When firefighters, police, paramedics and other emergency responders become traumatized by their work, who rescues the rescuers? According to two Toronto social workers, traumatic stress in the emergency services is a widespread phenomenon that requires a sophisticated approach to prevention and treatment.
“Emergency responders are exposed to huge numbers of traumatic situations,” said Cheryl Regehr, a professor of Social Work at U of T and co-author of In the Line of Fire: Trauma in the Emergency Services. “At any time, approximately one-quarter of firefighters and paramedics are suffering from traumatic stress.”
According to Regehr and co-author Ted Bober, exposure to distressing events does not automatically produce traumatic symptoms. Most emergency responders are highly resilient and have effective techniques for dealing with stressful incidents. How, then, to explain the fact that a particular event-a plane crash, say, or a terrorist bombing-will traumatize some workers but leave others unaffected?
Regehr and Bober argue that many factors influence whether an emergency worker will suffer from traumatic stress. They favour an “ecological approach” to prevention and treatment that examines “the interplay between an event, the person encountering the event, the public and media response to the event, the organization in which responders work, and the supports and life that they have outside the workplace.”
This perspective is a far cry from the traditional approach to trauma in the emergency services, which, according to the authors, “tended to ignore the problem or attribute the traumatic reactions to inherent character flaws… In many organizations, the culture has not allowed for the expression of distress.”
Some of their findings are unsurprising. Critical events involving violence, multiple casualties, or a line-of-duty death cause significant distress for a large percentage of emergency responders. Human-caused events, such as terrorism or child abuse, are particularly stressful.
“When an event has occurred because of malicious intent-that’s much harder on workers,” said Regehr. “You also have no way of knowing whether, when the rescue workers get there, another bomb is going to go off.”
Traumatic symptoms include sleeplessness, flashbacks, avoidance, high levels of stress and tension, and extreme anger. Long-term effects include “a reduced capacity to handle stressful events, depression, and substance use.” Families of afflicted workers often suffer as a result.
Both authors have extensive clinical and administrative experience in emergency mental health. For most of the last 15 years, they have been co-directors of the Greater Toronto Airport Authority’s Crisis and Disaster Response Team. (To get an idea of the scale of this operation, imagine being responsible for an emergency response community that includes about 100,000 people.)
Interestingly, some of the main sources of stress for emergency responders are only indirectly related to their work in the field. The authors found that organizational dysfunction-including bureaucratic hassles, lack of autonomy, shift work, and poor relations with management-can contribute significantly to traumatic stress.
“One thing that surprised us was how powerful non-traumatic events were,” said Bober. Being subjected to public inquiries is another major source of stress for emergency responders. Often highly political, inquiries can last for years and produce intense media criticism. Many workers feel that their employers do not adequately support them during the inquiry process-for instance, by providing adequate legal representation or protecting workers in the aftermath of an inquiry.
According to Bober, “the aim is to improve the system but [inquiries] can be one of the most stressful experiences for emergency responders. We were surprised at how many emergency responders went through the experience alone.”
Regehr concurred. “It’s very important for society to think again…if we’re asking people to do really important jobs that the rest of us don’t want to do, then we need to cut these people some slack.”
Regehr and Bober have clearly thought through many aspects of traumatic stress in the emergency services. In the Line of Fire nicely combines a theoretical discussion of traumatic stress with empirical research and observations from the authors’ experience in the field.
Although the authors take pains to delineate the different symptoms of trauma, the terminology they use can be confusing at times. Emergency responders are variously described as suffering from stress, distress, extreme stress or distress, trauma, traumatic stress, post-traumatic stress disorder, and depression. For the most part, however, the authors did a good job of balancing readability with clinical precision. On the other hand, the book could have used a good copy editor. The text contains typographical errors such as missing or extra punctuation, repetitive phrasing, wrong verb tenses as well as a few gummed-up sentences.
One of the most admirable aspects of In the Line of Fire is the authors’ commitment to what they describe as evidence-based practice; namely, “the conscientious, explicit, and judicious use of the best available scientific evidence in professional decision making.” Elsewhere, they observe that “those of us providing services must find ways to evaluate our practice so that we can ethically speak with confidence about the benefits of what we are providing.” Not a bad place to start.
