When I was a young mother of two boys, we moved out to the country where there was a volunteer Fire Department. We had a shed burning up in our backyard and I called 911. When the Fire Department arrived and put out the fire, the Chief began to tell me about the volunteer department and how they really needed more women to serve, as they only had one.

At that time I had been a Licensed Marriage and Family Therapist in private practice for eight years. I thought I could do this too and serve my community. I embarked on the journey of becoming an Emergency Medical Technician, taking courses at the local Community College and enrolling in the Fire Academy. This was a very difficult endeavor in many ways, physically and mentally. I succeeded and became a California Firefighter/Emergency Medical Technician.

At this time, EMDR therapy came onto the scene. With a few others in San Diego, I decided to take this training facilitated by Dr Francine Shapiro. I thought it was a strange modality, where I was to wave my hand and be quiet, yet I found I was getting results with my clients like never before. It didn’t take long to recognize how useful this would be with First Responders who had been exposed to critical incidents and a pile-up of traumatic stress exposure. I would hear their stories and the current symptoms they were describing.

Since I too was exposed to some horrific incidents, I received EMDR therapy myself and found my sleep improved and my flashbacks stopped. It seemed like a miracle treatment back then, over 30 years ago, since we had no real clue why it worked the way it did. The more calls I went on during my Fire Service, the more I recognized how important it is for First Responders to learn to identify when certain calls may be impacting them and how the negative cumulative impact can sneak up on you.

First Responders have a number of unique stressors in their professional careers.

First, they are chronically exposed to human tragedy day after day, year after year. They are called in often on the worst day of someone’s life and required to intervene no matter what the circumstances. Their personal risk is high and the implementation of their ongoing training can make the difference between life or death.

Secondly, for Law Enforcement in particular, their families face the day-to-day reality that they may die in the line of duty and not come home. Most of us don’t concern ourselves with this thought as we head out the door each morning.

Additionally, First Responders are required to make split-second decisions on a day-to-day basis under extraordinary circumstances. This requires them to maintain a high level of physical, mental and emotional health to perform at their best. I consider First Responders ‘peak performers.’

The impact on their partners and families is also unique. They often have long shifts and may be away for days or weeks at a time. Their schedule is changed to accommodate the 24-hour demands and this impacts the family’s ability to function and for the First Responder to be able to help the ones they love most. The First Responder Family makes a commitment to this career, not just the First Responder themselves.

The prevalence of PTSD among First Responders can vary based on numerous factors, including the type of incidents they respond to, the support systems available to them, and individual resilience. Researchers have summarized their findings by saying that First Responders grapple with a suicide rate and clinical levels of PTSD that are three times higher than the general public.

Current research suggests that the prevalence of PTSD among First Responders can range from around 6% to as high as 20% or more, depending on the study and population surveyed. This wide range highlights the complexity of the issue and the variability in experiences among First Responders.

As for whether one profession has a higher likelihood of PTSD than others, it's challenging to make broad generalizations. However, some studies suggest that certain professions within the First Responder community may have higher rates of PTSD.

For example, Police Officers are involved in frequent exposure to traumatic events, including violence, accidents, and crime scenes. Correctional Officers have the highest rate of physical assaults. Some studies have indicated that police officers may have higher rates of PTSD compared to other First Responder groups.

Firefighters also face exposure to traumatic incidents, such as fires, accidents, and rescues, as well as being exposed to toxic chemicals regularly. While the prevalence of PTSD among Firefighters can vary, it's generally recognized as a significant issue within the firefighting community.

Emergency Medical Technicians (EMTs) and Paramedics frequently encounter traumatic situations, such as severe injuries, medical emergencies, and fatalities. Research suggests that EMTs and Paramedics may also experience higher rates of PTSD than the general public.

911 Dispatchers have also been shown to have high rates of PTSD due to their chronic exposure to traumatic stress, where they are required to be psychologically on scene and ensure that the First Responders and citizens have what they need. 

However, it's important to note that PTSD can affect individuals in any First Responder profession and the specific risk factors can vary widely depending on factors such as the frequency and severity of trauma exposure, the level of support available, and individual coping mechanisms. Additionally, factors such as organizational culture, stigma around mental health, and access to resources for mental health support can also influence the likelihood of PTSD within different professions.

