Does your organization have a plan for the psychological, physical, and financial effects of stress? Are all personnel in your organization, especially management, aware of, and do they understand, the latest research concerning the effects of stress? Are they even aware of the proven devastating short- and long-term effects of stress? Doing something about stress, becoming proactive, must be done on an organizational and an individual level.
Many organizations can see only an injury’s physical effects and are not able to recognize the mental or psychological aspects and their hidden costs to the organization and, worse, the toll it takes on an organization’s greatest resource, the employees. The old Ostrich theory applies: If it’s unseen, it can’t be there. The profound effects of stress can be invisible, at least until one becomes aware of the signs and symptoms.
Hiring a new employee today is not a simple matter that involves automatically hiring the boss’s nephew. The hiring process today is long and involves many aspects-interviews, reference checks, physicals, background information, drug screenings, and a lengthy period of comprehensive orientation and training. Even a small employee turnover could be disastrous to an organization. Constant turnover means a continued stream of new employees, leaving a dwindling numbers of older, more experienced staff members. Without a strong experienced base, an organization could likely be unable to continue providing effective service.
One by-product of stress is burnout. Burnout in its least destructive form may cause an employee to leave an organization prematurely. But, if that employee stays on long after the effects of burnout, reactions such as negative attitudes and abuse of sick leave could create unhappy coworkers and have devastating effects on the rest of the organization. The financial costs and hidden by-products of stress could cripple an organization.
Since fire departments encounter high amounts of stress daily, the command staff is responsible for providing a reasonably safe, healthful environment. Every effort should be made to teach the effects of stress early in the career, at the academy, for example; provide stress support during stressful situations; and offer peer and professional support from within the organization as well as from the outside.
STATISTICS
The statistics concerning the effects of stress being reported today are staggering. It has only been within the past decade or so that the effects of stress have actually been tallied.
• Stress is America’s #1 health problem. Forty-three percent of all adults suffer adverse health effects caused by stress. Seventy-five to 90 percent of all visits to primary care physicians are for stress-related complaints or disorders.1
• Workers’ compensation claims for “mental stress” in California rose 200 to 700 percent in the 1980s, whereas all other causes remained stable or declined.2
• Tranquilizers, antidepressants, and anti-anxiety medications account for one-fourth of all medication prescriptions written in the United States each year. (2)
• In one study by the St. Paul Fire and Marine Insurance Company, the frequency of hospital medication errors declined by 50 percent after prevention activities were implemented. In another study by St. Paul, there was a 70 percent reduction in malpractice claims in 22 hospitals that also implemented stress-prevention activities. (2)
• According to data from the Bureau of Labor Statistics, workers who must take time off from work because of stress, anxiety, or related disorders are off the job for about 20 days. (2)
Stress manifests itself in different ways: normal everyday stress, chronic stress, cumulative stress, and critical incident stress (traumatic stress). Initially, stress reactions are adaptive and sometimes helpful. As stress and the stress reactions increase, there is a greater chance that they will become maladaptive and disruptive. As Systems Theory-a theory that states we do not live within a vacuum and that what affects one will affect all with whom we interact-has proven, once an individual begins to be affected by stress, a group or organization will be affected.
OVERVIEW OF STRESS
Stress is a normal part of life that can help us learn and grow or can cause us significant problems. If we don’t take action, the stress response can lead to health problems. Prolonged, uninterrupted, unexpected, and unmanageable stresses are the most damaging. Many of our ways of dealing with stress-drugs, pain medicines, alcohol, smoking, and eating-actually worsen the stress and can make us more reactive (sensitive) to further stress. Although there are promising treatments for stress, successfully managing stress depends primarily on the individual’s willingness to make the changes necessary for a healthful lifestyle.
WHAT IS STRESS OR CHRONIC STRESS?
Stress is the reaction to those aggravating things that go wrong during the day, at work and at home, that disrupt routines and interrupt sleep. All have a cumulative effect on the brain, especially on its ability to remember and learn. As science gains greater insight into the consequences of stress on the brain, the picture that emerges is not a good one. A chronic overreaction to stress overloads the brain with powerful hormones intended only for short-term duty in emergency situations. Their cumulative effects can damage, kill, and permanently change the way cells function.
