How the mental illness is affecting our first-line responders

firefighter-thumbnailIt was a call he says he'll remember for the rest of his life.

There had been a crash involving a child and a vehicle — and Darren, a firefighter with the Calgary Fire Department, or CFD, since 2000, was one of the first on scene.

Darren, who asked not to use his real name due to the sensitivity of the story, said the child had been dragged by the vehicle and was conscious the whole time.

He remembers the boy asking him if he was going to die.

Professional firefighting is considered one of the most dangerous and stressful occupations. These first responders attend not only fire-related incidents, but are also trained emergency medical technicians. The events they witness on a daily basis would leave most people in shock.

Fire departments across Canada have seen an increase in post-traumatic stress disorder symptoms among firefighters and have decided that more needs to be done to combat this mental health issue.

But accurate statistics regarding how big of an issue this really is are hard to come by.

Which is why in September 2011, the Canadian Association of Fire Chiefs (CAFC) unanimously passed a resolution to lobby the federal government to create a committee examining the issue of post-traumatic stress disorder and its subsequent addictions within fire services personnel across the country, as well as to provide funding for treatment services.

Post-traumatic stress disorder, more commonly known as PTSD, is a term closely associated with military personnel, a mental health issue most civilians perceive as something that couldn't possibly affect them.firefighter1Post-traumatic stress disorder affects one in 10 people.
Photo by: Tessa Clayton

It's caused by a traumatic event, called a stressor, that involves death or serious injury to oneself or others — things like violent personal assault, car accidents, natural disasters and military combat are all listed stressors by the Canadian Mental Health Association. They cause the individual so much anxiety that it can become difficult for them to lead a normal life.

But PTSD can hit closer to home than we realize.

It's a well-known issue within the RCMP. A Globe and Mail article published in August 2011, citing statistics provided by Veterans Affairs Canada, stated more than 1,700 Mounties were receiving post-traumatic stress disorder pensions — up from 1,437 in 2010 and 1,239 in 2009.

And it's expected that when our Canadian soldiers return from military missions overseas, a certain percentage of them will eventually be diagnosed with PTSD.

That begs the question: if our national police force and military members are expected to suffer from this disorder, what does the local situation look like when it comes to first-responders who attend critical incidents on a daily basis?

The images in your head

Post-traumatic stress disorder is one type of several anxiety disorders that affects one in 10 people, making it the most common mental health problem, according to the Canadian Mental Health Association.

The disorder is very individualistic — what affects one person may have no effect on another whatsoever and can be compounded. However, there are common symptoms: re-living the event through memories, nightmares or flashbacks, avoidance and emotional numbing, increased alertness and aggression or insomnia. It can also lead to drug or alcohol addiction, depression or other illnesses.

Darren recalls two specific incidents that left him not "feeling right."

It was the second incident involving the child who had been hit and dragged by a vehicle roughly three years ago that really affected him, he said.

Darren said he specifically remembers the details of the boy asking him if he was going to die.

"And then he reached up and actually touched my face, so I'm trying to comfort him but trying not to tell him 'yes' or 'no,'" Darren said, adding that at that time in his career he'd attended other medical and fire-related calls where people had died on scene.

"As much training as you can be given ahead of time there's nothing that trains you or prepares you for that type of situation."

Due to Freedom of Information laws, Darren wasn't able to track down the boy to find out how he was doing, or if he had even survived, which made dealing with the situation worse.

Over the course of the next few weeks, the incident continued to bother Darren — he said he wasn't sleeping well and became more irritable.

He was working a shift with a member of the critical incident stress team when he took the first step to dealing with the issue. The two friends sat and talked about the incident and through the other member Darren was able to find an external counsellor who he received further help from. He said he did eventually find out through unofficial channels that the boy did survive.

Darren never received an official diagnosis, but his counsellor suggested he might have been suffering from PTSD.

The 'rescue mindset'

Fire departments across Canada have measures in place to help those who may be affected by a particular call — resources such as critical incidence response teams to provide debriefing, counseling and physicians for further referrals — which are mostly covered by employee health benefits.

But despite the range of services available to those who may be struggling, the actual numbers of how many members access these is relatively unknown, due to the sensitivity of the issues at hand and confidentiality concerns.

Ian Crosby, co-ordinator of the wellness and fitness centre for the CFD, said only one to two per cent of their members are officially diagnosed with PTSD each year.

