Our emergency service workers are often put into physical and mental danger in the course of their working day and it is costing lives.
Over the past five years in WA, a new focus and commitment has been given to the identification and treatment of post-traumatic stress disorder (PTSD) among the state’s emergency services – or first responders. Action has been partly spurred by a spate of suicides and union agitation which sparked independent reports and parliamentary inquiries.
The spotlight fell sharply on St John Ambulance after five suicides of paramedics and volunteers over 16 months. Reports from the Chief Psychiatrist, Dr Nathan Gibson (November 2015), Phoenix Australia (Centre for Post traumatic Mental Health, February 2016) and an Independent Oversight Panel (August 2016) explored everything from management culture to wellness and health training programs.
Dr Gibson in his findings said the five suicides in WA among the 6000 SJA paramedics and volunteers represented “a significant human tragedy for families, friends and colleagues alike and is a matter for public concern.”
In his reviewers’ interviews with families and colleagues, he identified as significant sources of stress in the lives of the five:
- Their first responder roles
- Workplace factors
- Organisational factors
- Social factors
- Individual factors
“What emerges is a complex interplay between work and non-work factors where their combination and relative importance is unique for each individual.”
Impact of cumulative stress
The reviewers found “little evidence that exposure to ‘critical incidents’ in their role as first responders was a key factor” in the deaths of the five, though concerns were raised about “cumulative stress and the challenges associated with the changing nature of the job in having to deal with abusive and aggressive patients and those affected by alcohol and drugs.”
Most of the five were receiving mental health treatment and when management was made aware of their struggles, support was offered. “A majority … made use of the SJA funded external counselling service. Others sought treatment independently from SJA from external providers.”
The Independent Oversight Panel, which comprised Dr Neale Fong, Mr Ian Taylor and Adelaide PTSD expert Prof Alexander MacFarlane, did an extensive literature review and made 27 recommendations that encompassed the need for a more detailed understanding of the unique psychological needs of the ambulance workforce, development of more effective career transition pathways, an integrated wellbeing and support strategy and mental health screening.
Prof MacFarlane who spoke about his PTSD research at a psychiatry masterclass in Perth earlier this year, has done a lot of work in the area of cumulative burden of trauma exposure. The panel wrote in the report that this cumulative burden was “an important risk factor that could be better anticipated and managed by St John in relation to the predictable rates of psychological injury and the related risk of suicide in ambulance officers.”
Reluctance to own PTSD
However, an ironic twist is the reluctance of first responders to acknowledge the mental health risks of their job. In submissions received and at hearings conducted by the panel, participants were “generally silent on the connection between the nature the role…and mental health problems.”
The report said: “… this was not surprising, as previous studies have shown that frontline workers accept these exposures as part of their work but tend to underestimate the associated risk and effects. What the workforce does not anticipate is the impact of organisational stresses which they contend can exacerbate unnecessarily the consequences of the traumatic stresses in the workplace.”
SJA was asked to respond to this story but its publication coincided with the CEO being away and an official response was unable to be given. That said, Medical Forum understands from other media reports that the organisation has instigated widespread changes.
In March 2016, there was a WA Parliamentary Standing Committee looking into WA Police and a subsequent report was presented, How do they Manage? Police officers who gave evidence said they felt they were not valued once they revealed a serious medical issue. The report said: “This raises questions about the culture within the police service, as well as the provisions in place to compensate officers. WA is the only state which does not have a workers’ compensation scheme for police officers and it is rare to be awarded an ex gratia payment. Medically retired officers often struggle financially.”
Grey zone of workers comp
The authors of the parliamentary committee’s inquiry drew on the WA Police Union’s Project Recompense report and a previous committee’s report: The Toll of Trauma on Western Australian Emergency Staff and Volunteers.
George Tilbury, president of the Police Union, told Medical Forum mental health issues had been a concern to the union for many years.
“The Project Recompense builds a case to advocate for a fair and sustainable process to compensate our members without the need for ad hoc ex-gratia payment applications. WAPU has been so overwhelmed with requests for assistance with ex-gratia applications that it was deemed necessary to undertake research into not only members’ experiences of work related physical or psychological trauma and the agency’s response but also the forms of compensation available.”
Road to Recovery
Hollywood Clinic has the government contract to deliver mental health services for serving military personal and veterans, so it has extensive experience in the treatment of PTSD through its Trauma and Recovery program led by psychiatrist Dr Mathew Samuel.
Mathew said that there were a growing number of first responder emergency workers – police, ambulance paramedics and firefighters – who were being treated for trauma-related illness.
He said there were three vital first steps in treatment for PTSD:
- Assessment – “This is the first and most crucial. People must be assessed appropriately and urgently. Both a medical and psychiatric assessment is extremely important”.
- Medication – “A lot of people suffer from sleep disturbance, hyper-arousal, flashbacks, nightmares and increasing anxiety. They have increasing difficulty getting on with their job and getting on with their lives.”
- Therapy – “Individual therapy managed by a psychologist trained in trauma is important. Not all psychologists are trained in trauma and if not properly managed this therapy can do more harm than good.” And group therapy – “Sharing experiences with people who have had similar experiences can be beneficial. People feel it’s not just happening to them. Often people think a weakness in their personality has given them PTSD and don’t realise that others face similar challenges.”
