By NIKKI PENN
A firefighter/paramedic once came to my office seeking services to help get his life back and told me, “I’ve taken 10 PTSD [post-traumatic stress disorder] quizzes, and I’ve scored positive on every single one, missing only one question on each: being able to name the single traumatic event that caused the symptoms.”
- Calling a Mayday for Your Mind
- Help, This Job Is Killing Me!
- The Impact of Mental Health Stigma in the Fire Service
- Relax, Don’t React for Less Stress, Better Performance, and Well-Being
PTSD is becoming a commonplace topic among fire department leadership and in fire journals, continuing education classes, fire academies, and even the firehouse. However, the conversations sometimes miss the notion that the symptoms and the trauma that caused them do not have to rise to the level of a PTSD diagnosis to incapacitate a firefighter to the point that he no longer can or wants to do his job.
All too often, firefighters won’t seek services when the symptoms they experience are more subtle, such as personality changes, having a growing dislike for work, or having developed an overall lackluster life. It all just seems to be normal, a part of the job. Over the course of a simple off-duty drive, every firefighter may pass by multiple locations at which he has responded to emotionally traumatic calls such as a suicide, fatality accident, or pediatric cardiac arrest. And, perhaps most tragically, firehouse culture has conditioned most to believe that it is “just part of the job” and that the associated “emotional baggage” should be accepted as normal.
The Diagnostic and Statistical Manual
It hasn’t helped that the counseling arena, including payment for services, diagnostic criteria, and treatment, has too many times been dependent on a mistaken Diagnostic and Statistical Manual (DSM) that said a PTSD diagnosis is only for those who have “been exposed to a traumatic event” in which both of the following were present:
- The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.
- The person’s response involved intense fear, helplessness, or horror.1
Fortunately, through more research and understanding, the DSM was updated in 2013 and now states a person who was exposed to “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence through indirect exposure to aversive details of the trauma, usually in the course of professional duties.” This means an emergency responder could be dealing with PTSD based on work exposure if he has the other symptoms.2
This change in the DSM opens doors to further investigate the plight of emergency responders. However, we know emergency responders just aren’t seeking help like they should. A survey asked 7,000 firefighters about the mental health challenges associated with their job and found that “19 percent of respondents experienced suicidal thoughts, 27 percent struggled with substance abuse, and 65 percent are haunted by memories of traumatic work situations”; more than 80 percent stated that “asking for help would make them seem weak or unfit for duty.”3
Firefighters are the first to respond but the last to seek help. Multiple reasons for this include pride, fear of being perceived as weak, concerns about being passed over for promotions, and worries about being told they are “really messed up.” These thoughts can cause a nervousness that prevents firefighters from taking back their lives. They often just continue to deal on their own with a vast range of symptoms that may include sleepless nights, irritability, loss of confidence, intrusive thoughts, anger, inability to focus, increased alcohol intake, unexplained aches and pains, anxiety, panic attacks, suicidal thoughts, decreased work performance, sensory overload, a brain that won’t “shut off,” or any combination thereof. However, because there is no one defining event in their minds, it doesn’t seem as though there is anything that needs to be done. They may feel that they just need to hang in there until they can retire.
One way to understand the effect of PTSD more clearly is to imagine that everyone is driving a semitruck and trailer. The trailer is the storage for all the stuff that no one ever wanted to see, hear, smell, or experience. To avoid becoming overemotional and continue to perform their jobs, emergency responders tend to compartmentalize those sensory experiences the best they can. When emergency responders encounter unsavory experiences, both the experience and the associated emotion are loaded into the metaphorical trailer. The more emotionally charged calls that are experienced, the fuller the trailer becomes. By the end of a firefighter’s career, the trailer is likely full and may even be overflowing. And, just as an overloaded semi can experience engine overheating, blown tires, or brake failure, so too can an emotionally overloaded brain cause similar issues within the responder’s own body.