But he said he believes the actual number of members who may be affected is much higher.

"It's pretty hard to say how many people we have affected and how many are out there that we have no knowledge of," Crosby said.

The CFD has more than 1,360 members now — 91 per cent of those in uniform — making it the third largest department in Canada.

He said he believes there are two main reasons behind a firefighter's lack of willingness to come forward: the stigma attached to mental health issues and the "rescue mindset" found in emergency services.

"There's that stigma attached to it I think, in the general population anyway, but in emergency services I think it's compounded even further," Crosby explained.

"You're dealing with people that tend to have a 'rescue mindset,' where you're helping others and not necessarily looking to whatever issues you might be having internally. You tend to kind of put that aside."

And while this attitude is courageous, it can be dangerous as well.

Dr. Cory Wowk, a physician at the CFD's wellness and fitness centre, said he and his colleagues treat firefighters with some element of a mental health issue at the centre almost every day. While this doesn't mean full-blown PTSD, even a minor diagnosis of mild depression "may play a role of some PTSD stuff in the past."

Implications of PTSD on the job depends on the severity of the issue, he said, because it can hinder firefighters from performing at top level, cause poor sleep, lower concentration skills, and increase irritability. Only in extreme cases is a leave of absence given, as Wowk said these factors often affect the firefighter's quality of life more than their job, and as such are still able to work effectively.

But the biggest hurdle is that PTSD is a very personal issue.

Most firefighters are "self-medicating," meaning they prefer to deal with emotions and other stresses on their own, another cultural aspect that makes getting help difficult.

This means that more often than not, mental health issues within fire departments go unreported and undiagnosed — making it harder for medical professionals to provide the help that firefighters need.

The most in-depth study done on mental health within fire services was back in 1986 by researchers from the U.S. Institute for Occupational Safety and Health. They wanted to identify potential workplace stressors, assess psychological distress and problems with alcohol abuse to help find out if there was a relationship between the three.

firefighter3Symptoms of post-traumatic stress disorder include: re-living the event through memories, nightmares or flashbacks, avoidance and emotional numbing, increased alertness and aggression, and insomnia. Photo courtesy of: Jeremy Schoustal

"Results of this study suggest that over one third of the firefighters surveyed were experiencing significant psychological distress," the report stated. The authors also concluded "it is significant that the firefighters surveyed scored poorly on all measures of mental health in comparison with the results of other published studies utilizing these instruments in community or occupational settings."

In 2009, a joint study by the University of Ottawa and University of Washington focused specifically on PTSD and duty-related trauma within fire services in Canada and the United States. In Canada, 625 firefighters were surveyed.

The study suggests that 1.2 per cent of the Canadian community male population had PTSD, while 17.3 per cent of the Canadian firefighters surveyed were found to have the disorder.

The same figure in the study showed that Canadian firefighters fit right between the percentages of Vietnam-era veterans overall and those wounded in combat who had been diagnosed with PTSD (15.2 and 20 per cent respectively).

The study went on to say that 85 per cent of the Canadian firefighters had at least one traumatic-incident exposure within the past year, based on categories such as "serious injury accidents excluding nonfatal motor vehicle accidents" and "civilian fire fatalities".

Dr. Wowk said he had a recent discussion with a CFD firefighter who was wondering if he maybe had PTSD.

"I think his answers probably give us the answer: He said he's seen 20 — and he could count them, 20 kids exactly — that had died on his time on the job that he's seen, and he said he could picture pretty much every one of their faces," he shared. "That's something that's shocking even to me, and I'm used to dealing with some of this stuff."

"But we don't think of these things and these front-line workers and the things they see and do and have to live with."

No 'cookie-cutter' solution

Darren said that seeing the counsellor helped, but from time to time he still finds himself thinking about the incident. He has stopped seeing his counsellor, but said he still experiences some anxiety when he attends or hears about calls involving pedestrians and vehicles — something he doesn't think will ever go away.

There are certain criteria that must be met in order to receive a PTSD diagnosis, the most significant either witnessing or being part of an event that includes serious injury or death.

Other criteria include intense feelings of helplessness or horror, reluctance to enter similar situations and flashbacks. Despite this, Dr. Wowk said physicians sometimes need to use their own personal judgment because not everyone displays symptoms in the same way.

