Mental Health for First Responders
The following experts contributed to our guide:
Police officers, firefighters, and emergency services personnel are the first ones to arrive at the scene of an emergency. Often, they have no idea what they’ll encounter when they get there or what steps they will need to take. They have to assess the situation on the spot, make immediate decisions, and take swift action.
The expertise and bravery of first responders have saved countless lives. Yet the nature of their work often takes a toll on them: It’s estimated that 30% of first responders develop conditions such as depression and post-traumatic stress disorder (PTSD). In contrast, the prevalence of similar issues in the general population is 20%.
This guide discusses specific causes of mental health issues for first responders. It also focuses on things first responders, their managers, and their loved ones can do to address and overcome mental health challenges.
Since 1949, Mental Health America (MHA) and its affiliates have led the observance of “May Is Mental Health Month.” The goal is to spread the message that mental health is something everyone should care about and encourage mental health screening. To support this year’s theme, Tools 2 Thrive, MHA is providing a free toolkit everyone can use to improve mental health and increase their resiliency. The kit includes education, outreach, and screening resources, as well as guidelines for using social media to spread these important messages.
We hope this guide can serve as an additional tool for promoting the importance of mental health awareness as it relates to first responders—and everyone else.
How you can help:
(more ideas provided in MHA toolkit)
Why Are First Responders So Susceptible to Mental Health Issues?
The jobs of first responders are difficult and demanding—but so are many other jobs. Other professionals also deal with violence, suffering, injury, and death. Why, then, are first responders more likely to have mental health problems?
Misty Springmeyer, who was a police officer in California for 15 years and is currently an investigator for the Santa Clara District Attorney’s office, says: “The job absolutely affects our mental health. So many factors from emotional stress involved with traumatic scenes, internal stress from a demanding job, stress of feeling unappreciated, and the physical stress of working long/odd hours. If you are not careful, it can easily affect you in a negative way.”
First responders work in positions that expose them repeatedly to crisis, trauma, and emotional distress. Additionally, their roles typically require them to make significant and immediate decisions to address the problem and remain calm and alert throughout the entire process.
A significant cause of stress is the unknown, and first responders continually face this—when a call comes in, they often don’t know a great deal about what they will find when they get to the scene. It might be a minor incident that can be easily resolved. Or it could be a full-blown crisis that requires an immediate life-saving response or even puts the first responders in danger. They need to be ready to deal with whatever comes their way.
Although not every call will be traumatic or upsetting, it’s the cumulative stress that can be dangerous. No matter what type of emergency they’re dealing with, responders always need to be on the alert. Often this state of awareness spills over into everyday life. As a 16-year police force veteran put it in an interview in 2019, “I can’t turn it off. The word for it is hypervigilance.”
First responders also have to deal with the stigma of admitting to mental health struggles. “There is a culture and expectation that these individuals are to remain strong and in control, which can lead to them suppressing their own emotional and physical well-being in the process,” Alizadeh explains. In fact, a recent survey by the International Association of Fire Fighters and two NBC stations found that 80% of firefighters felt they would seem weak or unfit for duty if they asked for help.
This sentiment, unfortunately, often goes all the way to the top. Many managers are uncomfortable hearing their employees open up about their feelings. When they themselves were in the trenches, the advice they got from their managers was to “toughen up.” So they pass this sentiment along to their employees when they’re the ones in charge. Springmeyer notes: “My employer provides mental health resources…[but] there is a stigma with asking for help in our profession. It is okay to express anger or frustration with calls/scenes, but not far beyond that.”
The result of this stigma is that first responders often don’t seek help. They try to ignore their distress or feel guilty for feeling it in the first place.
Mental Health Conditions Linked to First Responders
The pressure and intensity of a first responder’s job can manifest in various ways. The primary mental health issues they face include depression, PTSD, suicidal ideation and attempts, substance abuse, and complex/cumulative trauma.
Depression
It’s certainly not unusual for a police officer to feel anxiety after encountering an armed suspect, an EMT to feel sadness at the loss of a life, or a firefighter to be discouraged after fire devastates homes and communities. However, when these feelings persist or get stronger over time, they may become problematic.
A report by the Ruderman Family Foundation estimates that up to 22% of firefighters and 35% of police experience mild to severe depression at some point. When compared to the figure for the general population—6.7%—the numbers take on greater significance.
Depression can result in a lack of interest in daily activities, difficulty concentrating, sleeping too much or too little, and isolating oneself from others.
