breaking the cycle: first responders, trauma, and
TRANSCRIPT
Breaking the Cycle:First Responders, Trauma, and
Substance Use
Anna Lisa De Lima, Ph.D., LMHC, NCC
Learning Objectives
1. Examine how trauma exposure affects first responders from a biopsychosocial perspective for the purpose of developing treatment strategies.
2. Discuss potential barriers to treatment `unique to the first responder culture.
3. Explore evidence-based treatments for trauma and co-occurring disorders effective with this population.
First we need to define three important terms:
•Normal
•Crisis
•Trauma
NORMAL
Equilibrium Homeostasis
Euthymia
Flatline
Crisis
Crisis is the perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms resulting in a state of disequilibrium.
• Perception is what matters
• Intolerable event
• Exceeds coping mechanisms
Characteristics of Crisis
▪It is both danger and opportunity
▪Crisis can provide the seeds of growth and change
▪No panaceas or quick fixes
(Mitchell, 2006)
Transcrisis States
▪Events immediately following the crisis have a large impact on the duration and probability of developing a “lasting injury”.
▪A transcrisis state occurs when unresolved issues from a previous traumatic event resurface because of a current stressor.
▪Transcrisis states are not synonymous with PTSD though all PTSD involves transcrisis states.
What is Trauma?
Individual trauma is an injury resulting from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.
(Substance Abuse and Mental Health Services Agency, SAMHSA, n.d.)
Symptoms of Trauma
• Avoidance of trauma reminders, including memories
• Exaggerated startle response
• Irritability, anger, and other negative emotions
• Flashbacks to the traumatic event
• Distressing dreams and other sleep problems
• Self-blame regarding the traumatic event
Everyone’s experience with trauma is unique. Some people will develop every symptom, while others develop very few.
Predisposing Variables of PTSD
•Degree of threat
•Degree of bereavement
•Speed of onset
•Duration of the trauma
•Potential for recurrence
•Degree of exposure to death and destruction
•Proportion of the community affected
•Degree of moral conflict inherent in the situation
•An invalidating environment
Effects of Trauma
• Attachments and Relationships• Physical Health: Body and Brain• Emotional Responses• Dissociation• Avoidant behaviors including
substance use• Cognition: Thinking and Learning• Self-Concept and Future
Orientation• Long-Term Health Consequences• Mental Health Disorders• Self-harm• Suicide
First Responders and Suicide
•Firefighters have a higher rate of suicidal behavior than the general population.
•An estimated 125-300 police officers commit suicide annually.
(SAMHSA, n.d.)
The Scope of the Suicide Crisis
•2017 US suicides: 47,173
•2017 US suicide attempts: 1,400,000
•Middle age white males have the highest rate
•People ages 15-24 have the highest increase during the past 30 years.
•2nd leading cause of death
•25% of all suicides occur in people over 65 years of age
The Brain and Trauma
•Trauma appears to increase activity in the amygdala.
•Traumatic stress is associated with increased cortisol and norepinephrine responses to subsequent stressors.
•The human brain can be re-wired.
(Koenigs & Grafman, 2009).
Secondary or Vicarious Trauma
• “Experiencing similar symptoms to trauma victims as a result of indirect traumatic exposure via close contact with the survivors”.
• Psychological injury resulting from secondary exposure to someone else’s trauma.
(Brooks et al., 2015; SAMHSA, n.d.)
Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
• Direct exposure• Witnessing the trauma• Learning that a relative or close friend was
exposed to a trauma• Indirect exposure to aversive details of the
trauma, usually in the course of professional duties (e.g., first responders, medics)
Criterion B (one required):• Unwanted upsetting memories• Nightmares• Flashbacks• Emotional distress after exposure to
traumatic reminders• Physical reactivity after exposure to
traumatic reminders
Criterion C (one required):• Trauma-related thoughts or feelings• Trauma-related reminders
Criterion D (two required):
• Inability to recall key features of the trauma
• Overly negative thoughts and assumptions about oneself or the world
• Exaggerated blame of self or others for causing the trauma
• Negative affect
• Decreased interest in activities
• Feeling isolated
• Difficulty experiencing positive affect
Criterion E (two required):
• Irritability or aggression
• Risky or destructive behavior
• Hypervigilance
• Heightened startle reaction
• Difficulty concentrating
• Difficulty sleeping
Criterion F (required): Symptoms last for more than 1 month.
Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational).
Criterion H (required): Symptoms are not due to medication, substance use, or other illness.
