and an estimated one in 11 people will be diagnosed PTSD in their lifetime (APA, 2019). The statistics taken from the APA include civilians as well as Fire Fighter personnel. Studies of ﬁre ﬁghters have generally found rates of PTSD ranging from 13% to 18% over 1– 4 years following large-scale response events (Benedek, Fullerton, & Ursano, 2007). As further stated, fire fighters are repeatedly exposed to mutilated bodies, mass destruction, life-threatening situations, and physically demanding activities. The psychological distress found feelings of fear, anger, hatred and resentment often interfered with effective functioning (Fullerton, McCarroll, Ursano, & Wright, 1992). Repeated exposure to trauma can put rescue workers, especially first responders such as fire fighters and police officers at increased risk of developing post-traumatic stress disorders (Fullerton, McCarroll, Ursano, & Wright, 1992). The National Commission on Fire Prevention and Control declared that fire-fighting is the most hazardous and dangerous occupation in the United States. Every day approximately 280 fire fighters are killed or injured. Every year, over 650 are forced to retire due to occupational illness, including PTSD. (Fullerton, McCarroll, Ursano, & Wright, 1992). Understanding the nature and consequences of trauma and PTSD among firefighters is important, due to the potential for ongoing stress and trauma exposure in the context of employment, as well as the negative sequelae associated with PTSD (Paltell et al., 2019).
Depression in Fire Fighters
Depression (major depressive disorder) as defined by the American Psychiatric Association is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home (APA, 2019).The Substance Abuse and Mental Health Services Administration states that depression is commonly reported in Fire Fighters, rates of depression as well as severity vary across studies. In a case-control study of EMS professionals (Fire Fighters and Rescue personnel) depression was reported at 6.8 percent, with mild depression the most common type a 3.5 percent (SAMHSA, 2018). First responders involved in these occupations are exposed to hazards inherent to the nature of their jobs. Examples include (direct or indirect) to death, grief, injury, pain, or loss as well as exposure to long hours of work, frequent shifts which leads to poor sleep, physical hardships, and other negative experiences (SAMHSA, 2018)
The American Psychiatric Association explains that anxiety is a normal reaction to stress. It can alert us to dangers and help us prepare and pay attention. Anxiety disorders differ from normal feelings of nervousness or anxiousness, and involve excessive fear or anxiety. Anxiety disorders are the most common of mental disorders and affect nearly 30 percent of adults at some point in their lives (APA, 2019). A study confirmed the perception of threat to self as highly stressful to firefighters, also suggested that “routine” aspects of duty such as performing CPR may be stressful to firefighters (Benedek, Fullerton, & Ursano 2007). Firefighters are exposed to unique stressors resulting from their diverse, dangerous, and potentially traumatic job-related responsibilities (Steinkopf, Klinoff, Van Hasselt, Leduc, & Couwels 2016). Emotion regulation is a complex and multi-dimensional construct encompassing the following domains: the awareness and understanding of emotions, the acceptance of emotions, the ability to control impulsive behaviors and engage in goal-directed behavior when experiencing negative emotions, and the ability to flexibly access effective emotion regulation strategies to regulate emotional responses and to meet individual goals and situational demands (Paltell et al., 2019).
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Many studies have assessed the risk and protective factors for behavioral health issues among first responders (SAMHSA, 2018). Further stated, researchers have recommended preparedness and assessing the suitability of new staff for the first responder role before they begin work, in order to ensure that their personality and mental health status are such that they can handle the stress of the work of a first responder. The current study proposes to explore the impact of natural events as well as human caused events on fire fighters over time and how PTSD, depression, and anxiety are associated in response to these traumatic events. The goal is to highlight that more research in the field is needed to recognize preventative measures that will improve protective factors to protect our first responders.
This study will focus on career firefighters not volunteers. The International Association of Fire Fighters (IAFF) maintains a data base of registered Fire Fighters, this data base will be used to invite participation in a national study. The study sample will be Fire Fighters registered IAFF with at least five years of service. Registering with the IAFF ensures they are career fire fighters and not volunteer fire fighters. No Fire Fighters were be offered compensation, however referrals for counseling will be provided upon debriefing. All participants will be asked to provide occupational information of employment status, rank, and length of service. This will enable the study to differentiate responses from career fire fighters with less than five years of service.
Survey Monkey will be used for the online survey. Participants will be assigned a random number to identify them and remove any link to their personnel information. Once a random number is assigned a link to an informed consent will be provided. After the informed consent has been completed access will be granted to each participating Fire Fighter to a secure website containing several scales to test and measure responses. The location of the participation in the study is the participant decision, this will give the participant control of their own comfort and privacy. Participants will be requested to complete one open ended questionnaire and 3 scales. Total estimated time to complete is approximately one hour. Once completed the surveys are uploaded to a secure website with only the random number assigned as an identifier. Once the surveys are completed a link is provided to complete the debriefing and a referral to counseling is provided.
Participants will be asked to answer open-ended questions to establish number of hours worked (average) per week, frequency of number of calls per week (average) and to list number of incidents that involved a fatality in the previous year. In addition a list of “typical” natural and human caused events will be listed and the participant will be asked to circle any they he/she has responded to as a fire fighter. Typical natural events will be wild fires, tornadoes, floods or earthquakes and human caused events will be car accidents, overdosing, mass shootings, terrorism, accidental fires or arson.
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Post-Traumatic Stress Diagnostic Scale (Foa, 1995) is a short checklist to identify potentially traumatizing events. The scale is intended to screen for the presence of PTSD. The test is self-administered and can be completed within 10-15 minutes and requires a reading age of ~ 13 years. The PDS has 49 items, the questions relate to the frequency of distressing and intrusive thoughts. The test mirrors DSM IV criteria for PTSD (Foa, 1995). Fire Fighters will indicate which of these events has troubled them the most in the last month. The use of four-point scale respondents then rate 17 items representing the symptoms of PTSD experienced in the past 30 days. The PDS does include a symptoms severity score which ranges from 0 to 51, this is obtained by adding up the individual’s responses of selected items. As further stated in Foa’s PDS the cut offs for symptom severity are 0 no rating, 1-10 mild, 11-20 moderate, 21-35 moderate to severe and > 36 severe.
Beck Depression Inventory (BD1-11) is a 21-item self- report multiple choice inventory that takes ~ 10 minutes to complete and is designed to assess the severity of depression in adults and adolescents aged 13 years and older. According to the authors, the 21 items in the BD1-11 are representative of the DSM-IV criteria for depression. The BDI-11 items are rated on a 4-poing scale ranging from 0 to 3 based on severity of each item. Raw scores of 0-13 indicates minimal depression, 14-19 indicates mild depression, 20-28 indicates moderate depression and 29-63 indicates severe depression (CUP, 2011).
Beck Anxiety Inventory (BAI)scale is a self-report measure of anxiety that contains 21 multiple choice items that is used for measuring the severity of anxiety. This scale is designed for individuals 17 years of age or older and is estimated to take 5 – 10 minutes to complete. The BAI utilizes a Likert Scale ranging from 0 to 3 and raw scores ranging from 0 to 63. The scores are classified as minimal anxiety (0 to 7), mild anxiety (8 to 15), moderate anxiety (16 to 25), and severe anxiety (30 to 63) (Community-University Partnership, 2011).
A Bivariate correlation will be conducted. It is expected that the scales will show that fire fighters are impacted by the frequency and repeated responses to traumatic events in an emotional, physical and or psychological manner. It is hypothesized that fire fighters will be exposed to mental health problems such as post-traumatic stress disorder, anxiety, and depression.
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