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First responders are professionals who initially respond to emergency situations in order to provide treatment or assistance. First responder is a broad term that includes volunteer workers as well as professional workers, such as:

  • Firefighters
  • Paramedics
  • Police officers
  • Military personnel
  • Mental health workers
  • Emergency dispatchers

First responders are at risk to develop numerous medical and mental health issues due to the intensive nature of their work, and the types of trauma and stress they witness. These individuals are at an increased risk to also develop a substance use disorder as they are often exposed to extreme amounts of perceived stress that can result in the development of a trauma- and stressor-related disorder.

First responders may develop post-traumatic stress disorder (PTSD) even if they are not personally threatened because individuals who witness the effects of severe traumatic situations are an increased risk to develop this disorder. Individuals who develop trauma- and stressor-related disorders, particularly PTSD, are at a significantly increased risk to develop substance use disorders and other mental health conditions like depression.

Moreover, people employed in the above professions often have a sort of cultural mindset that involves the use of alcohol as a method to relax or deal with stress. Very often, firefighters, police officers, paramedics, and other first responders have regular meetings at bars or restaurants where alcohol is served, and may use alcohol as a means of promoting social interaction in addition to dealing with stressful situations. This combination of acceptance of alcohol as a means to deal with stress or to socialize, and being closer to potentially stressful and traumatic situations can further increase the risk that people who are employed as first responders may develop alcohol use disorder.

Trauma- and Stressor-Related Disorders

The American Psychiatric Association (APA) categorizes several different disorders as trauma- and stressor-related disorders. The two disorders that are most relevant here are PTSD and a disorder known as acute stress disorder. PTSD represents a more chronic representation of a reaction to trauma or stress, whereas acute stress disorder is only diagnosed if a person displays PTSD-like symptoms for a period of four weeks or less after experiencing a stressful or traumatic event. Very often, the symptoms of acute stress disorder will resolve within this period of time. Individuals with acute stress disorder may be prone to binge drinking or excessive alcohol use, but they generally do not develop alcohol use disorders.

PTSD represents the presentation of specific symptoms that have been present over a period of greater than four weeks after being exposed to some traumatic or perceived stressful event. The exposure to the event does not have to be direct; the person does not have to be present when the traumatic event occurs, but may develop PTSD as a result of witnessing the aftereffects of the event or the effects of the event as they occur to others. Traumatic events that may affect first responders might include:

  • Natural disasters, such as hurricanes, fires, floods, tornadoes, etc.
  • Accidents, especially accidents involving forms of mass transportation, such as airliners, trains, etc.
  • Acts of terrorism
  • Instances of severe physical or sexual abuse
  • The aftereffects of war or other large social conflicts, such as riots

Only a trained mental health clinician can diagnose these disorders. However, the signs and symptoms of PTSD typically include:

  • Experiences where the person actually relives the traumatic event, such as experiencing vivid memories, recurrent dreams, or even flashbacks
  • Experiencing anxiety when reminded about aspects of the traumatic event
  • Attempts to avoid reminders of the event (e.g., not watching television shows about emergency situations, avoiding driving for fear of getting in a car accident, etc.)
  • Developing hypervigilance to potential or imagined similar types of events
  • Depression, anxiety, loss of motivation, becoming overly pessimistic, or isolating oneself from others
  • Cognitive issues, such as problems with attention or memory
  • Feeling detached from reality or from other people
  • Self-destructive behaviors that can include self-harming behaviors or significant substance abuse

In first responders, and in people who are actually involved in traumatic events, PTSD may not develop immediately following the experience of the event. In some cases, symptoms of PTSD may occur months or even years after experiencing one or more traumatic events. Because first responders are often exposed to multiple events that are associated with marked stress and horrific conditions, they may develop PTSD symptoms from the experience of several events that eventually wear down their resistance.

Research studies have suggested that the rate of PTSD among first responders may be between 15% and 30%. As an overall figure, it is estimated that about 20% of all individuals with the diagnosis of PTSD will also have a co-occurring substance use disorder.

According to APA, individuals who have PTSD and experience flashbacks, intrusive thoughts, recurrent dreams about the traumatic event, nightmares, or other aspects of re-experiencing the traumatic event may be at a higher risk to develop a co-occurring substance use disorder, such as an alcohol use disorder, compared to individuals with the diagnosis of PTSD who do not have these types of symptoms.

Alcohol is one of the most common substances of abuse in individuals who develop PTSD due to its central nervous system depressant effects (it deadens feelings or memories), its availability, and its acceptance across nearly every level of society. Moreover, the relationship is bidirectional, such that developing PTSD is a risk factor for developing a substance use disorder, and having a pre-existing substance abuse problem or substance use disorder is a risk factor for the development of PTSD in all individuals.

Other substances of abuse that are commonly used by individuals with PTSD include benzodiazepines (as these are often prescribed for anxiety), opiate drugs (often prescribed for issues with pain), cannabis products, and illicit drugs. It should be noted that first responders are far less likely to abuse illicit drugs that other individuals.

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Other Challenges Faced by First Responders

People who are first responders are often performance-driven, have high levels of self-esteem, are motivated to do well and get results, and are often very attuned to how they feel they present themselves to others (often referred to by psychologists as high self-monitors). Individuals employed as firefighters, police officers, healthcare workers, etc., may begin to interpret issues with anxiety, flashbacks, feelings of isolation, avoidance, etc., as signs of weakness and may be very motivated to hide these feelings from others.