Post-Traumatic Stress Disorder
PTSD is a mental health issue that occurs after a trauma or series of traumas. It can manifest itself in many ways, ranging from daily symptoms of mild depression or anxiety to severe negative reactions to specific triggers related to the trauma(s). The National Institute of Mental Health identifies the following components of PTSD:
PTSD can lead to all of the other conditions discussed here—depression, anxiety, suicidal tendencies, and substance abuse. Its prevalence in first responders is also up to five times higher than in the general public.
A related issue is secondary traumatic stress (STS). The condition is a result of witnessing the suffering and trauma of others. Family members of first responders sometimes develop this condition. The symptoms of STS are similar to those of PTSD; they include feeling numb or detached, feeling tired all the time, experiencing confusion and difficulty making decisions, a decrease in job performance, and closing oneself off from family and friends.
Suicidal Thoughts and Behaviors
When a person feels hopeless—that they will never overcome depression, nightmares, anxiety, fear, or other symptoms—their thoughts can turn to suicide. Lack of control in one’s life is a contributing factor to the feeling of hopelessness, and first responders often have little control over the situations they will face and, despite their best efforts, the outcomes.
It is a sad fact that firefighters are more likely to die by suicide than in the line of duty. Similarly, about twice as many police officers die by suicide than by gunfire or traffic accidents combined.
The results from a 2015 survey by Fitch & Associates’ Ambulance Service Manager Program showed that 37% of fire and EMS professionals reported contemplating suicide, nearly 10 times the rate of American adults. 6.6% of the fire and EMS professionals reported having attempted suicide, compared to just 0.5% of all adults.
Substance Abuse
Substance abuse is a coping response to many mental health issues. Alcohol abuse is a particularly frequent struggle for first responders. A number of studies show that binge drinking is more common among first responders than the general public. Not only is alcohol misuse a problem in and of itself—a study found that alcohol was involved in over 85% of police officer suicides.
Complex (Cumulative) Trauma
Although much of this article has discussed the impact of one or more traumatic events, it’s important to realize that often it’s the cumulative effect of events that leads to mental health issues. Even if only a small proportion of 911 calls turn out to be traumatic, not knowing what will happen, day after day, month after month, year after year, can lead to the same types of emotional issues as having experienced one major crisis.
Because of this, it’s important that first responders “check in” with themselves on a regular basis to make sure their cumulative experiences aren’t starting to negatively impact them (see the guidelines that follow).
Ways to Support the Mental Health of First Responders
There are many ways to help reduce the prevalence of mental health issues for first responders. Some of these strategies are things they can do for themselves, while others are things that managers and loved ones can do to help.
The following suggestions come from a variety of resources, including organizations such as the Center for Disease Control and Prevention (CDC), mental health professionals, and first responders themselves.
What First Responders Can Do
To take care of others, you must take care of yourself. Here are some strategies you can use before, during, and after an emergency response.
Prepare yourself.
Try to learn as much as you can about the event you’re responding to beforehand. While this isn’t always possible, even then, you can mentally prepare yourself by using positive affirmations (“This may be a bad one, but I can get through it”) or calming strategies (deep breathing, mindfulness). You can find apps on the web to help you master these strategies—two such apps are Headspace and Calm (available on Apple Store and Google Play).
Validate and Manage Your Emotions.
If during a response you find yourself becoming rattled or stressed, take a mental step back. Springmeyer says, “When responding to a traumatic scene, I remind myself that this is part of my job and that people are looking to me for help, strength, and calming. I have acquired the ability to keep my adrenaline and emotions in check. I definitely feel them coming, but can push them aside and focus on the task at hand.”
Watch for signs of burnout or stress.
This involves two components. First of all, you need to become educated about the signs of burnout or more severe emotional distress (the resources below are a great place to start). Secondly, you need to be self-aware. Try to notice changes in your actions and behaviors. Look for warning signs that indicate you might be headed for trouble. Keeping a journal to track your mood and behaviors may be helpful. This doesn’t mean you should become a mental health hypochondriac, but rather that you stay in tune with yourself and are able to recognize when you feel out of whack. One way to keep tabs is to do regular screening. The Mental Health Association has a series of 14 screening tests you can take for various conditions. Also watch out for any of the symptoms described above.
Find a support network.
Peer support is important, but it isn’t always easy to talk to coworkers about mental health issues. If you’re lucky, your employer has put into place some kind of peer support policy that formalizes interaction in areas including mental health. If not, find a support network outside of work. There are numerous groups and organizations dedicated to first responders (see the resources below), and many of them have blogs, forums, or other ways to network. You can also look for Facebook groups relating to your profession or any mental health concerns that you have.