The ability to deal with stress has a huge impact on the body’s reaction to it. For example, if the stressor is in the form of a threat, whether the threat is real, remembered, or imagined, the brain will automatically respond quickly with powerful chemicals that initiate dramatic changes throughout the body. The heart pounds, the chest heaves, muscles tighten, senses sharpen, time slips into slow motion, and to a certain extent the individual becomes somewhat impervious to pain. Under certain conditions, if you were preparing for battle, this would be an appropriate healthy response. The trouble arises when the stress is not related to a threat but is just a significant reaction to a stressor. For example, you might be sitting in your car in traffic or at your desk dealing with an overload of work. What reaction would you have? How would you handle your reaction? How would your reaction affect your environment?
WHAT IS A CRITICAL INCIDENT?
A critical (traumatic) incident is an event that has the potential to create significant human distress and overwhelm an individual’s or group’s usual coping mechanism.3
Following are some examples of critical incidents common to public safety:
• Suicide of a colleague or friend.
• Line-of-duty death.
• Serious line-of-duty injury.
• Divorce, separation, or child-custody dispute.
• Involvement in a deadly-force situation.
• Disaster/multiple-casualty incident.
• Incidents involving children.
• A serious injury to self or family.
• Lawsuit or other internal investigation (suspension).
• Involvement in a shooting incident.
WHAT IS A TRAUMATIC OR CRITICAL INCIDENT STRESS RESPONSE?
Traumatic or critical incident stress response results from an emotionally traumatic event. The person experiences a stress response from an event involving actual or threatened death or injury to himself or others and experiences fear, helplessness, or horror. If this response persists for more than a month after the traumatic event and causes clinically significant distress or impairment, the reactions could progress to a diagnosis of Post-Traumatic Stress Disorder (PTSD).
Such critical incidents usually involve the perceived threat to one’s physical integrity or the physical integrity of another. Most importantly, critical incidents are determined by how they undermine a person’s sense of safety, security, and competency. This constitutes a form of psychiatric injury, also called traumatic stress. (3) You do not need to be directly involved to be adversely affected by a critical incident. Generally, the closer you are to the actual event and the people involved, the more severe the impact. Since 9/11, we have come to realize that an entire nation could be traumatized by witnessing horrific events without actually being present or knowing anyone who was present.
WHAT IS A CUMULATIVE STRESS RESPONSE?
The stress reaction or psychological injury from being exposed to numerous stressful events or critical incidents is known as a cumulative stress response. The reaction may or may not worsen as time goes by. There may be no obvious physical or emotional reaction until one final event or exposure that forces a reaction to the surface.
TRAUMA’S PHYSICAL EFFECTS
There is evidence that increased or accelerated stress responses can cause various diseases or conditions such as anxiety disorders, depression, high blood pressure, mood and sleep disorders, relationship difficulties, gastrointestinal diseases, some cancers, immune system deficiencies, job dissatisfaction, burnout, low morale, and even accelerated aging. Stress also seems to increase the frequency and severity of migraine headaches, asthma attacks, and blood sugar abnormalities, which can be devastating in a diabetic. Overwhelming psychological stress (critical incident stress) can cause temporary (transient) and long-lasting (chronic) symptoms, possibly leading to the diagnosis of PTSD.
Research has shown that the mind and body form a complex and totally integrated system that communicates through biochemical messages. One system can’t be activated without the other responding. When stressful events occur, physiologically, we attempt to create meaning within the context in which they occur. Consequently, there is always a strong subjective component in people’s responses to traumatic events.
Normally, when the stressor is removed or the perceived threat is over, the brain initiates a reverse course of action that releases different types of biochemicals throughout the body, attempting to bring the internal environment back into balance and seeking equilibrium between the stimulating and the tranquilizing chemical forces in the body. If one of these forces dominates the other without relief, an ongoing state of internal imbalance results. This condition is known as an accelerated stress response, and it can have serious consequences for the brain cells.