In many cases, these individuals may internalize their feelings, which can result in their emotional reactions becoming very painful and unsettling for them. This can result in increased feelings of depression, anxiety, and confusion that can lead to resentment and even burnout on the job. If not checked, they may result in additional clinical problems, such as a major depressive disorder and even suicidal thoughts or attempts. Educating first responders about the signs of stress-related issues and the development of trauma- and stressor-related disorders and co-occurring substance abuse can be extremely important.

Some of the symptoms that may occur in first responders are outlined below.

  • Trouble sleeping is often an initial sign of stress in individuals who are first responders. Individuals who begin sleeping significantly less (e.g., five hours a night or less when the person normally slept seven or more hours a night) may be displaying early signs of stress or even PTSD.
  • Problems with isolation, disengagement in relationships, and even expressions of frustration may indicate that the person is beginning to experience stress-related issues.
  • Personality changes, such as uncharacteristic anger, can be a sign that the individual is experiencing increased levels of stress.
  • Issues with fatigue are often early signs that stress is a problem for the person.
  • Giving up activities that the person typically engaged in, such as sports, social activities, spending time with family, etc., may be a sign that the person is experiencing stress and may be using alcohol or drugs.
  • Not being able to feel pleasure is a serious sign that an individual is experiencing significant problems and a sign of a potential psychological disorder.
  • Chronic feelings of detachment, emotional numbness, or being emotionally drained are signs that there may be some serious issue.
  • When an individual begins viewing their use of alcohol as something they need to do, this can represent a serious sign that the person may be experiencing stress and an alcohol abuse issue.
  • Excuses for excessive drinking (e.g., binge drinking, which is defined by APA as more than four drinks for women, and more than five drinks for men, on a single occasion). When people rationalize repetitive binge drinking, such as reporting that alcohol helps them to relax, feel better, unwind, etc., it can be a sign that the person is developing a substance use disorder.

Treatment for First Responders

The terms used to describe the situation where a person has a diagnosis of a mental health disorder such as PTSD and a concurrent diagnosis of a substance use disorder such as an alcohol use disorder is dual diagnosis or co-occurring disorders. In order for any form of intervention to be effective, both disorders must be treated at the same time. Attempting to treat PTSD without addressing the alcohol use disorder will exacerbate both disorders, whereas the same situation will occur if the clinician attempts to first treat the individual’s alcohol abuse issues and not address the symptoms of the person’s PTSD.

The treatment approach in these situations is to use what is termed an integrated treatment program. This specialized program combines specialists from different backgrounds to treat the individual according to their areas of expertise. The specialists are often referred to as a multidisciplinary team, and the team meets to discuss the treatment goals and progress of the individual, and then meets separately with the client to address their specific issues.

The team can consist of physicians, therapists, counselors, volunteers, and other workers who combine their efforts for the benefit of the client. The treatment process begins with an overall evaluation by trained professionals, such as physicians, psychologists, or trained intake workers, to assess the individual at all levels, properly diagnose their issues, and develop an overall treatment program for the person. Then, the multidisciplinary team implements the program, documents its progress, makes any needed adjustments along the way, and follows the person throughout treatment.

Integrated treatment is often a long-term commitment. It is holistic in nature in that it addresses all of the individual’s needs, including their physical, psychological, and social needs. This means that individuals will often be treated with medicines, therapy, social support, and other interventions as identified in the initial assessment. For individuals with alcohol use disorders and co-occurring PTSD, the initial steps of treatment would most likely include the use of a physician-assisted withdrawal management program (medical detox) followed by an intensive aftercare program.

Because it has been empirically demonstrated that Cognitive Behavioral Therapy methods (CBT) are the preferred treatment methods for both PTSD and substance use disorders, some form of CBT will often be the main component of treatment. The use of medications can help the person get through the withdrawal process, reduce cravings, and lessen symptoms like depression and anxiety, but medications do not address the causes and consequences of the person’s co-occurring disorders and cannot prepare them to adjust their behavior in order to address their issues.

Other interventions are extremely useful, including the use of social support groups like 12-Step groups (e.g., Alcoholics Anonymous). First responders often react better to social support groups when the members are other first responders or in similar professions.

Some of the specific goals of treatment for first responders are:

  • Helping the person express their own needs in a manner that does not result in them feeling inadequate or exposed (frequent issues with first responders)
  • The development of a strong social support system, including family members and coworkers that can assist the person
  • An integral part of the social support system should be the person’s family members, potentially strengthened through family therapy
  • The development of interests outside of work, to deal with the stress associated with the intensive nature of their work
  • Continued participation in group therapy and psychoeducation classes to help the individual recognize the signs of traumatic stress and substance abuse

People with alcohol use disorders and co-occurring PTSD need to remain in treatment long enough for them to develop the skills necessary to avoid relapse of either of these conditions. This involves being able to recognize situations that can increase the potential for relapse and understanding the signs of relapse. Treatment should provide individuals with tools to deal with these conditions when they are recognized early in their development, and also allow for the person to easily transition back into the treatment if they feel they need to return based on their own self-assessment or recommendations of supervisors or family members.

Resources for First Responders

  • Employee Assistance Programs (EAPs) often offer referrals or classes to help individuals with high levels of perceived stress or substance abuse issues. These programs can be very helpful, and interested individuals should contact their human resources department to find out about the EPA programs in their organization.
  • The Substance Abuse and Mental Health Services Administration offers a treatment provider locator so individuals can locate treatment options in their area.
  • The PTSD Foundation of America offers useful resources and references.
  • Alcoholics Anonymous may offer local meetings that cater to specific demographics.
  • For individuals with thoughts of self-harm, the National Suicide Prevention Lifeline is available 24/7 at 1-800-273-TALK (8255).