First responders are the initial responders to emergency situations who provide assistance to individuals. First responders can include:
- Police officers
- Emergency dispatchers
- Military personnel
These individuals may be susceptible to a wide range of medical issues and mental health problems, including an increased risk for the development of substance abuse or a formal substance use disorder. Because of the stressful nature of their roles, these individuals often experience extreme stress that may itself trigger a mental health disorder known as post-traumatic stress disorder (PTSD).
The connection between stress associated with being a first responder is often considered to be a significant factor that interacts with other potential risk factors to make these individuals more vulnerable to developing issues with substance abuse and other mental health conditions. In addition, a co-occurring factor that can increase the risk for the development of a substance use disorder is that many individuals employed in these professions typically use alcohol as a means to “blow off steam” or deal with stress. It is not unusual for coworkers in these professions to meet at bars and other places where alcohol is frequently served. As a result, alcohol abuse is often common in many of these professions.
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PTSD and Related Conditions
The link between substance abuse, stress on the job, and PTSD is often considered to be the most significant relationship that makes individuals who are employed as first responders vulnerable to issues with substance abuse. PTSD is a formal psychiatric/psychological disorder that occurs in conjunction with an individual experiencing a traumatic event, directly witnessing a traumatic event, or witnessing the aftereffects of some traumatic event.
The American Psychiatric Association (APA) has developed a list of diagnostic symptoms that are used to diagnose PTSD. Briefly, these symptoms include:
- Reliving the traumatic event by means of flashbacks, vivid memories, dreams, etc.
- Attempts to avoid situations that remind the person of the event
- Anxiety associated with reminders of aspects of the event
- Feelings of detachment
- Issues with mood, motivation, isolation, pessimism, and hypervigilance to potential or imagined traumatic situations
- Cognitive issues
- Difficulty expressing emotions or enjoying things that one used to enjoy
- Self-destructive behaviors that can include substance abuse
When the symptoms have occurred for less than a month following the event, the individual receives a diagnosis of acute stress disorder, and the PTSD-like presentation often resolves. When the individual constantly displays symptoms of PTSD for longer than a month, they are given a formal diagnosis of PTSD. The symptoms can develop relatively quickly following the experience of the traumatic event, or it may take months and, even in some cases, years before they develop.
As a group, first responders express a prevalence of PTSD at a rate between 15 percent and 30 percent, depending on the study and the particular group. Of individuals diagnosed with PTSD, it is generally considered that about 20 percent of these individuals will also have a co-occurring substance use disorder. Thus, because not everyone who experiences a traumatic event develops PTSD and not everyone who develops PTSD will develop a substance use disorder, it cannot properly be stated that experiencing a traumatic event causes one to develop PTSD or that developing PTSD causes one to develop a substance use disorder. Obviously, other factors, including other risk factors, must play a part in the development of these issues.
The research does suggest that one of the risk factors for the development of PTSD is a pre-existing substance abuse issue, and that individuals who are diagnosed with PTSD and express significant issues with re-experiencing the event (e.g., flashbacks, intrusive thoughts, dreams, nightmares, etc.) are at a higher risk to be diagnosed with a co-occurring substance use disorder than individuals who do not express these particular symptoms but are still diagnosed with PTSD.
According to APA, common substances of abuse for individuals diagnosed with trauma- and stressor-related disorders, such as acute stress disorder or PTSD, include:
Specific First Responder Issues
Individuals who are employed in positions where they are first responders to emergency situations that are the result of very traumatic events are often individuals who are self-motivated, performance-driven, proud, and, at the same time, sensitive about their image. Many times, these individuals may interpret their feelings or responses to stress as signs of weakness and may attempt to hide them or deal with them via the use of alcohol or other substances. Often, individuals in these professions are not well practiced at asking for assistance themselves, even though they have spent a good portion of their lives giving assistance to others and taking pride in their ability to help others.
They are often looked upon as very heroic (e.g., firefighters, police officers, people in the military, etc.) because of their unselfishness directed at helping others. At the same time, the nature of the work can often produce issues with depression, burnout, and even resentment. These issues result in significant rates of depression and suicide among those in these groups.
Some specific warning signs of stress-related issues and the development of a substance use disorder that may occur in this group are outlined below.
- The individual becomes isolated. The person may come home after work, isolate, and try to unwind alone. They become indifferent and disengaged in their relationships, and this creates frustration in the relationships. When individuals fail to talk with significant others or coworkers about issues, this can be a sign of escalating isolation.