Sometimes it’s obvious, and sometimes it’s more subtle. When the “trailer is full,” it becomes more difficult to handle everyday issues, which build up into what is called “cumulative-chronic stressors.” These stressors may include crying children, the household to-do lists, financial hardships, cars in disrepair, children with disabilities, a relative in need of constant care, and marital distress, just to name a few. The brain consumes about 20% of a person’s overall energy.4 It is thought that the more stress one is under, the more energy that is used and the more fatigue one feels.5,6 Sometimes, seemingly overnight, the cumulative stressors can become much less tolerable, even overwhelming.
For many years in the history of emergency response, there were limited resources to help firefighters clear out their “emotional trailers” and thus live more fulfilling lives. It is now known that emergency response work doesn’t have to lead to a road of burnout, serial divorces, substance abuse, or the myriad of negative outcomes that seem to plague emergency responders. We now have a better understanding of trauma, how it’s stored in the brain differently than regular memories, and how to treat it in such a way that a person can successfully diminish its consequences. It is also understood that trauma isn’t always about that “one life-changing call”; it’s also about an accumulation of the necessary evil to which the brains of emergency responders are exposed.
In addition to the challenging work experiences, many who go into helping professions such as emergency response work do so because of difficult experiences they had earlier in life. These experiences can add a richness to one’s ability to connect and have compassion for others. However, early traumatic experiences can also predispose someone to negative life outcomes. The Adverse Childhood Experiences (ACE) scale has been used in studies across the country that show a direct correlation between adults who, as children, suffered from different types of abuse, neglect, exposure to domestic violence, parental drug abuse, familial mental illness, and/or a parent who went to prison due to their own drug/alcohol abuse, suicidal ideation, and increased physical complaints and diseases, among other things.7
Many of the things the ACE research shows as being high-risk outcomes are some of the very things first responders have a tendency to deal with. Granted, the more resilience present in a person, through an innate tendency or hard work and effort, the less undesirable the outcomes.8 Resilience is built through positive relationships, being proactive with one’s mental and physical health, having a spiritual connection, endorsing a greater sense of purpose, positive coping mechanisms, and embracing a flexible approach to life.
How the Brain Works
With every experience, neural networks are built in our brain. Similar experiences get paired together. Negative memories are more likely to be stored in the right hemisphere, while positive memories are more likely to be stored in the left. The neural networks of nontraumatic memories will encompass interactions between both hemispheres, increasing one’s ability to express feelings verbally and to see things in a balanced way. There is also the capacity for neural networks to connect between the upper and lower brain centers.
With little exception, all information that enters the brain is routed through the thalamus, which acts like a traffic controller and tells the incoming information which path to take. There are two options: Nonthreatening, nondisturbing information is sent for processing through the prefrontal cortex (upper brain center), which is responsible for logic and rationality. This incoming information will be processed using various parts of the brain and is organized at night during sleep, more specifically, during the rapid eye movement (REM) phase of the sleep cycle. The nondisturbing information is then routed, organized, and stored in such a way as to not later be “retriggered” in some negative, intrusive way.
If, however, the new experience is disturbing or life-threatening, to save time, the thalamus will route the information away from the prefrontal cortex and into the limbic system. The limbic system (lower brain center) controls the fight, flight, and freeze responses. Once activated, the amygdala (a component of the limbic system) begins a cascade of events within the body with the ultimate goal of increasing one’s chance of survival. The amygdala will send an immediate signal of distress to the hypothalamus, which activates the adrenal glands to release epinephrine. As this happens, glucose is released. Among the many changes occurring during this process, senses sharpen; the heart rate increases; and blood shunts from the extremities and fine motor areas to the heart, lungs, and brain.
If the stressor continues to be present, the sympathetic nervous system activates another level of response, activating the hypothalamic-pituitary-adrenal (HPA) axis, and starts the production of cortisol; this keeps the body amped up and on alert. All these changes increase a person’s likelihood of survival when a threat is present.
As items travel the second path, they don’t work in tandem with the upper brain, have much less access to the updated logic, and are less likely to get “time stamped” or fully stored in the past; they are considered to be improperly encoded neural networks. They may or may not cause conscious intrusive thoughts, but they will take up space and energy in the brain.