"Each individual can present a little bit variable so I think sometimes it (PTSD) can be difficult to recognize," he said, adding that how easily a diagnosis is made depends a lot on how forthcoming the individual is about the feelings they're experiencing.

Dr. Wowk said firefighters may not recognize the symptoms because they feel these events and feelings are a part of the job they have to deal with, even though "in reality, these can be very traumatizing events that people experience and repeatedly experience."

Darren is an exception — he said he was able to identify that something wasn't quite right after the incident due to previous training courses he had taken, which made getting help easier for him and probably prevented things from getting worse.

He said his biggest concern was that if he was constantly being distracted by memories of the incident he would be putting those working with and under him at risk — a chance he wasn't willing to take.

"You can't hesitate — you have a fraction of a second to make a decision that's going to affect someone's life," Darren explained.

"I had to make sure I was focused on what I was doing and not thinking about this thing. I didn't want to be responsible for someone else [getting hurt] because I wasn't paying attention, I wasn't at the top of my game."

Dr. Wowk said he feels there is a large majority of people diagnosed with PTSD after other things have happened in terms of relationships, depression, alcoholism or trouble sleeping, acting as red flags for another issue at hand.

That was the case for Jeff Mack, a 26-year veteran currently with the Fredericton Fire Department in New Brunswick.

In February 2005, Mack attended a structure fire with his partner. Despite textbook execution on their behalf, his partner fell through the floor to where the fire had started. When he fell, he knocked off Mack's oxygen mask, rendering him semi-unconscious. As he came to, his partner was screaming for the hose line to fight the fire, and when they tried to radio in a mayday call the batteries were dead, meaning Mack had to leave his partner in the burning building to get help.

The two survived with smoke inhalation, but that six-minute window changed Mack's life forever.

He said he started exhibiting symptoms of PTSD almost immediately — he was fearful of going back to work, his drinking went through the roof, he wasn't sleeping, lost interest in almost everything, and developed anger issues. He said he attended a debriefing session after the incident, and a month after the fire he sought counseling.

Within a year, Mack was seeing a psychologist who diagnosed him with PTSD and chronic alcoholism.

"My best buddy was my beer bottle — that's all I wanted. That was my comfort, that was my sanity," he said.

Mack attended two 28-day addiction rehabilitation programs in 2007 and 2008, relapsing both times. He deteriorated physically and spent time in jail for driving under the influence. He was losing his family, had a workplace intervention, was placed on light duty and then sick leave. The psychologist told him he had to get his alcohol addiction treated before they could move forward with his PTSD treatment.

But Mack had already been through all of the municipal and provincial support systems in place, and wasn't getting better. He was given one last shot through the show "Intervention," which airs on A&E, in 2008. He agreed to follow through with this olive branch and spent four and a half months in Nanaimo, B.C. at the Edgewood Addiction Treatment Centre, considered a critical care hospital in the province. He was told at that point he would have had roughly three months to live before he died from his alcohol abuse.

Treatment for PTSD can be expensive — according to Ian Crosby, depending on how severe the issue has become it can cost roughly $200 an hour to see a psychologist and $1,500 a month to treat other addictions or illnesses. Some services are only offered in certain places, like Mack's intense rehabilitation in Nanaimo.

"It depends in terms of how long you're looking at treatment and again, it's very variable," said Dr. Wowk.

"It's very individual so the treatment is going to be very individualized ... There's no cookie cutter way of doing things."

Support systems in place

Mack received the treatment he needed for both his alcohol addiction and PTSD at Edgewood, and said he believes he's one of the lucky ones. So does Deputy Chief Dan McCoy from Kennebecasis Valley, N.B.firefighter2A joint U.S. - Canadian study found that 17.3 percent of Canadian firefighters had post-traumatic stress disorder.
Photo by: Tessa Clayton

"There is no avenue available for most municipal fire departments, union or non, or especially any volunteers dealing with this — there's nothing out there to help them with this problem," he stated.

He said most employee assistance programs can provide only very little in means of treatment, and most of that is not in-depth enough to treat PTSD.

The Calgary Fire Department has three physicians at their wellness centre, all part-time staff, and only one specializes in mental health. These physicians were brought on board in 2005.

Within the CFD budget, there is no line specifically for PTSD, or even counseling services. Crosby said this is because the department has critical incident response teams, which provide immediate assistance after an event if someone of higher rank feels debriefing is necessary, or when requested.