- Many first responders who begin to develop trauma- and stress-related issues begin having serious issues with sleep. When an individual is sleeping five hours or less per night on a regular basis, this can be a sign that they are under significant duress.
- Outbursts of anger that are uncharacteristic of the person may signify an issue with stress and the potential development of issues with substance abuse. In some individuals, this may represent the onset of depression, which is an increased risk factor for substance abuse and PTSD.
- Issues with negativity, pessimism, distrust, suspiciousness and even cynicism may also represent the onset of depression.
- Exhaustion may be a factor.
- The person may view the use of alcohol as a perceived need. When individuals begin justifying their alcohol use as a means for them to relax, forget issues at work, or help them fall asleep, this is a serious sign that they may be developing a substance use disorder.
- When these individuals find that activities that used to give them pleasure no longer do so, this is a significant sign that the individual may be developing a mental health disorder. Feeling detached, emotionally numb, drained, etc., are signs that one is developing a serious issue that needs to be addressed.
Special Treatment Considerations
When any individual is diagnosed with a substance use disorder and a co-occurring mental health disorder, such as PTSD or acute stress disorder, it becomes essential that these disorders be treated concurrently. It is not possible to successfully treat one of the disorders (e.g., the substance abuse issue) and ignore the other or hold it constant. When individuals have two or more co-occurring mental health conditions, the conditions become intermingled in a manner where they fuel one another and exacerbate the distress associated with them.
The major issue is for individuals in these professions to be able to recognize signs and symptoms that a potential issue with substance abuse or some other mental health condition is developing in one of their coworkers. Individuals should be encouraged to discuss their personal concerns, or concerns regarding a coworker, with their supervisor.
First responders should also undergo periodic physical and mental health checks and be exposed to educational services regarding the signs and symptoms of these conditions as well as the consequences of not treating them. It is far better to err on the side of safety and intervene than to ignore these issues and allow them to worsen.
In terms of the actual treatment approach for first responders who may have issues with trauma- and stressor-related disorders and substance abuse, it has long been determined that Cognitive Behavioral Therapy (CBT) is the preferred method of treating both issues. Medications can be used to assist in the control of the symptoms of these disorders; however, the formal treatment of these disorders is best accomplished by the use of CBT.
Most comprehensive approaches will use a combination of medications and therapy, which will be most likely based on the principles of CBT. CBT attempts to reduce issues associated with PTSD in a controlled setting by helping the individual to reprocess their associations with the traumatic event and deal with the stress associated with the event itself. CBT also addresses irrational beliefs and behaviors associated with substance abuse.
For first responders, CBT can be effectively delivered in a combination of both individual sessions and group sessions where participants can learn from and identify with others in their profession who are experiencing the same issues. According to the book Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbid Disorders, counseling and therapy for individuals with occupational-related stress issues and potential trauma- and stress-related disorders should attempt to:
Help the individual learn to express themselves with compassion for others and their coworkers: As a result, participants focus less on their personal goals. Attempting to maintain an attitude that is less self-centered and one of service to others can assist the individual in experiencing more meaning in their work and help them avoid issues with isolation, pessimism, suspiciousness, etc., that can lead to issues with substance abuse.
Help the individual develop a strong support system that they trust: Often, first responders who are experiencing significant issues with stress and substance abuse become isolated, and this exacerbates their issues. Treatment should establish an open and caring support system for the individual where they can feel free to be honest without feeling vulnerable. Support groups made up of other first responders are excellent for these individuals. First responders should also be able to look to their families and close friends as an additional means of support.
Encourage other interests: First responders need to have lives outside of work. This means they should be involved in activities they found to be enjoyable before they became involved in their profession. Having important activities, goals, etc., away from work can help to counter the effects of stress.
Encourage specialized care: Periodic consultations with counselors and therapists who specialize in treating issues associated with first responders can be a preventative step that can address stress-related issues and substance abuse. These can be educational in nature and help the individual to address any personal issues they face by teaching them stress management, coping skills, etc.
Encourage regular exercise: Maintaining an ongoing program of exercise can also help to reduce the effects of stress and promote healthy sleep.
Most of these occupations, such as police departments, fire departments, etc., have Employee Assistance Programs (EAPs) available for their employees. These programs often provide referral sources, educational sources, and other local resources that can be of assistance. Employees can contact their human resources department to learn more about their own EAP programs.
The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a number of resources for individuals who may have issues with substance abuse. There is a national helpline that can be reached at 1-800-662-4357 (662-HELP).
Individuals who may be at risk to engage in self-harm can get assistance at the National Suicide Prevention Lifeline: 1-800-273-8255 (273-TALK).