When a person is exposed (acutely or cumulatively) to a threat of danger, as in a critical incident, the body’s limbic system immediately responds by way of the autonomic nervous system (ANS), the complex network of endocrine glands that automatically regulates metabolism. The ANS consists of the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The SNS turns on the “fight or flight” response; in contrast, the PNS promotes the relaxation response. The SNS and the PNS carefully maintain metabolic equilibrium by making adjustments whenever something disturbs this balance. Physiologically, to maintain this balance the endocrine glands produce hormones, chemical messengers that travel through the bloodstream to accelerate or suppress metabolic functions. Unfortunately, when under stress, some hormones don’t know when to quit pulling. They remain active in the brain for too long-injuring and even killing cells in the hippocampus, the area of the brain needed for memory and learning.
If a threat subsides quickly, with little or no injury or damage, the fight or flight response ceases, and the biological system returns to normal within a short time. However, the more severe the threat or injury, the longer the threat continues to be present and the more damage there is, or the more prolonged and severe the fight or flight responses are. This is the basis for traumatic stress. As the body’s biochemical systems continue to be significantly aroused, the more deeply entrenched the adverse affects become, and the ability of the mind and the body to function normally deteriorates.
Instead of using emotions as cues to attend to incoming information, people with intense reactions are likely to proceed to fight or flight reactions. Thus, they are prone to go immediately from stimulus to response without making the necessary psychological assessment of the meaning of what is going on. This makes one prone to freeze or, alternatively, to overreact and intimidate others in response to minor provocation.4
As a result of Kolb’s (1987) work, it was proposed that excessive stimulation of the CNS at the time of the trauma could result in permanent neuronal changes that negatively affect learning, habituation, and stimulus discrimination. These neuronal changes would not depend on actual exposure to reminders of the trauma for expression.5 The normal startle response characteristic of PTSD exemplifies such neuronal changes.6 Chronic exposure to stress (many types of stress) affects both acute and chronic adaptation: It permanently alters how an organism deals with its environment on a day-to-day basis, and it interferes with how it copes with subsequent stresses.7 Chronic and persistent stress inhibits the effectiveness of the stress response and induces desensitization.
In many people who have undergone severe stress, their initial stress responses may fade over time, whereas in others it may continue to manifest into debilitating reactions that may affect normal functioning. Not everyone who experiences a traumatic event will develop PTSD. It is when the criteria for the diagnosis of PTSD spelled out by the Diagnostic and Statistical Manual of Mental disorders, Fourth Edition, persist for weeks or months, or when they are extreme, that professional help is needed. While PTSD is the “prototypical” traumatic disorder, some people-or some stressors-present different reactions. Depression, anxiety, and dissociation are three responses that may sometimes arise after a traumatic exposure.
The three main symptom clusters in PTSD are intrusions, such as flashbacks and nightmares, where the traumatic event is reexperienced; avoidance, in which the person tries to reduce exposure to people or things that might bring on intrusive symptoms; and hyperarousal, the physiologic signs of increased arousal, such as hypervigilance or increased startle response. (5)
People who have experienced a traumatic event seem to compensate for chronic hyperarousal by shutting down on a biological level by avoiding stimuli reminiscent of the trauma and on a psychobiological level by emotional numbing, which extends to trauma-related and everyday experience.8 Simply stated, people who have been traumatized in the past will attempt to avoid at all costs being exposed to, or taking a chance of being exposed to, additional traumatic events. They may not realize they are doing this.