DSM-5 PTSD Diagnostic Criteria
Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
• Direct exposure• Witnessing the trauma• Learning that a relative or close friend was
exposed to a trauma• Indirect exposure to aversive details of the trauma,
usually in the course of professional duties (e.g., first responders, medics)
Case Studies
▪Mike▪23 y/o fire fighter without PTSD▪Crisis event at 16 years old▪Transcrisis response following call
Case Study
▪Jack▪60 year old engineer without PTSD▪Crisis event as 30 year old USAF fighter pilot (168)▪Transcrisis response following the 1995 Oklahoma City federal building bombing
Case Studies
▪Jeremy▪11 year old student with PTSD▪Crisis event at 10 years old witnessing assault and subsequent entry into system
What makes First Responders More Prone to Negative Effects from Trauma?
Let’s revisit these three important terms:
•Normal
•Crisis
•Trauma
What makes First Responders More Prone to Negative Effects from Trauma?
•Exposure•Culture•Social climate• Level of job satisfaction• Lack of support or resources• Lack of training •Perception of lack of control•Hiring practices• Innate coping skills
(Corneil, Beaton, Murphy, Johnson, & Pike, 1999; Stanley, Hom, & Joiner, 2016).
Unique aspects
•Firefighters may spend more than one-third of their time with their crews
•Society’s perception of first responders as heroes or villains
•“Highly masculinized” image
•94.9% of firefighters are male and only 5.1% of firefighters are female.
(Chung, Lee, Jung, & Nam, 2015; Haugen et al., 2017; Richardson & James, 2017; U.S. Bureau of Labor Statistics, 2018)
First Responders and Trauma
•85% have experienced symptoms related to mental health issues
• 1 in 3 have received a formal diagnosis of a mental health disorder
•84% said they have experienced a traumatic event on the job
•1 in 5 will suffer from PTSD in their career(IAFF, n.d.; University of Phoenix, 2017)
Historical methods of Coping
•Sitting around the dinner table sharing past experiences
•Senior officers modeled these behaviors
•Use of morbid humor
•Going out for a drink after shift
(Khan et al., 2018; McFarlane & Yehuda, 1996)
First Responders’ Methods of Coping
•Firefighters tend to isolate rather than seek out support
•Their existing support system is imperative in the healing process
•Use of problem-focused coping and wishful thinking
•Use of substances to numb
•Use of behaviors to avoid
(Gulliver et al., 2018; Haugen et al., 2017; Lee et al., 2018; Richardson & James, 2017)
Unhealthy Coping skills for trauma
•Psychological Avoidance
•Behavioral Avoidance
First Responders and Substance Use
Increase in substance use disorders with a history of trauma exposure:
•29% of firefighters engage in alcohol abuse
•10% of firefighters may be currently abusing prescription drugs.
(PR, 2018).
PAIN
AVOID
TEMPORARYRELIEF
CONTINUALUSE
LIFECOMPLICATIONS
• Discomfort/Distress• Physiologicalpain• Psychologicalpain/
distress• Anxietyresponses• Fear,Frustra on,Hurt
(Anger)
• Psychologicalavoidance• Avoidancebehaviors:
• Substances• Food• High-risk
behaviors• Sexualac ngout• Rela onships• Gambling• Overworking• Overspending• Extreme
exercising• Technology
• Posi vereinforcement-physiologicallyandpsychologically
• Avoidancebehaviorprovidesabreakfordistressingsymptoms
• Addic on• Necessarycon nual
usetocreatephysiologicalresponse
• Necessarycon nualusetoavoid/numboutphysiologicalandpsychologicalresponse
• Lifecomplica onsdevelopandincreasefromcon nualuse
• Causeincreaseofpain/distress
M.Dezelic,PhD&G.Ghanoum,PsyD©2015
TheTrauma-Addic onCycle:HowLifeBehaviorsareUsedtoAvoid/ReceivePhysiologicalandPsychologicalResponses
TRAUMA-ADDICTION
CYCLE
Traumaand/orPhysicalPain
Barriers to Clinical Care
• Concerns about clinicians not understanding
• Fear of using the EAP
•Difficulty admitting to experiencing fear or emotions
•Mistrust of the counseling process
•Gender may also play a role in help-seeking behaviors
(Gulliver et al., 2018; Haugen et al., 2017; World Health Organization, n.d.)
Barriers to Substance Abuse Treatment
• Stigma
• Culture
• Difficulty imagining life as “sober”
• Re-integration to life
• Maintenance
• Family resistance to change
• Lack of support
• Need for anonymity (reluctance to attend meetings)
• Fear of job loss
Treating first Responders
•Tap into their innate coping skills
•They have difficulty with maintaining attention and concentrating
•Use concrete ideas and facts as a means of developing rapport
•Understand and normalize
(Lee et al., 2018)
UNIQUE ISSUES WITH RETIREES
This issue of brain chemistry and emotional dysregulation is heightened in retirement: Retirees often experience anhedonia.