Within the department's benefit plan there is assistance for behavioural health, but whether or not the individual accesses it is up to them.

The Calgary Police Service and EMS have similar structures in place, although in some areas they are more robust.

In every sector, all official debriefings are voluntary — meaning that the debrief must be specifically requested after an incident, it's never mandatory. This is because what constitutes as "traumatic" is different for every individual, said all three spokespersons.

Looking to the future

However, all aspects of PTSD and issues surrounding it have become more prevalent within the fire community over the years.

Besides debriefing teams and other resources, the CFD launched a pilot project in January 2011 that aims to provide funding for members who physicians feel should pursue counselling immediately or are already in counselling, extending financial help for things not covered by their benefit plan.

This is being funded by the department's medical budget, and as far as Crosby knows, is the only program in place in the country.

While this is helpful, Darren said he thinks more needs to be done to make sure members are aware of services available through the program. He still feels that peer debriefs are more effective because of the relationships already in place between CFD members as opposed to members and doctors and wishes that officers had more training about how to deal with individuals after a critical incident.

The fact that the Canadian Association of Fire Chiefs has recognized PTSD as an issue that needs more attention is another big step forward.

"We're already behind the eight-ball because of our line of work so if you're medicating like I did that's [addiction] what the result is," Mack said.

"Help us — we should be at work healthy and alert, not suffering from what we experience in our job. What we experience in our job makes us sick, this we know, we can't ignore it."

In an email, CAFC president Rob Simonds said the decision behind the approval of the resolution was based on concerns that firefighters across Canada are suffering from PTSD, "in some instances with little or no support mechanisms in place to support their need."

"Accordingly, the CAFC would like the government to take the lead on developing a benchmarking program (in concert with our provincial and territorial leaders) to assess how prevalent the issue is in our country."

Lobbying for anything at the federal level takes time and patience; results can take years to materialize. The most recent big issue the CAFC lobbied for was a tax credit for volunteer firefighters, which was passed in June 2011 after 10 years of hard work, said a news release on their website.

But due to the "complexities and challenges of collecting and collating the data," the CAFC is unsure when they will have a proposal for the government.

Not 'a part of the job'

While departments wait for that date, those within the service are doing what they can to help those who may be affected.

The view that there's a "chink in the armour," and that counselling and speaking out is a sign of weakness is an important issue all involved are trying to tackle.

Both Darren and Mack say that their own experiences have made them more aware of and attentive to their co-workers who may be suffering from PTSD and subsequent addictions.

"It probably makes me a little more sensitive to other things that have happened to people or other calls I go on, [to] make sure that 'Hey, you guys are good?'" Darren explained.

Because his experience was played out on a TV show, Mack was prepared for the publicity he would receive. He said he thinks this made him more comfortable to do his presentation for groups about PTSD and addiction.

His personal story and resulting national committee and funding idea was the main push behind the resolution submitted by the New Brunswick Association of Fire Chiefs to the CAFC last year.

Mack said part of his biggest problem after his fire was the next thing that could happen — death. At the time he thought his partner wasn't going to come out of the building alive and he said he wasn't prepared to experience the next worst thing, causing him to back away from the job he loved. That incident was the one that finally popped his cork.

He explained that he felt ashamed of himself because he felt he no longer fit the profile of how a firefighter should act and feel, which is neither healthy nor accurate, he said.

"It's the biggest crock of bull that I ever fell into and that's still the mindset out there right now," he stated.

"That's why I'm so passionate about the fire chiefs and what I've been trying to do for the past two years: to get this mindset cleared up so that firefighters no longer think that we're supposed to go and experience these traumatic events and be unaffected."

He doesn't expect or want the public to change their perceptions of firefighters, but he does want those within the service to realize that they really are no different from everyone else.

"We're human beings at the end of the day and at the end of the day if we've seen something that human beings aren't meant to go through then we have to be honest with ourselves and say, 'That sucked.' And take a minute to say it's OK to feel this way, this is normal and I shouldn't feel guilty about feeling bad or out of sorts," he said.

"That's why I don't look back, when I do these presentations, I'm not embarrassed, I'm not ashamed — I'm actually grateful I did go through that because if those things hadn't happened, I'd still be an alcoholic and I'd still be messed up from not dealing with all these other traumatic events."

Also see: Brotherhood environment helps volunteer firefighters cope with job stress

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