THE TRAUMATIC IMPRINT
Is what one witnesses at a traumatic event forgotten soon after the event, or is there some sort of memory or imprint that remains within the psyche? Is a traumatic imprint registered somewhere inside the brain? Will that experienced memory return indirectly, sometimes unconsciously, and can it influence how a person thinks or sees himself or life in the future? Does an experience need to be horrific to be placed permanently in the brain as a memory or an imprint? When we experience physical pain, we say we “hurt.” When we experience emotional pain, like the death of a loved one, we also refer to these feelings as pain (i.e., “I am hurting so bad since my wife died”). Why do we do this? Does the physical body actually feel pain when the mind has been traumatized, or is it only a figure of speech? Can emotional pain from traumatic incidents or severe stress create physical ailments? Some researchers, such as Perry (1999), indicate it can. Perry reports that during the 1993 standoff between federal agents and the Branch-Davidians cult in Waco, Texas, the pulses of the 21 children who had been evacuated from the compound did not go below 120, even during sleep, for eight days.9
The central nervous system, specifically the brain, is composed of nerve cells. These nerve cells, called neurons, are specifically designed to respond to and modify themselves in response to external cues. Simply stated, the brain changes with experience-all experience, good and bad. The brain creates internal representations of the external world and transforms this information into patterned neuronal activity. A characteristic of this internal representation is that the brain makes and stores associations between bits of sensory information (e.g., sights, sounds, smells, positions, and emotions) from a specific event (e.g., the pairing of seeing a tiger and the danger), allowing the individual to generalize to sensory information present in current or future events. (9)
The human brain is organized from the most simple (e.g., fewest cells, brain stem) to the most complex (e.g., most cells, frontal cortex). The various functions of the brain, from the most simple and reflexive (e.g., regulation of body temperature) to the most complex (e.g., abstract thought), are mediated in parallel with these levels. The more a certain neural system is activated, the more built-in this state becomes, creating an internal representation of the experience corresponding to this neural activation. This capacity to make internal representations of the external or internal world is the basis for learning and memory.
All areas of the brain and body are accessed and tasked for optimal survival during threats. This total participation in the threat response is important in understanding how a traumatic experience can affect and alter functioning in such a pervasive fashion. Cognitive, emotional, social, behavioral, and physiological memories of a trauma may affect an individual for years, or even a lifetime. When an experience is recorded and the associated memory imprinted, there is an increase in heart rate and breathing. If a similar or same experience is reexperienced, the first reaction of the body would be, once again, to increase the heart rate and breathing (patterned response). The body would react with a similar response before the higher-functioning part of the brain (thought) can interpret the experience. The patterned response, already imprinted, would be presented before the brain realizes it is not a threat, thereby not allowing it to slow the physiological response as it normally would.
This threat-response capacity for association allows the brain to rapidly identify sensory information in the environment associated with threat, allowing the organism to act rapidly to promote long-term survival. Yet, the remarkable capacity of the brain to take a specific event and generalize, particularly with regard to threatening stimuli, makes humans vulnerable to the development of false associations and false generalizations from a specific traumatic event to other nonthreatening situations. These processes are crucial to understanding memory and trauma. (9) A sensitizing pattern resulting from a traumatic experience can dramatically change the sensitivity of the brain’s alarm system.10 The result is a state of anxiety, even in the presence of what were originally nonthreatening cues. A sensitized stress response is a likely etiology of trauma-related symptoms where it has been demonstrated that exposure to chronic and repeated stressors alter a variety of brain stem-related functions, including emotional and behavioral functioning.11
Children who have been repeatedly traumatized and can’t learn easily, even though they are considered bright by their teachers, usually are labeled as “learning disabled.” Because of their trauma histories, these children are in a constant state of arousal and cannot sit in a classroom and learn. Even at rest, different areas of the children’s brains are activated, affecting their functioning. The capacity to internalize new verbal cognitive information depends on having portions of the frontal and related cortical areas activated, which, in turn, requires a state of calm, a state the traumatized child rarely achieves.12 Can a comparison be made between these children and people who are repeatedly exposed to traumatic experiences?
The highly elevated physiological responses that accompany the recall of traumatic experiences that happened years or possibly even decades before illustrate the intensity and timelessness with which traumatic memories continue to affect current experiences.13,14
PAYING THE PRICE
Are people in public safety careers-people exposed to traumatic events daily-susceptible to any behavioral changes because of traumatic experiences? If in fact this research is correct, will traumatic memories have any effects on the body? Will those effects possibly manifest into physical injuries? Will they affect learning, create burnout, or possibly influence how one deals with interactions?