Take care of yourself on a daily basis.
Waiting until the weekend—or until that upcoming vacation—to unwind and deal with stress just won’t cut it. Self-care needs to be ongoing. Springmeyer shares, “Not bringing the job home can be more difficult some days than others. I rely on exercise as a major stress reliever. I exercise daily and use that time to focus on the positives in my life. If I had an especially hard day, I will talk about it with my husband after the kids have gone to bed. I focus on talking about it, without dwelling.” Find ways to integrate self-care into your daily life. This may be in the form of any activity you enjoy. Many choose exercise, yoga, or meditation, or simply taking time to self-reflect.
Seek professional help.
You’ve probably heard this advice over and over again, both directed at you and at others. You may think it’s an extreme measure exclusively for people in crisis, or one that just doesn’t apply to you and how you are feeling. The hidden message in this suggestion is that you need to get into the mindset of seeking help as an option. Try not to think of it as a major decision or action—it’s no different than calling a doctor to check out a physical ailment. Also think of working with a mental health professional as preventative care. You know well enough from your profession that the earlier you intervene, the better the outcome.
What Managers Can Do
One of the most important things you can do as a manager of first responders is to normalize mental health discussions. Alizadeh emphasizes, “Companies employing first responders should embrace and advocate the importance of emotional and physical health at all times.” You can do this in a number of ways.
Focus on preparedness.
The more first responders know about what they are going to encounter, the more in control they feel. When discussing response strategies in general or specific upcoming events, give your employees as much information as possible about what their roles will be. Help them anticipate problems and discuss how to resolve them. Discuss the types of emotional challenges they might face and normalize those challenges.
Debrief.
Imagine if a child who experienced a school shooting was expected to go back to school the next day as if everything were normal, with no acknowledgment of what happened. That’s essentially what first responders do on a regular basis. Taking time—even briefly—after a stressful event to let your teams discuss what happened, ask questions, and share ideas can be critical to helping them process the event and get past it.
Make mental health resources easy to find.
To begin with, every first responder in your team should be aware of the policies and protocols your company has for dealing with mental health issues. They should also have access to educational resources. “It is very important first responders are educated and encouraged to assess their own mental health and physical needs by learning the warning signs and symptoms these individuals are often suspectable to due to the demands of their jobs,” Alizadeh stresses. Finally, provide information about how they can get professional help anonymously. Your employees shouldn’t have to come into your office to ask for help.
Institute the buddy system.
In a buddy system two responders team up to support each other and monitor each other’s stress, workload, and safety. Making this kind of peer support part of your program helps to “institutionalize” the practice of sharing and seeking help from coworkers. This is particularly critical in environments where such interaction can otherwise feel threatening.
Provide training.
Professional organizations such as the First Responder Center for Excellence offer “stress first aid” training courses for both first responders and their managers. Other programs, such as Critical Incident Stress Management (CISM), are designed to be ongoing resources for education and management. Check out our resources section below for more information. You might also consider reaching out to other organizations in your area to find local programs.
What Loved Ones Can Do
As a family member or loved one of a first responder, you know how challenging their work can be. You have no doubt witnessed their sadness, anger, or emotional distress after a particularly difficult day. You’re also often in a tough position—trying to be supportive but not suffocating, trying not to let their emotions affect you in a negative way. Here are some steps you can take.
Be accepting and do not judge.
Stigma is bad enough for first responders when it comes from coworkers or management—but it can be devastating coming from a family member or close friend. Reactions like “Why are you still so upset about something that happened a month ago?” can make people defensive and cause them to close up. If your loved one expresses any concerns about their mental health or makes comments that worry you, support them. “With encouragement and support from people they care about, first responders may feel less stigmatized to seek out and receive mental health treatment and support,” says Alizadeh.
Make mental health a priority.
“Family and friends of first responders would benefit from encouraging them to make their emotional and physical health a priority within their daily lives to prevent and manage and stress or emotional difficulties they are continuously experiencing from their jobs,” Alizadeh advises. Discussing mental health should be a common occurrence, not something that only happens in extreme situations.
Watch and listen.
You probably know your first responder better than most people do. Look for changes in their emotional behaviors or thinking processes. Remember that some days will be better than others—the idea is to watch for any trends over time. You might even keep a journal to keep track of the changes you see. Also keep an eye out for any sign of suicidal thoughts. The ACT method describes signs and things you can do.
