Unique Barriers to Mental Health, SUD Care Affect First Responders

Ongoing, on-the-job hazards and exposure to trauma can put first responders at an increased risk for mental health conditions, such as post-traumatic stress and substance use disorders. At the West Coast Symposium on Addictive Disorders this week, Anna Lisa De Lima, PhD, LMHC, QS, NCC, executive clinical director, Hanley Center at Origins Behavioral Healthcare, discussed how trauma affects first responders, strategies for mitigating barriers to treatment, and interventions that can improve the efficacy of treatment for this population.

Ahead of her session, Dr De Lima spoke with Addiction Professional about warning signs that clinicians should look for, barriers to treatment faced by first responders, and interventions that have demonstrated efficacy for the first responder population.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional (AP): How does on-the-job trauma exposure affect first responders?

Dr De Lima: First responders are affected by on-the-job trauma exposure in a variety of ways. First responders are the best at compartmentalizing, a skill that they need to use to be effective at their jobs. However, as they are so good at compartmentalizing, they often do not recognize that they are struggling until it affects other areas of their lives. Repeated exposure to trauma, without support, can result in a myriad of issues from anxiety to depression to difficulty concentrating to medical issues. Ongoing exposure to trauma can be extremely taxing on the body and brain. Coupled with the lack of sleep that most first responders experience due to the nature of shift work, they are at high risk for compassion fatigue, mental health issues, and physical issues. Unfortunately, for some, the contribution of repeated exposure to trauma can even result in self-harm or suicide.  

AP: What are some signs to look for?

Dr De Lima: When someone is struggling, it is often evident in behavioral and emotional changes from their norm. These changes can include increased use of substances to cope, increased isolation, anger, irritability, sadness, and exhaustion, difficulty relaxing or concentration, emotional dysregulation, loss of purpose, apathy, or even disinterest in things that were previously important (family, hobbies, career, friends).

AP: Are there unique barriers that first responders face to getting treatment? If so, how can those barriers be mitigated?

Dr De Lima: First responders often lack trust in the therapy process. This lack of trust may be due to concerns about confidentiality or the feeling that clinicians do not understand them. Both concerns are based in reality. In the past, concerns of confidentiality were legitimate as many first responder departments perceived seeking out treatment a sign that someone was not fit for duty. Therefore, there was a legitimate concern about risk to employment. There has also been a cultural perception in the first responder population that being affected by what they experience on the job makes them weak. Many were told to “suck it up” or reminded that “this is what you signed up for.” Fortunately, we have begun to see a shift in the culture protecting those who seek out help and departments providing preventative support, but we are a long way from perfect. I have been told by many first responders that “counselors do not understand us and our jobs.” It is important that clinicians honor the unique coping skills that first responders need to be able to do their jobs and work on ways of helping first responders find healthy outlets to process what they experience. Clinicians need to educate themselves on this unique population to understand what works best for them. They also need to be transparent about confidentiality and barriers to confidentiality. First responders, like anyone else who has a history trauma, value authentic, direct communication.

AP: Are there specific interventions and treatment modalities that have demonstrated efficacy with the first responder population? Are there treatment modalities/interventions that may be appropriate for the general population, but not necessarily for first responders?

Dr De Lima: There are many approaches that are effective with this population. Early on in a crisis or to get someone the professional help they need, interventions that utilize peers or peer support are the usually most effective. Once they are agreeable to professional help, other evidence-based approaches may be used. Not to generalize, but I would say that most first responders I have worked with initially have been more receptive to the interventions that they can understand conceptually. For example, cognitive behavioral therapy (CBT) and its derivatives such as dialectical behavioral therapy (DBT) are often effective because these interventions demonstrate cause and effect. The use of bibliotherapy or psychoeducation early on may help to reduce skepticism and increase commitment to the therapy process with the first responder population. Cognitive processing therapy (CPT) and eye movement desensitization and reprocessing (EMDR) can also be very helpful in managing trauma. Mindfulness-based interventions also demonstrate high efficacy with this population.

Referencing evidenced-based treatment modalities, in general, I wouldn’t say that that they are interventions that are not appropriate for first responders. Instead, I would say that it may be prudent to use certain interventions at specific stages of treatment and depending on the presenting symptoms. At the beginning of the process, you may have to utilize certain approaches which make sense to the individual and help to stabilize their symptoms. As treatment progresses and they gain trust in the process and experience some relief, they may be more open to other types of approaches.

AP: Is there anything else that you’d like to add?

Dr De Lima: The first responder population is such a special population who risk their lives daily for their community. As clinicians, I view it as an important mission to ensure that we provide ethical, culturally informed care to ensure that they not only are effective in their jobs but are able to live fulfilled lives.

Reference

De Lima AL. Not all heroes wear capes: first responders, trauma, and substance use. Presented at: West Coast Symposium for Addictive Disorders. June 2-4, 2022. Palm Springs, California.