Trauma appears to be associated with significant direct negative consequences to health and subjective well-being, including “poor self-reported health, morbidity (as indicated by physical exam or laboratory tests), utilization of medical services, and mortality.”15 There is a growing body of literature that describes symptoms and behavior problems in individuals reporting a history of traumatic experiences. Many of these studies describe high rates of multiple somatic (physical) symptoms in this population.16-19 Typical symptom patterns reported to physicians include headaches, face and head pain, musculoskeletal complaints (back and extremity problems), gastrointestinal problems (ulcers), genitourinary difficulties, breathing problems (asthma), menstrual problems, fatigue, and neurological symptoms. Psychological issues associated with the traumatized populations include affective disorders, PTSD, anxiety disorders, dissociative disorders, eating disorders, and substance-abuse (legal and illegal drugs and alcohol) disorders.
Because of the public’s general lack of knowledge of the psychological effects of repeated stress or trauma, patients with a predominance of somatoform symptoms might be more likely to seek assistance in the medical care system, perhaps with costly and ineffective results. Is the patient’s and physician’s perception of the presenting problem as a somatic injury accurate? Is it to be treated as such, or should the problem be seen as a possible result of a psychological wound? As Perry (1999) notes: “The clinical situation with the somatizing patient is inherently ambiguous. In many clinical situations, there is no definitive medical test to ‘prove’ that a symptom or symptom cluster is caused by a somatoform condition as opposed to a medical illness. In fact, somatoform symptoms, medical symptoms, and amplification of medical symptoms can all coexist in the same patient. At different times, any one (or more) of these may explain an upsurge in symptoms.” (9)
Sometimes an injury is so chronic and so resistant to any medical intervention that a consult or collaboration between a physician and a mental health professional may be warranted. To be successful, treatment must remain centered in the dual psychic and somatic nature of these clinical problems.
WHAT CAN BE DONE
According to recent studies, the differences in individual characteristics such as personality and coping styles are most important in predicting whether certain job conditions will result in stress. In other words, what is stressful for one person may not be a problem for someone else. This viewpoint leads to prevention strategies that focus on workers and ways to help them prepare for and cope with demanding job conditions.
Although the importance of individual differences cannot be ignored, scientific evidence suggests that certain working conditions are stressful to most people. According to the National Institute for Occupational Safety and Health (NIOSH), exposure to stressful working conditions (called job stressors) can have a direct influence on worker safety and health.
As a general rule, actions to reduce job stress should give top priority to organizational change and improving working conditions. But even the most conscientious efforts to improve working conditions are unlikely to completely eliminate stress for workers. For this reason, a combination of organizational change, stress management, and crisis intervention is often the most useful approach for preventing and dealing with stresses at work.
Some of the individual and situational factors that can help to reduce the effects of stressful working conditions include the following:
• A balance between work and family or personal life;
• A supportive network of friends and coworkers;
• A relaxed and positive outlook;
• A supportive working environment;
• Stress training for supervisors and employees;
• The availability of professional and peer assistance when needed;
• Recognition of employees for good work performance;
• Opportunities for career advancement;
• An organizational culture that values the individual worker;
• Management actions that are consistent with organizational values; and
• Collaboration among management, Employee Assistance Programs, union officials, and employees.
As previously noted, the individual’s willingness to make the needed changes is necessary for successfully managing stress. Before individuals can take steps to resolve the problem, they must recognize that there is a problem. As Perry (1999) observes: “When an individual becomes self-aware, there is the potential for insight. With insight comes the potential for altered behavior. With altered behavior comes the potential to diminish the continuation of the dysfunction or destructive ideas and practices.” (9) Therefore, public safety managers should set as a priority the development and implementation of educational programs that increase workers’ knowledge about stress, including how to recognize when intervention is needed and how to go about getting help. ■
References
1. Panzarino, Jr., PJ, LJ Schoenfield, “Stress,” 2002. Retrieved July 28, 2003, from http://www.medicinenet.com/script/main/art.asp?ArticleKey=488&pf=3&track=qpa488.
2. Stress facts. The stress resource network. (2002). Retrieved July 28, 2003, from http://www.stresscure.com/hrn/facts.html.
3. Cardinal, S “What is a critical incident?” (2002). Retrieved July 25, 2003, from http://www.criticalincidentstress.com/critical_incidents.