Think of it like downloading a movie on a slower computer using dial-up Internet. As the movie downloads, the other computer functions seem slow, bogged down, and full of glitches. Similarly, the brain will have a harder time making decisions and will be less confident and less able to concentrate and focus, among other things. The brain wants to stay hypervigilant to keep one safe. So, basically, the brain starts constantly scanning the environment for anything that could go wrong, waiting for the other shoe to drop, and feels like it cannot shut down. This prompts escapism through constant activity, nonstop television or gaming, alcohol, or other addictive behaviors to try to cover it up.
Looking for Solutions
So, what is the answer? Research suggests the interventions used to decrease negative impacts need to work with the limbic system in the brain rather than the prefrontal cortex.9 This is because the limbic system is the part of the brain designed to deal with the unmentionable calls, whereas the prefrontal cortex deals with logic, rational decision making, and so on. These interventions are called “bottom-up” therapies. They work, starting with the lower part of the brain, the limbic system, and organically allow for change to trickle up to the prefrontal cortex.
Traditional talk therapy, considered a “top-down” therapy, works primarily with the prefrontal cortex. It can help organize the “trailer” and create more space by tidying things up and can even teach the driver how to maneuver the “vehicle” with more care and better routes. However, it uses the prefrontal cortex, which is not the part of the brain that controls disturbing memories. Traditional talk therapy is limited regarding the amount of time it takes, the requirement of homework, and the number of times the trauma must be revisited.10
Although there are different bottom-up techniques, one of the most researched and effective methods of dealing with the limbic system is eye movement desensitization and reprocessing (EMDR), which uses bilateral stimulation to decrease disturbance associated with particular memories; this is done through the use of protocols that use eye movements and/or tapping. As one does EMDR, the negative thoughts, feelings, images, and body sensations will start to fade, feel farther away, and become less attached. Studies suggest that EMDR mitigated the symptoms of PTSD in 84% to 100% of single-trauma victims after the equivalent of three 90-minute sessions.11 It is not hypnosis or amnesia, nor does it require the use of drugs. EMDR simply uses the brain’s natural capacity to heal itself.
Visualize someone who has had a bike wreck. He has a gash on his leg. Over a few days, the leg will try to heal. It will likely succeed unless it has debris, germs, or other artifacts in the wound. In that case, it could end up infected and cause the whole body to end up sick. Once the debris is cleaned out, the wound will heal.
Our brains have the same capacity to heal. They handle all kinds of stress, but the type of stress that lands in the trailer will need to be cleaned out for the healing to take place. EMDR does that; it kick-starts the natural process the brain was designed to do. It works by targeting maladaptive networks and connecting them to other parts of the brain. This allows for integration of new perspectives and a cleaner, more spacious trailer. Firefighters who undergo EMDR report that disturbances seem further away, like they are watching them on a television screen with poor reception, or they have a hard time bringing up the images, sounds, or smells. The specifics of how EMDR works is still being researched. However, a few of the working theories include the following:
- Bilateral stimulation mimics the intention of REM sleep, engaging both hemispheres and allowing for added communication in the brain to help process the targeted memories.12
- The bilateral stimulation activates the anterior cingular cortex, which allows for deeper communication and processing between the higher and lower parts of the brain.13
- The dual attunement sparked through the bilateral stimulation imposes on the working memory and hinders the ability to focus on the disturbance associated with the targeted memory.14
The research is ongoing, but we know EMDR works, and, most likely, we know it works through a combination of the above theories.
Although parts of the firehouse culture promote health and well-being such as the comradery, a joint sense of a greater purpose, shared meals, tailboard talks, having each others’ backs, off-duty cookouts, and the family environment, there are things that also need to change. Firefighters and other emergency responders must know it’s okay to not be okay, and they must know it is okay to get help. The mental health stigma must decrease. As I have worked with different departments, I have been encouraged by seeing leaders of both paid and volunteer departments step up and make a difference. They are securing employee assistance programs that have vetted therapists, not just any counselors but those who are willing to learn about the fire service and understand its norms, schedules, and challenges.