Loss of identity, crew/family, support system, and sense of purpose.
Treatment for PTSD and the Effects of Trauma
•Multiphasic/multimodal treatment
•Psychotropic medication
Treatment of SUDs
• Individual therapy and group therapy
•12 step programs (Alcoholics Anonymous/Narcotics Anonymous/Celebrate Recovery)
•Non 12 step programs (Smart Recovery)
•Medication management
Important to successful therapy
•Therapeutic alliance is integral
•Explain confidentiality
•Take time to understand their culture
•Direct communication
Treatment Goals
Education on:
•Hypervigilance
• Impact of stress
•Posttraumatic responses
•Family system
Treatment Goals cont’d
•Explore character & values
• Identify and replace cognitive distortions
•Recognize what a balanced lifestyle looks like
•Healthy use of innate coping skills
Growth from trauma
Posttraumatic Growth (PTG):Is positive change experienced as a result of thestruggle with a major life crisis or a traumatic event.
(Kehl, Knuth, Hulse, & Schmidt, 2014; Tedeschi & Calhoun, 2004)
Growth from trauma
Characteristics of PTG: • Greater appreciation of life• Changed sense of priorities• More intimate relationships• Greater sense of personal strength• Recognition of new possibilities or paths for one's life and
spiritual development.• Increased resilience
(Kehl, Knuth, Hulse, & Schmidt, 2014; Tedeschi & Calhoun, 2004)
What makes growth after trauma more likely?
•Possessing certain identified characteristics
•Receiving organizational support
•Processing the trauma
•Protective factors
•IE: SUPPORT, SUPPORT, SUPPORT(Sattler, Boyd, & Kirsch, 2014; Tedeschi & Calhoun, 2004).
▪Social support
▪Coping skills
▪Physical health
▪Sense of purpose
▪Self-esteem
▪Healthy thinking patterns
Questions?
References• American Psychiatric Association. (n.d.). What Is addiction? Retrieved from https://www.psychiatry.org/patients-families/addiction/what-is-addiction
• American Society of Addiction Medicine (ASAM). (n.d.). The ASAM criteria. Retrieved from https://www.asam.org/resources/the-asam-criteria/about
• Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behaviour Research and Therapy, 42(10), 1129–1148.
• Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C., … Foa, E. B. (2002). Trauma Screening Questionnaire. PsycTESTS. https://doi-org.ezp.waldenulibrary.org/http://supp.apa.org/psyctests/supporting/999904710/aagbaqhv71ga.html
• Brooks, S. K., Dunn, R., Amlot, R., Greenberg, N., & Rubin, G. J. (2016). Social and occupational factors associated with psychological distress and disorder among disaster responders: A systematic review. BMC Psychology, 4(18). https://doi.org/10.1186/s40359-016-0120-9
• Chung, I., Lee, M., Jung, S., & Nam, C. (2015). Minnesota multiphasic personality inventory as related factor for posttraumatic stress disorder symptoms according to job stress level in experienced firefighters: 5-year study. Annals of Occupational & Environmental Medicine, 27(1), 1–6. https://doi-org.ezp.waldenulibrary.org/10.1186/s40557-015-0067-y
• Corneil, W., Beaton, R., Murphy, S., Johnson, C., & Pike, K. (1999). Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries. Journal of occupational health psychology, 4(2), 131.
• De Lima, A., (2020). Measuring levels of posttraumatic growth in firefighters. (Unpublished doctoral dissertation). Walden University, Minneapolis, MN.
• Dezelic, M. & Ghanoum, G. (2015). The trauma-addiction cycle: How life behaviors are used to avoid/receive physiological and psychology responses. Retrieved from https://www.drmariedezelic.com/trauma-addiction-cycle
• Ehlers, A. (2013). Trauma-focused cognitive behavior therapy for posttraumatic stress disorder and acute stress disorder. In Simos, G., & Hofmann, S. G. (eds). CBT for anxiety disorders: A practitioner book (pp. 161-190). New York, NY: Wiley.
