First Responders Essay

First responders have different challenges compared to the rest of the population. The challenges are due to the motto’s they swear to uphold and the public they serve. They have their own culture consisting of beliefs, language, traditions and values that are specific to their group. They are more likely to witness traumatic events that are outside the norm. They are sometime expected to kill and even be killed, especially law enforcement and military. The culture is very different then the civilian or mental health culture, for example: collectivism versus individualism. Therefore, when it comes to building a relationship with combat veterans and first responders it is essential to understand the culture. Lastly, there are common diagnosis among first responders making it important to use specific assessments. These assessments are used to identify trauma and stress related disorders such as: Post Traumatic Stress Disorder (PTSD), Acute Stress Disorder (ASD), Generalized Anxiety Disorder (GAD), Depression, and Substance Use Disorder (SUD).

Culture

The culture of first responders such as: Combat Veterans, police officers, EMTs, Firemen, and Emergency Room staff are unique from other occupations. The reason is the magnitude first responders are

exposed to traumatic situations. They are also in a profession where they are viewed as being in control, keeping the public safe, and upholding the law creating more occupational stress. The nature of the job exposes them to high stress situations requiring them to be in danger and/or to be responsible for saving lives. First responders and combat veterans “often experience stressful and traumatic incidents on a daily basis, and sometimes several times per day” (Cross & Ashley, 2007, p.26). This frequency and types of events are not normal for the average person; therefore, they develop acute and chronic effects on the emotional, physical, and psychological well-being (Cross & Ashley, 2007). With the expectation of these professions to remain calm and collective with no room for error can cause distress from cognitive distortion and suppressing emotions. This is beneficial to help them survive, but having the emotional regulation to transition after the event is over is necessary. Some of the things they will do after a stressful event are avoidance and stuffing emotions, instead of being encouraged to seek help as soon as possible (Cross & Ashley, 2007).
The culture could be seen or described as an emotional rollercoaster. Meaning that they have somewhat of a sedentary time on the job where it is low stress and in an instant have to go to a high stress environment. This can also make them crave the adrenaline rush and not be content in mundane everyday situations. Moreover, first responders are more likely to drink alcohol and binge drink to ease anxiety and suppress emotions. Furthermore, they must maintain high expectation to the community, loved ones, and employing agency. They must be prepared to conscientiously and continually react, respond, serve, and protect (Cross & Ashley, 2004). There is a slight difference in all the branches of service as well as the different first responders, because their mission is different.
The elements of a military warrior culture are: discipline professional ethos, ceremony, etiquette, and cohesion.

There is also an element of subculture such as: types of unit, branch, war fighting community, and special operations (Hsu, 2010). The basic tenets of the military culture are “duty, honor, country”; discipline; hierarchy; and prioritizing group over the individual (Hsu, 2010). The military law requires members to demonstrate virtue, honor, patriotism, and subordination at all times even off duty (Hsu, 2010). The terms used to describe military life are: uniformity, anonymity, depersonalization, expendability, hard work, boredom, teamwork, camaraderie, stoicism, loneliness, trust, and orderliness (Hsu,