More information is available at the following links:

https://doi.org/10.1186/s13728-016-0049-x
https://doi.org/10.1016/j.psychres.2015.06.015
https://doi.org/10.1007/s11896-018-9276-y 

There is a body of research done on what is known as ‘protective factors’ within the First Responder population. These protective factors are important as they can provide a ‘cover’ or level of protection from the negative aspects of traumatic stress exposure. These protective factors preserve the First Responders’ psychological resiliency. They include:

• Strong and consistent social support networks at home and work

• The ability to bring meaning and purpose to work and even critical incidents

• Positive self-esteem

• A collective positive self-esteem where the First Responder encourages and supports others with respect personally and professionally.

It has also been shown that when a First Responder agency or department has an organized Critical Incident Stress Management and Peer Support Team with easy access to culturally competent mental health services, positive productivity increases.

More information is available at the following sources:

https://pubmed.ncbi.nlm.nih.gov/21448365/
https://doi.org/10.1016/j.comppsych.2013.06.004
National Center for Injury Prevention & Control, Division of Violence Prevention, 2012

When we consider that the pile-up of traumatic stress exposure in First Responders is one of the primary causes of their PTSD, we can hope that regularly processing any memories that appear to be influencing dysregulation would decrease the incidence of full-blown PTSD.

There is some preliminary evidence that EMDR Early Intervention Protocols may decrease the incidence of delayed-onset PTSD. However, we know that each individual brings with them a history of their own and has a unique capacity for resilience, as well as different types of traumatic or critical incidents.

If we look at Sub-threshold PTSD or what is called Posttraumatic Stress Injury (PTSI), this is where symptoms such as hypervigilance, sleep disturbances, flashbacks, irritability and difficulty concentrating operate below the surface on a regular basis. This drains the First Responder while they are being required to continue to do their job day in and day out, potentially compounding the symptoms. Many First Responders don’t say anything as they believe this is just ‘part of the job’ and they just need to ‘toughen up.’

There is an emerging belief that providing annual stress check-ups can help identify any potential pile-up sooner rather than later and provide an opportunity to teach stress management tools. I believe doing this, like going to your primary doctor each year for a check-up, can help First Responders stay on top of their psychological wellbeing.

More information is available at the following sources:

https://doi.org/10.1891/1933-3196.5.4.156
https://doi.org/10.1891/1933-3196.13.2.100
https://doi.org/10.1002/jts.22792

Any mental illness, if left untreated, will likely worsen. Negative coping mechanisms, like an increase in alcohol consumption and risky behaviors, tend to show up in a First Responder who is suffering. They are trying to manage the symptoms that are worsening. Erratic behavior and angry outbursts can be a sign that the pile-up is causing the First Responder to slowly collapse. Relationships suffer, job performance suffers and physical health suffers. Depression and anxiety can increase to the extent that they may begin to feel suicidal, wanting the pain to end. If left untreated, PTSD is like a flame blower in the brain, firing up the nervous system until it is unbearable. 

The good news is there are specific treatment programs for First Responders who have gotten to this point. They are culturally sensitive and bring together a variety of treatment modalities, including EMDR therapy, to address the layers of symptoms and to initiate the healing process, ideally getting the First Responder back to work.

More information is available at the following sources:

https://doi.org/10.1016/j.pscychresns.2016.03.003
https://doi.org/10.3389/fpsyg.2018.01458
https://doi.org/10.1176/jnp.17.4.526

Critical Incident Stress Management (CISM) is an overarching term for how an agency can take care of their team following a critical incident. The trainings in CISM include Peer Support Team training, Chaplaincy training and mental health provider training on how to respond with First Responders following critical incidents.

Critical Incident Stress Debriefing (CISD) is a component of CISM. This is where a group of those involved in the critical incident get together with a mental health professional, Chaplain and peers to do an organized stress debrief. Over the decades that I have been trained in and involved with CISM, there have been mixed reviews on whether debriefs are helpful. What I have seen on the frontlines, after facilitating over 100 debriefs, is that at the very least it provides an opportunity for the team to get together, go over some things and offer support to one another. It also provides the mental health professional and Chaplain to do some education, notice if anyone is having a particularly impactful time with this incident and follow up with support.