• Gulliver, S. B., Pennington, M. L., Torres, V. A., Steffen, L. E., Mardikar, A., Leto, F., … Kimbrel, N. A. (2018). Behavioral health programs in fire service: Surveying access and preferences. Psychological Services. Retrieved from: https://doi-org.ezp.waldenulibrary.org/10.1037/ser0000222.supp
• Haugen, P. T., McCrillis, A. M., Smid, G. E., & Nijdam, M. J. (2017). Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis. Journal of Psychiatric Research, 94, 218-229. doi:10.1016/j.jpsychires.2017.08.001
• International Association of Firefighters (IAFF). (n.d.). Retrieved from https://client.prod.iaff.org/
• James, R., & Gilliland, B. (2013). Crisis Intervention Strategies, 7th Edition.
• Khan, K., Charters, J., Graham, T. L., Nasriani, H. R., Ndlovu, S., & Mai, J. (2018). A case study of the effects of posttraumatic stress disorder on operational fire service personnel within the Lancashire fire and rescue service. Safety and Health at Work, 9(3), 277–289. https://doi-org.ezp.waldenulibrary.org/10.1016/j.shaw.2017.11.002
• Kehl, D., Knuth, D., Hulse, L., & Schmidt, S. (2014). Posttraumatic reactions among firefighters after critical incidents: Cross-national data. Journal of Aggression, Maltreatment & Trauma, 23(8), 842-853. doi:10.1080/10926771.2014.938143
• Koenigs, M., & Grafman, J. (2009). Posttraumatic Stress Disorder: The Role of Medial Prefrontal Cortex and Amygdala The Neuroscientist, 15 (5), 540-548 DOI: 10.1177/1073858409333072
• Lee, J. H., Park, S., & Sim, M. (2018). Relationship between ways of coping and posttraumatic stress symptoms in firefighters compared to the general population in South Korea. Psychiatry Research, 270, 649–655. https://doi-org.ezp.waldenulibrary.org/10.1016/j.psychres.2018.10.032
References Cont’d
• Linehan, M. (1993). DBT? Skills training manual. Guilford Publications.
• McFarlane, A.C. & Yehuda, R. (1996). Resilience, vulnerability, and the course of posttraumatic reactions. In B.A. van der Kolk, A.C. McFarlane & L. Weisaeth (Eds.), Traumatic stress: The effect of overwhelming experience on mind, body, and society (pp. 155-181). New York: Guilford.
• Mitchell, J. T., & Everly, G. S. (2006). Critical incident stress management (CISM): Group crisis intervention. Fourth Edition, Revised. Ellicott City: Chevron Publishing Corporation.
• National Center for PTSD. (n.d.). PTSD: National center for PTSD. Retrieved from: https://www.ptsd.va.gov/professional/assessment/screens/span.asp
• PR, N. (2018, May 17). Recovery centers of America launches groundbreaking program to help first responders overcome substance use disorders. PR Newswire US. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=bwh&AN=201805170800PR.NEWS.USPR.PH98469&site=eds-live&scope=site
• Richardson, B. K., & James, E. P. (2017). The role of occupational identity in negotiating traumatic experiences: the case of a rural fire department. Journal of Applied Communication Research, 45(3), 313–332. https://doi-org.ezp.waldenulibrary.org/10.1080/00909882.2017.1320573
• Substance Abuse and Mental Health Services Administration (SAMHSA). (2018). First responders: Behavioral health concerns, emergency response, and trauma. Disaster Technical Assistance Center Supplemental Research Bulletin. Retrieved from https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf
• Sattler, D. N., Boyd, B., & Kirsch, J. (2014). Trauma-exposed firefighters: Relationships among posttraumatic growth, posttraumatic stress, resource availability, coping and critical incident stress debriefing experience: posttraumatic growth. Stress and Health, 30(5), 356–365. https://doi.org/10.1002/smi.2608
• Shapiro, F., & Forrest, M. S. (2016). EMDR: The breakthrough therapy for overcoming anxiety, stress, and trauma. Basic Books.
• Stanley, I. H., Hom, M. A., & Joiner, T. E. (2016). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and paramedics. Clinical Psychology Review, 44, 25–44.
• Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1-18.
• University of Phoenix Survey Finds Majority of First Responders Have Experienced Symptoms Related to Mental Health Issues. (2017). Mental Health Weekly Digest.
• Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2014, February 5). PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD. Retrieved June 3, 2015, from http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
• Weathers, F. W., Litz, B. T., Herman, D., Huska, J., & Keane, T. (1994). The PTSD checklist-civilian version (PCL-C). Boston, MA: National Center for PTSD. Try it yourself: http://traumadissociation.com/pcl5-ptsd
• World Health Organization (WHO). (n.d.). Gender disparities and mental health: The facts. Retrieved from https://www.who.int/mental_health/prevention/genderwomen/en/
Anna Lisa De Lima, Ph.D., LMHC, NCC
Program Director
Hanley Center at Origins
(561)-841-1003