2010).
Best Practices
There are several best practices for establishing a relationship with a first responder/combat veteran. First, there are a few guidelines to practice when establishing a relationship with this client group. The first is to be educated regarding the culture, so that they feel understood and are not re-traumatized. This also means to have knowledge of terminology/language that they use. If a counselor has to stop and ask what a rank or word is during treatment it can take away for the relationship. Some clients may get frustrated if the therapist does not understand the differences between warrior culture and mental health culture and underutilize mental health services. The military culture is also taught that they are stronger and separate then the civilian population as well. Therefore, if the counselor shows interest and understanding about military life it will increase rapport and respect.
When establishing a relationship the therapist needs to understand how each individual soldier feels about the combat they were in. Some may have wanted to return to war and have a hard time relating to normal routines and family life. Therefore, they may not want to talk about the trauma but about their relationship with their spouse, children or how they were passed up for promotion. It is also important for the therapist to not be afraid to hear what the client has to say regarding personal life and experiences. Additionally, combat veterans may have felt helpless or participated in a heinous act that once out of the war zone no longer fit into their understanding. They may need help realizing they did what they were trained to do for the greater good of their country.
Important strategies to use when treating first responders and combat veterans are: providing a safe environment that normalize symptoms; stress-management, psychoeducation on effects of compassion fatigue; and understanding trauma (Cross & Ashley, 2007).Therefore, it is important to provide a safe therapeutic environment that is free of judgment. This means explaining client confidentiality rights, so that they can be open and honest about their presenting problems. Many clients will have a fear that they will be unfit for duty if they are labeled with a diagnosis such as MTBI and PTSD (Ruzek, et.al., 2015). Additionally, this may be accurate as they can be medically discharged from duty. Some have been debriefed and were judged or criticized and view seeking help as a failure, therefore understanding their journey to seek help will be beneficial in developing the relationship (Ruzek, et.al., 2015). Lastly, the best practice is to actively listen and acknowledge their fears and worries in order to empower them and collaborate in the treatment process (Ruzek, et.al., 2015).When building the relationship it is important to acknowledge skills that were attained during service; honor the relationships made during service; move them towards identity integration; and foster communication with values by gaining awareness (Hsu, 2010).
Screening Assessment Criteria
There are a few screening assessment criteria used for first responder/combat veterans. First, it is important to determine if they had a potentially traumatic event (PTE) and this is going to be subjective. This is because what is a traumatic experience to one person may not be to another. It is necessary to address traumatic stress symptoms and trauma-specific disorders, because it could cause poor engagement in treatment, early termination of treatment, and lead to relapse of substance use (NCBI, 2014). It is also imperative to remember that clients who have experienced trauma can have symptoms that relate to other disorders (NCBI, 2014). Therefore, early screening and identification can improve treatment outcome, because it determines the nature of the clients’ problem. Establishing a first responders’ baseline during assessment is important to make an accurate diagnosis, because everyone processes trauma differently. The areas that are measured and assessed are impairment in life functioning such as: occupation, family, and health (Cross & Ashley, 2007). There are a variety of clinical symptoms that are assessed as well to include: mood, anxiety, somatoform, sleeping disorders, self-injurious behavior, and eating disorders (Cross & Ashley, 2007).
The best screening assessments are trauma informed screenings to identify trauma related symptoms. The common criteria to assess are: “trauma-related symptoms, depressive or dissociative symptoms, sleep disturbances, and intrusive experiences; past and present mental disorders, severity of a specific trauma (combat experience); substance abuse; social support and coping styles; availability of resources; risks for self-harm, suicide, and violence; and health screening” ( NCBI, 2014, para 6). One screening assessment that can be used for first responders and combat veterans is the Patient Health Questionnaire (PHQ) and the PHQ GAD, which is a questionnaire that relates to criteria in the Diagnostic Statistic Manual (DSM) for Generalized Anxiety Disorder (GAD) (Ghafoori, Neria, Gameroff, Olfson, Lantigua, Shea, & Weissman, 2009). A great question to ask is: “Over the last 4 weeks, how often have you been bothered by feeling nervous, anxious, on edge or worrying a lot about different things” (Not at all, several days, more than half the days)” Ghafoori, et.al., 2009, p. 220). The screening assessment criteria that is used is Criterion C of the DSM-5 such as: restlessness, easily fatigued, difficulty concentrating, irritability, trouble falling asleep or staying asleep (Ghafoori, et.al., 2009). Another assessment is the PTSD Checklist and to assess for somatic symptoms. The PTSD screen asks four questions to aid in detecting PTSD (Jones, Young, & Leppma, 2010). Combat soldiers may also need to be assessed for Mild Traumatic Brain Injury (MTBI) because it has some of the same symptoms as PTSD such as: concentration problems, irritability, and intrusive memories (Jones, et.al., 2010). It is also necessary to assess if there are other reasons interfering with a clients’ ability to recover such as non-event stressors to include marital problems (Jones, et.al., 2010). The assessment questions for MTBI is: “were you hit in the head?” or “Did you ever lose consciousness” (Jones, et.al., 2010)?
The assessment is essential for planning treatment goals and to continue conducted assessment throughout the treatment process. This is important to make any changes and to evaluate the effectiveness of treatment. Unfortunately, the emergence or aggravation of mental health conditions may occur at higher rates for first responders, because of the occupational stress (Rutkow, Gable, & Links, 2011). Lastly, they need to be assessed and regularly screened for stress and trauma related disorders, depression, and suicide. The common questionnaires are the occupational stress exposure and the Trauma Screening Questionnaire (TSQ) (Rutkow, et.al., 2011). It is best if they receive excess to screenings in order to get timely treatment. The screenings for first responders need to be done before, during, and after trauma and emergencies (Rutkow, et.al., 2011).
Conclusion