A 10-week program is seen to be the most effective though Mathew said a four-week program had been developed because 10 weeks was a long time for people to be engaged in therapy.
Ripple effect on families
“The program delivers psychological education, relaxation techniques and we also have a chance to meet with the family because PTSD has a huge ripple effect with anxiety and flashbacks often played out on family members,” he said.
“We have learnt a lot from military veterans and found that these modalities, if appropriately given, produce improvement. We can either get people back to work or help them move on to a new phase and we can help the families to resettle as well.”
Mathew said there was no quick fix and the journey to good mental health from a diagnosis of PTSD required a lot of support and, critically, follow-up with groups called back at three, six and nine months.
“People are allocated a psychologist or if they have seen another psychologist before coming to the clinic we work with that person. We also recommend regular follow-ups with GPs or a psychiatrist if they are taking medication for PTSD. The important thing is continuity. When they leave the treatment plan they need to have something to fall back on if they have a crisis.”
Mathew said he and his team had just received ethics approval to access data to see how their military patients’ fared five years after initial treatment.
“We know they do well in the in first 6-12 months but nobody has really looked at the long-term outcomes. A recent article in MJA suggests that people with PTSD have a higher chance of having other medical conditions. We want to know if their quality of life is the same or has changed. “
Mathew said the risk substance abuse was high in this cohort.
First address substance abuse
“Often their first response to the way they feel is to use alcohol, marijuana or sleeping drugs to numb their flashbacks or hyper-vigilance, which is why that medical assessment at the start of treatment is so critical. Before they are ready for any treatment for PTSD we want to make sure their alcohol use or drug dependence is addressed or the treatment will fail.”
Mathew said that emergency workers are a relatively new cohort on the Trauma and Recovery program.
“We have been only looking at this for the past 10-12 months, so that is less than 50 patients and that’s not enough for a data analysis. Phoenix Australia undertook an analysis of the 10-week program for military personnel and veterans and found positive results particularly at the three, six and nine-month follow-ups.”
Mathew has given evidence at both the standing committee and the SJA Independent Oversight Panel and believes the reports have had a positive impact within the organisations.
“We have met with health and welfare people at these organisations to stress how important it was that people with PTSD get appropriate and immediate help. There is a stigma for a lot of these first responders to seek help. For many, the places they have to go for treatment are places they take their patients in crisis. They feel that other people need help more than them.”
“So it is important they are given discreet but real help and I think there has been a definite improvement in the understanding by the police and the ambulance services to get help for those people.”
“The trauma field is quite a confronting field of practice. People are in crisis and there is a lot of expectation on clinicians and a fair amount of bureaucracy as well. But there is also great reward in helping people get back on the horse and resume their lives. I hope more psychiatrists and GPs want to become involved in delivering treatment to first responders. We have to play our part too.”
Training Early
Dr Petra Skeffington is a researcher and academic at Murdoch University and a clinical psychologist in the field of trauma and she is particularly interested in primary prevention. She believes more needs to be done to support the high-risk group of first responders.
Petra works with Department of Fire and Emergency Services recruits on a mental agility and psychological strength training program, which she developed.
“We look at the aetiology of how PTSD develops and how individuals might learn skills to derail its development,” she said.
“One of the key factors across high-risk and male-dominated professions is the number of barriers to treatment seeking. One of the core themes underpinning the training I do is normalising mental health, normalising the appropriate reactions and expected reactions we might have following any crisis or intense situation.”
“A lot of first responders have good knowledge identifying their physical injuries and know when they need professional support. It’s drawing those parallels so they can recognise when some other distress, which is not a physical injury, is occurring – to recognise it as a problem and identify if they need external support.”
There will always been populations in the community who will be at higher risk of mental health problems because of the nature of their work but the majority of first responders have developed their own coping strategies, Petra says. Training at the recruit level can help people develop those strategies from the start of their career.
“So it’s not even a resilience or prevention plan but a wellbeing plan so these workers can be their best selves,” she said.
Some in the community might think that these jobs are well known to be stressful, high risk and challenging, so if a person can’t cope with those pressures, they find another occupation.
“While I understand that logic, we don’t always know what will trigger a reaction in us. My experience working with these populations, and in my private practice, when there are large scale disasters, we can expect people to have an adverse reaction,” she said.
“But how we function and react to what’s going on in our lives is fluid. So things that might be OK in one part of your career may not be fine at another point. The most obvious example is attending accidents, anything involving children, which for many people can be OK for the most part until they have their own children. Or they attend an incident which may involve a child the same age as their child. These may not necessarily be massive crisis or trauma events but they hit a soft spot and that soft spot moves because we change over time. I don’t think we have good predictive power to be able to tell how we will react.”
Petra said as mental health was being talked about more freely and becoming a part of our regular vernacular, there was a danger that the term ‘trauma’ was being misused.
“People who have some distressing event will say, ‘I was so traumatised by this, I have PTSD now’. We see this in other spheres such as Obsessive Compulsive Disorder. What we have is the language to say these things but it massively diminishes what it is actually like for people who have these disorders,” she said.
“It can create an impression that for someone who has severe PTSD that they should be able to ‘get over it’ or move on because we can’t appreciate what they are experiencing when we are gauging it by people who have the language but not the disorder.”