4. van der Kolk, BA. “Psychological trauma.” In “The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress,” 1987. Retrieved July 25, 2003, from http://www.trauma-pages.com/vanderk4.htm.
5. Kolb, LC, “Neurophysiological hypothesis explaining posttraumatic stress disorder,” Am J Psychiatry; 1987:144-989-995. Retrieved July 25, 2003, from http://www.trauma-pages.com/vanderk4.htm.
6. Diagnostic and statistical manual of mental disorders, 4th edition. In “The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress,” American Psychological Association. 1993. Retrieved July 25, 2003, from http://www.trauma-pages.com/vanderk4.htm.
7. Yehuda R., EL Giller, SM Southwick, MT Lowy, and JW Mason, “Hypothalmic-pituitary-adrenal dysfunction in posttraumatic stress disorder,” Biol Psychiatry. In “The body keeps the score: Memory and the evolving psychobiology of post traumatic stress, 1991. Retrieved July 25, 2003, from http://www.trauma-pages.com/vanderk4.htm.”
8. Litz, BT and TM Keane, “Information processing in anxiety disorders: Application to the understanding of post-traumatic stress disorder,” Clin Psychol Rev., 1989. “In The body keeps the score: Memory and the evolving psychobiology of post traumatic stress.” Retrieved July 25, 2003, from http://www.trauma-pages.com/vanderk4.htm.
9. Perry, BD. “The memories of states: How the brain stores and retrieves traumatic experience,” In JM Goodwin & R Attias (eds.), Splintered reflections: Images of the Body in Trauma. New York: Basic Books, 1999, 9-38.
10. Kalivas, PW, P Duffy, R Abhold, et al., “Sensitization of mesolimbic dopamine neurons by neuropeptides and stress.” In P.W. Kalivas and C.D. Carnes, (eds.), Sensitization of the Nervous System, Caldwell, N.J.: Telford, 1990, 119-124.
11. Perry, BD, S Southwick, and E Giller, “Adrenergic receptor regulation in post-traumatic stress disorders,” In E. Giller, (ed.), Advances in psychiatry: Biological assessment and treatment of posttraumatic stress disorder. Washington, D.C.: American Psychiatric Press, 1990, 87-115).
12. Castro-Alamancos, MA and BW Connors, “Short-term plasticity of a thalamocortical pathway dynamically modulated by behavioral state,” Science; 1966:272-274-276.
13. van der Kolk, BA & O van der Hart, “The intrusive past: The flexibility of memory and the engraving of trauma,” In “The body keeps the score: Memory and the evolving psychobiology of post traumatic stress.” Retrieved July 25, 2003, from http://www.trauma-pages.com/vanderk4.htm.
14. Pitman, R, S Orr, and A. Shalev, “Once bitten twice shy: beyond the conditioning model of PTSD,” Biol Psychiat, 1993. In “The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress,” Retrieved July 25, 2003, from http://www.trauma-pages.com/vanderk4.htm.
15. Schnurr, PP, “Trauma, PTSD, and physical health,” PTSD Review Quarterly; 1996:2(3), 1-6.
16. Maynes, LC and LL Feinauer, “Acute and chronic dissociation and somatized anxiety as related to childhood sexual abuse,” Am J Fam Therapy; 1994:22, 165-175.
17. McCauley, J., DE Kern, K Kolodner, AF Schroeder, HK DeChant, J Ryden, LR Derogatis, and EB Bass, “The battering syndrome: prevalence and clinical characteristics of domestic violence in primary care internal medicine practice,” Annals of Inter Med; 1995:123(17), 737-746.
18. __________ “Clinical characteristics of women with a history of childhood abuse: Unhealed wounds,” J Am Med Assn; 1997:277(17),1362-1368.
19. Saxe, GN, G Chinman, R Berkowitz, K Hall, G Lieberg, J Schwartz, and BA van der Kolk, “Somatization in patients with dissociative disorders,” Am J Psychia; 1994:151,1329-1334.
Personality Traits of Public Safety Workers
Research has shown that public safety workers generally possess the following personality traits:
- They are action oriented.
- They live in the present moment.
- They dislike abstract theory without practical applications.