One of “my” departments is working hard to continually improve its mental health program. This department has an ever-growing peer support team and regularly hosts continued education about cumulative and traumatic stress and resilience. It offers free and confidential mental fitness checkups yearly and has been instrumental in adding education about mental health and wellness to the training academy to better prepare young firefighters for the emotional challenges of the job. This department also supports the mental health of firefighter families by offering marriage enrichment seminars such as “Always Kiss Your Firefighter Goodnight” and opportunities for firefighter spouses to bond through a spouse’s night out. And maybe, just as importantly, approximately half of this department’s leaders have set the example by receiving counseling, and many share their positive experiences to encourage others to try it as well.
Not only is it imperative that firefighters know the symptoms and changes they will experience because of their careers, they must also know how to seek help for those symptoms. The changes cannot continue to be considered as a hopeless and irreparable part of the job. There is help available that can extend the enjoyment of the job as well as decrease burnout, the likelihood of marital issues, addiction, mood swings, and suicidal ideation. As one firefighter said regarding EMDR, “This stuff works too well to not be known about. Can you imagine how this could change the future of every firefighter if they only knew?”
Endnotes
1. American Psychiatric Association. 2010. Diagnostic and statistical manual of mental disorders : DSM-IV-TR, Washington, American Psychiatric Association.
2. American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders : DSM-V, Washington, American Psychiatric Association.
3. National Data Shows Firefighters’ Mental, Emotional Health Not Getting Enough Attention. March 23, 2018. Retrieved from https://www.sprc.org/news/national-data-shows-firefighters%E2%80%99-mental-emotional-health-not-getting-enough-attention.
4. Mark Michaud, Study Reveals Brain’s Finely Tuned System of Energy Supply, August 7, 2016, https://www.urmc.rochester.edu/news/story/study-reveals-brains-finely-tuned-system-of-energy-supply.
5. Emma Bryce, How Many Calories Can the Brain Burn by Thinking, November 09, 2019, https://www.livescience.com/burn-calories-brain.html.
6. Ferris Jabr, Does Thinking Really Hard Burn More Calories, July 19, 2012, https://www.scientificamerican.com/article/thinking-hard-calories/#.
7. Felitti VJ, RF Anda, D Nordenberg, et. al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults, The Adverse Childhood Experiences (ACE) Study, American Journal of Preventive Medicine, Volume 14, Issue 4, P245-258, May 01, 1998, https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext.
8. Risk and Protective Factors, https://www.cdc.gov/violenceprevention/aces/riskprotectivefactors.html.
9. AM Khan, S Dar, R Ahmed, et. al. Cognitive Behavioral Therapy versus Eye Movement Desensitization and Reprocessing in Patients with Post-traumatic Stress Disorder: Systematic Review and Meta-analysis of Randomized Clinical Trials, Cureus, 2018 Sep 4;10(9), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6217870.
10. Krauss D. Bottom-Up Versus Top-Down Processing: How Interventions Work, Psychology Today, Posted November 1, 2021, https://www.psychologytoday.com/intl/blog/atypical-children-extraordinary- parenting/202111/bottom-versus-top-down-processing-how.
11. Shapiro F. The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological and Physical Symptoms Stemming from Adverse Life Experiences, Permanente, 2014 Winter; 18(1): 71–77, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951033/#b14-permj18_1p0071.
12. Stickgold R. EMDR: A Putative Neurobiological Mechanism of Action. Journal of Clinical Psychology, 2002, 58(1), 61–75.
13. Kaye B. Reversing reciprocal suppression in the anterior cingulated cortex: A hypothetical model to explain EMDR effectiveness. Journal of EMDR Practice and Research, 2008. 2(1), 88-99.
14. Van den Hout MA, MB Eidhorf, J Verboom, et. al. Blurring of Emotional and Nonemotional Memories by Taxing Working Memory During Recall. Cognition and Emotion, 2013.
NIKKI PENN is a licensed counselor and former emergency medical technician who has focused her career on treating first responders. She has a master’s degree from Arkansas State University and is a specialized law enforcement instructor, is dually licensed in Arkansas and New York, and has taught at different EMS training programs such as the Arkansas EMS Conference, PESI, and many fire departments across her state. She responds to departments in crisis after critical incidents, suicides, or other traumatic events. Penn is also a certified eye movement desensitization and reprocessing therapist and consultant who has developed a nationally recognized curriculum that she uses to train other therapists worldwide to be culturally competent in their work with first responders.
