3 Types of Trauma for First Responders - How You Can Help (Or Not)

When I attended the conference in Baltimore on Stress and Trauma, I heard quite a few stories about the bonds that form between first responders and the people they help. From almost every major incident that these first responders described, there were always inspiring stories about how a responder who saves a child or adult winds up forming a relationship with that person. Trauma survivors and their helpers wind up going to memorial services and anniversary events, particularly in the case of the Boston Marathon Bombing (where there were so many people who were helped by so many different police officers) and sometimes this bond can last for years. These bonds turn out to be quite healing for the first responder. 

In some of the breakout presentations, the presenters talked about providing counseling services for trauma survivors for up to two years following a major event. Other advice included allowing widows of first responders who die in action to move on: They may not want to go to memorial/remembrance services two and three years beyond the date of the actual event. This advice also included: Allowing loved ones to see the dead body - if they insisted on it - even if it needed to be covered up. Having food, water and other necessities for grieving loved ones and even being willing to have compassion for an angry spouse who isn't so happy with their spouse's career choice now that that spouse is no longer with them. As a bit of an outsider to this group, I was impressed by how many complex problems these peer counselors have to deal with that few, if any, other professions EVER have to even THINK about.

Another method for helping first responders and trauma survivors was discussed by Dr. Lisa Compton, who shared her research about using "emotional distancing" as a way to prevent PTSD. She described emotional distancing as the half-way point between the kind of connection you often experience with a compassionate nurse, (who all too often - by offering this kind of special care - winds up suffering from compassion fatigue) and an overly detached doctor who is all too often described as NOT having very good bedside manners. Her research, which she reported on in a breakout session, indicates that there is a sweet spot in between these two positions that actually helps prevent PTSD and secondary exposure to trauma which is their term for compassion fatigue.

She started her talk by describing three types of trauma. First there are those victims who experience the trauma directly. The people who were injured by the two blasts at the Boston Marathon are examples of this primary form of trauma. While this victim's trauma is GREAT, his or her exposure is limited and therefore sometimes this can be a helpful factor in keeping PTSD problems at bay. The event happens and it's over within seconds. (We need to constantly remind ourselves here that despite the horrific nature of a traumatic event, statistically speaking, the vast majority of people who experience trauma don't go on to experience PTSD.)

Then there are those who WITNESS the trauma. At the Boston Marathon there were 844 police on duty and many were within a few yards of the victims. So cops and first responders experienced this secondary form of trauma. While they don't experience the trauma first-hand, (none were injured directly) they SEE it up close and personal. When this secondary exposure to trauma is prolonged (like the officers who had to stand watch over the body of a dead boy overnight) and the trauma involves children, and involves multiple exposure to trauma (over the course of the event or an entire career), it all has a cumulative effect on how well these officers handle the trauma. Even their own childhood history with trauma can contribute to the emergence of PTSD up to thirty years after the trauma is over. (Vietnam Vets have been known to develop PTSD symptoms decades after their service.)

 Then there was a third type of trauma that Dr. Compton mentioned that I'd never heard of before. For the people who attended this conference, it was a major concern. As trauma counselors, they hear lots and lots of tales of trauma third-hand. They don't experience the trauma first-hand, they often don't even see it to experience it second-hand, but they spend hours and hours listening to people who have seen it or experienced it (usually) second-hand. So this cumulative third-hand exposure adds up too (because after a major event they do hours and hours of counseling) and this form of third-hand trauma can do just as much, if not more psychological damage as the first two types.

Dr. Compton's presentation was primarily about how to prevent damage from these secondary and tertiary forms of trauma. Her research seems to indicate that the ability to maintain a "balanced emotional separation," or hitting that sweet spot between being too caring and not caring enough, is an effective way to prevent PTSD from becoming an issue down the line. Obviously, you don't want to become the detached doctor (when helping people with firsthand or second hand exposure to trauma) with no bedside manners, but, as she put it: "You're balancing the ability to provide empathy with protecting your own heart."

So rather than do self-care (practicing stress management techniques) which, as a first responder herself, she admits: "nobody does, you can focus on maintaining emotional separation." She developed a self-test to see how well first-responders did at maintaining this healthy emotional distance. And her study showed that the ones that scored higher on the test and were able to maintain this healthy distance were also less likely to have issues with PTSD, later on. Given the limited options available to first responders, her conclusion was that teaching them the basics of how to maintain this distance would go a long way in helping them avoid PTSD.

She also talked about the trauma exposure you can control and that which you can't control. "I recommend trauma exposure only for the purpose of healing." She hears traumatic stories as part of her job but she limits the trauma she is exposed to by TV news and other media sources. "I don't watch TV news, read scary novels, or go to movies with a lot of blood and violence. I see enough of that as part of my job. And what's on the internet is either the Kardashians or trauma! What can I do to decrease my risk? I control the images that I see because it all adds up." She is echoing what I've been saying all along about stress for years: it's cumulative.

The American Group Psychotherapy Association offers the following advice for first responders who want to avoid having secondary issues with trauma:

• Self Care - Make sure first responders are meeting their own basic needs as an incident unfolds: sleeping, eating, hydrating and taking downtime for activities such as music, exercise and prayer.
   
• The Walk-Around - Someone needs to be on the ground offering a supportive presence and monitoring responders' emotional state. This may be a peer, chaplain or officially sanctioned service member. Eyes and ears on the ground can make a difference.
   
• Buddy Care - With their "Band of Brothers" mentality, first responders may likeliest respond to an informal inquiry about how their buddies are doing. They may be more open to sharing with one another and more attuned than an outsider to their peers' emotional state.

Teaching people how to manage stress is surprisingly effective, according to Compton's research in preventing problems with trauma. This is what she and The American Group Psychotherapy Association refer to as "self-care." The trouble is, as Compton observes, most first responders just don't do it. I even noticed this attitude toward managing stress sitting at our exhibit booth at the conference. While most of the first responders attending this conference were open-minded enough to understand the importance of managing stress, several walked by our table and openly scoffed at the idea of practicing stress management.

This reminded me of the time I was putting on a stress management program for a group of (mostly male) FBI recruits at the Marine Corp Base in Quantico, Virginia. The FBI officer who hired me warned that "this is probably the toughest group you'll ever have to face. If you can train these guys you can train anybody." It happened to be my first paid public speaking engagement. And yes, teaching these guys was a bit like teaching a class full of 7th grade boys! One of the especially rambunctious new recruits (who happened to be a former cop) raised his hand and announced: "You want to know how I manage stress? I beat the crap out of somebody." That remark got a big laugh from that macho culture.

And that's the problem in a nutshell. You've got a macho culture that doesn't really practice self-care and doesn't take stress management seriously and doesn't want to admit when they are hurting. You've got a profession that gets exposed to a lot of trauma and 8 to 30% of all trauma victims go on to experience psychologically debilitating effects of PTSD which can include flashbacks, severe insomnia, anxiety episodes, depression, suicidality and difficulties managing anger. On top of all that you've got one technique, Critical Incident Stress Debriefing that is the main weapon in the arsenal of these peer counselors and nobody is sure if it really works or not. So perhaps techniques like emotional distancing, mindfulness, cognitive restructuring and really getting people to practice stress management need to be looked at more carefully as important alternatives for helping people deal with trauma.