Developing an effective care plan for first responders’ mental wellness
There are three common elements that can drive the best outcomes
As a trauma psychologist who specializes in military and first responder wellness, I’m often asked, “What is your ideal treatment plan for a typical first responder?”
My beliefs are shaped by these three core philosophies:
- There is no “one size fits all” treatment plan for any individual or group. Treatment decisions must be based on a thoughtful evaluation of each individual and the challenges he or she faces.
- Treatment is best delivered by coordinated teams that are free of ego-driven decision-making. The best teams offer treatments across disciplines and work together to get people the best possible outcomes.
- The most effective treatments for first responders often involve a strategic fusion of biological, psychological and peer support interventions.
These are the three common elements that have driven the best outcomes I’ve seen with the first responders I’ve treated.
The first component: Comprehensive assessment & biological intervention
If I were to design a decision-making process for “best practice” treatment for first responders, I would start with a thoughtful evaluation. The evaluation would be comprehensive and include both physiological and psychological assessments.
This evaluation would occur routinely within first responder departments, with the goal of eliminating the stigma around seeking support. This model has been tested in the military with required annual visits with an embedded behavioral health provider. When everyone goes to the doc, no one feels singled out.
This evaluation would be conducted by a trusted entity operating outside the first responders’ department. Evaluators would not be required to report back to department leadership on the specifics of any individual case but would be accountable for providing feedback on what treatments they’ve delivered across individuals on a quarterly basis.
As part of the assessment, this question would be asked: “Could this first responder benefit from an innovative biological treatment that has been a go-to intervention among special forces operators?” This intervention, the “dual sympathetic reset” (DSR), is an advanced version of a procedure called a stellate ganglion block. DSR is clinically indicated for several symptoms common within both the special forces and first responder communities:
- Chronically disrupted sleep
- Sudden surges of irritability or anger
- Floods of anxiety or panic attacks
- Continual hypervigilance
- Difficulties concentrating
- An acute startle response to surprising stimuli
These symptoms are the result of repeated trauma exposure. They indicate a state of “chronic threat response” where the fight-or-flight system gets locked into the “on” position. This response is a normal, common occupational outcome for both special forces operators and many first responders. Of all the military populations I’ve treated, the special forces operators are the most like first responders. This similarity comes from the rhythm and cadence of their “high-velocity” or “high-trauma” exposures.
A common element among “protectors and defenders’’ is to travel back and forth between two different worlds, with different rules, norms and expectations. However, a war zone deployment of many months or more than a year is different from a succession of brief deployments interspersed with homecoming adjustments. In other words, special forces operators and first responders toggle between two worlds within short time frames. Many first responders have a kind of “emotional whiplash” from seeing the worst in humanity on a daily basis as they work to be open, relaxed, loving partners and parents.
DSR involves injecting a routinely used anesthetic medication into two clusters of nerves in the neck that are associated with the fight-or-flight system. The medication is non-psychoactive. It does not remain in the body, nor does it cause an individual to test positive on an employment drug screening. The treatment takes 15–20 minutes and is delivered in an outpatient setting. It is a no-stigma medical intervention based on the neuroscience-informed perspective that repeated trauma exposure causes an injury that can be healed with DSR, a biological intervention.
Research shows DSR is highly effective. In a sample of 327 individuals, 83% achieved a clinically significant outcome, and the average decrease in symptom severity was nearly 30 points on the PTSD Checklist for DSM-V (PCL). For context, a 10-point drop on the PCL is defined as a “clinically significant positive outcome” by the National Center for PTSD.
If someone has an overactivated fight-or-flight system, treatment with DSR is often a critical component of healing. DSR targets the loss of control that can otherwise lead to a full-blown mental health crisis. Special forces operators and first responders are also alike in their personality “wiring.” They are trained to exert a high level of control over their bodies and minds. They are calm within the chaos of natural and human-made disasters. However, over time, trauma exposures will alter their ability to retain control within their own bodies. An individual with the target symptoms identified above will often feel helplessness and a loss of emotional and physical control. This can be dangerous if it leads to the sense that one has become a liability at work or at home. Restoring calm and control can be critical for preventing suicide among first responders.
DSR is not clinically indicated for individuals who have a metal plate in their neck that covers the injection site...”
Not all first responders are candidates for this treatment. DSR is not clinically indicated for individuals who have a metal plate in their neck that covers the injection site (e.g., from a past surgery); an active psychotic process (loss of touch with reality) is also a poor fit. For those who are a good fit, DSR is like “primer to the paint” of other treatments. Those who are calm in their own bodies are mentally present for therapy and can integrate new thinking and behavior in a deeper, more permanent way. In this way, biological treatment with DSR paves the way for optimal outcomes, accelerating and enhancing an individual’s healing experience.