Start a conversation.
If you are worried about the changes you see, express your concerns to your loved one. This shouldn’t come in the form of accusations (“You’re always down in the dumps these days!”) but rather a simple statement explaining what you are noticing. Focus on the word “conversation”—listen and let your loved one respond. Ask questions. Avoid telling them what to do, but rather ask them what THEY think they should do. And, most importantly, take care to validate any feelings they share with you.
Take action.
Listening and talking are important. But if your concerns are growing and your loved one doesn’t want to take any positive steps, you might have to take steps yourself. Talk to a mental health professional for advice. Consult the resources below to learn more about other steps you can take.
Take care of yourself.
An article in Fire Rescue 1 refers to the families of first responders as “silent victims.” As former firefighter Nick Halmasy puts it, “They walk this journey with us, but they are the silent victims when things don’t go so well.” You suffer when they suffer. You feel guilty asking for help because their needs seem so much greater than your own. You worry and spend sleepless nights waiting for them to come home. That’s why it’s so critical that you also take care of yourself. Follow the guidelines above for supporting your mental health. Remember that you’re important, too.
Hope for the Future
There is real evidence that the climate is changing with regard to mental health care. At every level of society, changes are being made to confront the stigma of mental health problems and address them head on, as one would with any other kind of illness.
In January 2018, the Law Enforcement Mental Health and Wellness Act was signed into law. This legislation provides funding for a variety of initiatives, including the creation of peer mentoring programs and the evaluation of other initiatives such as mandatory mental health checks for members of law enforcement.
In 2020, the Helping Emergency Responders Overcome (HERO) Act was introduced in the senate. This bill would establish a series of programs to monitor and support the mental health of law enforcement officers, firefighters, ambulance crew members, and 911 operators. Included in the bill are provisions for creating a public-safety officer suicide-reporting system at the CDC and peer-support behavioral health and wellness programs within first responder departments.
States are also getting on the bandwagon. In 2019, Massachusetts passed a law protecting the confidentiality of first responders who participate in support programs following a crisis. The bill stipulates that mental health professionals are not required to testify or divulge sensitive information as a result of a traumatic event—barring the threat of bodily harm or admission of committing a crime.
Several other states, including Nebraska, New Mexico, and Virginia, have proposed bills that would compensate first responders for medical treatment and put resiliency training programs into place.
Currently, 9 states have laws allowing first responders to file worker’s compensation claims for PTSD. A total of 26 other states are considering such legislation.
Aside from legislative initiatives, first responder organizations and leadership are working to abolish the stigma attached to mental health issues. Organizations such as the National Alliance on Mental Health and the International Association of Fire Fighters (IAFF) have spearheaded anti-stigma campaigns that advocate for changes in both sentiment and behavior. For example, the IAFF provides guidelines for firefighters to follow that include:
Police leadership is also changing its views on mental health. For example, in 2017, the International Association of Chiefs of Police updated an earlier report entitled Breaking the Silence of Law Enforcement Suicides. In addition to outlining specific programs that law enforcement agencies can adopt, it focuses on the need for a cultural change “toward openness and support for all aspects of officer health and wellness, particularly mental health.”
Helplines
SAMHSA Disaster Distress Helpline:
Available 24/7
1-800-985-5990
Safe Call Now:
Availble 24/7 with first responder call-takers
1-206-459-3020
Fire/EMS Helpline:
Available 24/7
1-888-731-3473
Copline (law enforcement only):
Available 24/7 with police call-takers
1-800-267-5463
Frontline Helpline:
Availble 24/7 with first responder call-takers
1-866-676-7500
Suicide Prevention:
Availble 24/7
1-800-273-8255
Resources
These resources are for first responders, their employers and loved ones, and anyone else who wants to learn more about the mental health challenges that first responders face and ways they can get help.
Meet the Experts
Lisa Alizadeh, LPC
Lisa Alizadeh has more than a decade of experience providing therapy and psychological services to children and families in schools, hospitals, and outpatient settings. She has a master’s degree in clinical psychology and is licensed as a professional counselor (LPC). She has written for several research publications within the field of psychology. In her spare time, Lisa enjoys playing with her toddler and husband, recreational soccer, and living a healthy vegan lifestyle.
Misty Springmeyer
Misty Springmeyer was a police officer in California for 15 years. Currently she is an investigator for the District Attorney’s Office of Santa Clara county. She is assigned to Family Crimes, which covers sexual assault, child abuse, elder abuse, and domestic violence.