- They like to see immediate results for their efforts.
- They are fast-paced and energetic.
- They are flexible and adaptable.
- They are resourceful.
- They seldom work from a plan; they make things up as they go.
- They are highly observant.
- They are fun to be around.
- They have excellent memory for details.
- They have excellent people skills.
- They are good-natured.
- They have excellent ability to see a problem immediately and to quickly devise a solution.
- They are attracted to adventure and risk.
- They may be flashy or showy.
- They like initiating things but do not necessarily follow them through to completion.
Source: BSM consulting. (n.d.). “Career for ESTP personality types.” Retrieved July 27, 2003, from http://www.personalitypage.com/ESTP_car.html.
Critical Incident Stress Debrifing: Some Perspectives
BY LEE LOOK
This review examines the literature available on the topic of Critical Incident Stress Debriefing (CISD) as it relates to psychological stress in the profession of firefighting.
It is not unusual for a firefighter to be unable to rescue a victim and so be forced to witness sights such as the death of another human being or the pain of a burn victim. Not surprisingly, firefighters experience guilt, anxiety, and depression after the event. The impact of critical incidents may be debilitating; reactions may include recurrent intrusive images, persistent fear, displaced anger, guilt, and isolation.2 In the aftermath of 9/11, this is an issue that is no longer hidden from the American public.
Firefighting is a physically and psychologically demanding profession and a potentially hazardous occupation. From 1993 to 1997, an average of 93 U.S. firefighters died on the job annually. The leading cause of death among on-duty firefighters has been myocardial infarction (MI, a type of heart attack), according to Smith (2002).3 However, the magnitude of psychological strain has not been carefully studied. There is little information on how physiological stress will impact cognitive function, especially the ability to make decisions quickly and effectively. (3)
In one study, firefighter participants performed three trials of firefighter drills in environments of increasing temperatures. The results show a sizeable and significant change in psychological parameters. (3) In the aftermath of a true traumatic event, the results of the cognitive changes, combined with the individual reactions to the event, could create a potentially hazardous environment for the firefighters. Critical incident stress debriefing (CISD) is a way to manage this stress so that more of the firefighters’ faculties are available to confront the cognitive impairments.
Interest in CISD for firefighters has grown over the past decade. Some researchers report that debriefings protect firefighters from stress-related disorders, including Post-Traumatic Stress Disorder (PTSD). Supporters of this type of intervention claim the need for it and cite its extraordinary success. They report that CISD alleviates traumatic stress, accelerates the recovery process, and potentially restores employees to normalcy. (2)
Detractors contend that controlled and correlational studies have largely failed to demonstrate therapeutic effects.4 Interest in CISD has gained momentum in the fire and emergency services. Firefighters have been trained as debriefers, and many programs have been implemented to provide CISD on a voluntary or mandatory basis. One study found that debriefing did not significantly contribute to developing coping skills or affecting traumatic stress reactions. (4) One school of thought is that proper selection of members, training, and preparation, which leads to competence and resiliency, may be a more effective way of handling the stress on the job. (4)
When looking at national tragedies that involve heavy involvement of emergency services, such as 9/11 or the 1995 bombing of the Federal Building in Oklahoma City, some type of intervention is necessary before the stress reaches the “crisis stage,” according to the New York Daily News.5 After the bombing in Oklahoma City, research on the rescue workers found that eight emergency workers and three police officers committed suicide, police divorce rates increased 300 percent, and police disciplinary problems rose 45 percent. Since 9/11, at any given time, 75 Fire Department of New York firefighters are “off the line” for stress-related issues. Before 9/11, the average was five to 10. (5) The article includes interviews with people involved in the tragedies who indicate a need for counseling. The first-hand accounts of the stressors and the reflection on the care received show a true need for CISD.
Van Emmerik, et al, conducted a study to assess the efficacy of single-session CISD in preventing chronic symptoms of PTSD. After all results of the study were analyzed for validity and reliability, the results were surprising. Despite the intuitive appeal of CISD, the researchers found that it has no significant efficacy in reducing symptoms of PTSD and other trauma-related symptoms. In fact, the study suggests that it had a detrimental effect.6 The explanations for these results are varied.