This is why, as a psychologist, I actively promote this biological treatment. In treating first responders across more than 100 departments, the best outcomes have come from collaborating with physicians who deliver this powerful intervention – a procedure long-used and well-tested in the special forces population. And this is why I helped cofound Stella, the national organization with more than 40 clinics across the United States that offers the dual sympathetic reset to those who can benefit from treatment.
The second component: Psychological intervention
The second critical component in an ideal treatment model would be psychological intervention. Repeated trauma exposures cause not only biological injuries to our fight-or-flight systems but also change our thinking and behavior.
First responders would ideally be connected to such providers before experiencing acute symptoms. In practice, what often happens is that connection to therapists occurs in the context of a crisis. This is not ideal. Think about it this way: Imagine you were in a bar brawl. At the end of the fight, you discover your mouth is full of blood, and you’ve lost several teeth. Would this be a good time to find a competent dentist? Wouldn’t it be much better to have a trusted dentist on standby in this scenario? Getting connected to a good doc in advance of the need for their services works the same way. Establishing this connection can give first responders rapid access to a trusted professional.
Cultural competence is essential to this part of treatment. Any provider who has gained the trust of first responders has learned that self-destructive thoughts and urges are actually very common in this population. Just as medical school students begin to wonder whether they have any of the diseases they learn about, anyone who witnesses death, particularly death by suicide, among colleagues or civilians is more likely to be visited by thoughts of death themselves.
First responders need their docs to have a deep understanding of how suicidal thoughts emerge and progress over time. For example, in the field of psychology, we often treat suicidality as though it were fairly uncomplicated: Either you have a wish to die, or you don’t.
Is it possible for someone to have a fear of death and be deeply suicidal at the same time? Yes! I’ve seen this puzzling phenomenon often with the first responders I’ve treated. At one level, people may not want to die. They may even have a terrifying fear of death. Yet, at another level, they may feel relentlessly haunted by their demons. When the voice of despair is strong, it creates the feeling that suicide is the only logical solution.
Here is a related critical point: A first responder may never feel suicidal when he or she is off work. They may never actively form a plan to take their own life. That person may even talk to their therapist about a fear of death, which may lead a therapist to assume that the patient has a strong will to live. If that therapist had gone down the path of asking, “Do you have any suicidal thoughts?” the first responder would have said “no.”
Yet, in fact, a first responder can still be deeply suicidal. He or she can be in so much pain, and in such an altered state of mind, that he or she has no conscious awareness of how dangerously suicidal he or she has become.
Suicide is the threat in the blind spot of many of our warriors and first responders. They are intensively trained to focus on external threats and socialized to act like invulnerable “heroes.” As a result, it becomes difficult for many of them to perceive how deeply dangerous the internal voice of despair can become. Sometimes what masquerades as “heroism” on the job is actually the manifestation of a death wish – a desire to flip the script of a death-by-cop suicide plan.
For these reasons, first responders benefit from being connected to trusted experts who understand the threats in their blind spots.
The third component: Peer support
The final component of the ideal treatment framework is peer support. Asking, “Is peer support or professional support more effective?” is the wrong question. Professional support and peer support bring complimentary benefits for healing. When both are used in combination, individuals often get their best outcomes.
The nature of some challenges makes peer support especially important. For instance, when first responders suffer from survivor guilt or a moral injury, the most powerful approach is a communal intervention. The power of a group to release the sufferer from these afflictions is greater than the power of one-on-one therapy in many cases. This is because these challenges create intense feelings of shame. Shame is an emotion that is best dissipated by a healing group experience. Belonging within a group and normalizing a shame-based trauma are antidotes to these challenges.
There are options for safe circles of peers through organizations like the First Responder Support Network. These peer-led groups are run outside departments to offer the confidentiality and safety first responders need. The First Responder Support Network also hosts a high-quality retreat called the West Coast Post Trauma Retreat that is staffed by both peers and professionals. Their approach integrates the understanding that meaningful collaboration across providers and using multiple treatment modalities – biological, psychological and peer support – will often lead to the best outcomes.
Chicago Police Marines: An organization devoted to supporting Chicago Marine police officers,
F1RST: An organization that provides comprehensive and evidence-based training and therapeutic programming for first responders and their families.
- First Responder Support Network – For confidential peer support groups
- First Responder Wellness – An inpatient and intensive outpatient program for first responders
- Next Rung – An advocacy organization supporting first responders
- Premier First Responder Psychological Services: An organization that offers behavioral health, peer support development, and crisis response services.
- Stella – Biological treatments for trauma symptoms
- West Coast Post-Trauma Retreat – Retreats for first responders led by peers and professionals
- The Wounded Blue – An advocacy organization supporting police officers