For the most part, this has always been a positive experience. When an agency provides these services, First Responders often feel like they are being recognized and supported. The downside can be that the people on the call re-experience it too early when they are still in some aftermath of shock.

More recently, newer models of CISM and CISD are emerging that take neuroscience and memory into account and offer more resourcing, grounding, positive focus and team support, which helps each person self-regulate and reboot their nervous system. There is also more of a focus on stress management skill building and team building.

Dr Heather Williams of Premier First Responder Psychological Services/Coherence Associates, Southern California, and Sonny Prevetto, LCSW, Vermont Center for Responder Wellness, Connecticut, both EMDR therapists, are at the forefront of newer models of CISD that incorporate our foundational understanding of the Adaptive Information Processing model.

More information is available at the following sources:

https://doi.org/10.1891/1933-3196.13.2.100
https://doi.org/10.3389/fpsyg.2023.1129912 

This all depends on why they are coming in and what they have previously heard about EMDR therapy. There are a number of different ways First Responders think about EMDR. If they have never heard of it, this gives me the opportunity to teach them about the impact of traumatic stress, what EMDR is and how it might help.

Often their fellow First Responders have experienced EMDR and have shared their story with them. This helps with their initial skepticism. There are times that either they themselves have had a negative experience or they have heard that someone had a bad experience. This usually means that there may have been a flood of emotions they or their friend experienced and it was highly uncomfortable. They may even think of it as a ‘losing of control’ which they definitely don’t want to do.

Remember, First Responders have become experts at keeping their emotional responses at bay and they may interpret expressing emotions as weak. They may not understand why they are having the symptoms of irritability, sleep disturbance, flashbacks, and so on, and why they have not been able to ‘shake it off.’

EMDR is not the only aspect of working with this population. Building trust and rapport is paramount to have the process of counseling be effective. Also, building resilience with First Responders includes a lot of resource development, self-regulation skill building and reducing the presenting symptoms so they can feel confident in the work they do.

Once they experience the positive impact of EMDR, they feel better, their symptoms are either gone or significantly reduced and they become more willing to continue. They will be going back to work to keep doing their job and getting re-exposed to traumatic stress. A part of the process is helping them understand how important it is to come in as soon as they recognize their symptoms returning and to normalize that this is the nature of the impact of their work and this can be addressed along the way. I like to call it a reboot! This usually makes sense to them.

As EMDR therapists, we know that we are focused on the client in front of us and will adapt to their particular presentation and needs. First Responders are unique individuals who work in a demanding and unique profession.

The basic EMDR protocol works in processing traumatic material. Sometimes you may want to use one of the recent event protocols if a First Responder has had a recent critical incident. This may not be a time to reprocess earlier feeder memories. The goal is to get them back out into the field ready for the demands. If they are stabilized and further processing would be beneficial then I’d say go for it. They are exposed to most of life’s traumas and it can definitely trigger them if they have experienced something similar in their own lives.

There may be times that you will adapt Phase 3’s request for Validity of Cognition measure and the Subject Unit of Distress measure to allow this to emerge at a later time, which it will, not to interrupt the processing. I have found that asking for numeric measures can be a blessing or a curse. First Responders are data-driven. Numbers have a lot of meaning in a variety of circumstances. When we ask for a numeric measurement to ‘feeling’ something, this can throw them off. I often ask them to just keep ‘noticing’ what is happening.

You may also adapt things depending on how long you may have them in treatment. So often we only get a limited amount of sessions so we have to be as efficient as possible. In this case, it’s important to prioritize the presenting issue or symptoms. 

Peer support programs don’t necessarily prevent PTSD, however, if a department/agency has a good peer support program, they are supporting First Responder Wellness. They are hopefully providing easy access to competent mental health providers who are connected to the Peer Support Team. This collaborative team approach provides First Responders with options to work on their psychological and physical wellbeing.

Stress management training, resiliency training, mental health counseling and Critical Incident Stress Debriefing are all important and valuable pieces of the wellness pie to be provided to First Responders. When mental health providers participate in training, they can bring a science-based understanding of stress management and how EMDR can help in maintaining resilience over time. Encouraging First Responders to share their successful EMDR stories with their peers is one of the most impactful ways to help those in need reach out.