CISD might interfere with the natural processing of a traumatic event and might also lead to victims’ bypassing the support of family, friends, or other sources, choosing to use CISD instead. Also, CISD likely increases awareness of the normal manifestations of distress after trauma, effecting a sort of self-fulfilling prophecy. (6) A logical question following these results is, would the outcomes have been different if more than one session of debriefing were available?
Troy Dycus offers an opposing view. In a 1995 article, he discusses CISD following the Oklahoma City bombing. The fire departments in Oklahoma City clearly believe in the worth of CISD. The work involved not only post-event defusings but also prebriefings, which informed personnel of conditions on-site for that day, any changes, and what to expect on and near the site.7 Other on-site services included massage therapists, chiropractors, changes of clothing, and free phone service for calling home. The emergency community is in the process of educating its members on stress and how to manage it. (7) These examples show a much more significant commitment to CISD than the simple, one-session study.
This is confirmed by Bohl. (1) Sixty-five male firefighters from similar-type departments and who had been involved in a critical or traumatic incident (defined as an incident where human lives were lost or serious injuries were witnessed) participated. Thirty of the firefighters received treatment; the other 35 did not. Their departments were similar, and the groups did not differ significantly in demographic variables. Formal tests were used to measure anxiety, anger, depression, flashbacks, and changes in eating and sleeping habits. The results showed that the untreated group had more signs of stress than the treated group.
The study noted that firefighters sometimes witness episodes that are so far beyond the ordinary that they would evoke psychological distress in any healthy, normal individual but that because firefighters feel such a need to demonstrate that they are strong and in control, they often are reluctant to seek professional help on their own. (1)
Clearly, there is not a definitive answer as to whether CISD is valuable. It is a rather new phenomenon, coming to the public’s attention primarily after the Oklahoma City bombing and the tragedy of 9/11. It does seem that the efficacy of CISD is highly dependent on the structure of the treatment. The van Emmerik study included a single session of counseling that took place within one month of the incident. The Bohl study involved multiple sessions and had a larger window of opportunity for treatment (three months). The Dycus article, which discussed a holistic approach to CISD, also reported positive results.
On a personal note, as a firefighter/EMT, I’m comforted to know that CISD is available to me in certain situations. In the short time I have been in the fire service, I have seen a double murder/suicide, a child mauled by a dog, and lives completely displaced by destruction. If I need CISD, it’s there, no questions asked and (hopefully) no judgments passed. But, it requires a full commitment from the department to make the treatment effective and complete. ■
References
1. Bohl, Nancy, “Measuring the effectiveness of CISD: a study,” Fire Engineering; 1995; 148:8, 125-127. (ERIC Document Reproduction #9508232876).
2. Sacks, Susan B, Paul T Clements, T Fay-Hillier, “Care after chaos: use of critical incident stress debriefing after traumatic workplace events,” Perspectives in Psychiatric Care; 2001: 37:4, 135.
3. Smith, DL, “Effect of strenuous live-fire drills on cardiovascular and psychological responses of recruit firefighters,” Ergonomics; Feb. 20, 2002: 44:3: 244-255. (ERIC Document Reproduction #4051030).
4. Harris, Morag B, M Baloglu, James R Stacks, (2002).” Mental health of trauma-exposed firefighters and critical incident stress debriefing,” J Loss and Trauma; 2002: 7, 223-228.
5. “Trauma of Sept. 11 Weighs on New York Rescue Workers,” New York Daily News, Jan 20, 2002. (ERIC Document Reproduction #2W72777800608).
6. Van Emmerik, Arnold A P, Jan H Kamphuis, Alexander M Hulsbosch, Paul M G Emmelkamp, “Single session debriefing after psychological trauma: a meta-analysis,” Lancet; 2002:360 (9335), 766-772. (ERIC Document Reproduction #7277593).
7. Dycus, Troy, ”Treating the Mind: CISD,” Fire Engineering; 2002:148(10), 120-123. (ERIC Document Reproduction #9511202918).
Job Conditions that Lead to Stress
Following are some of components of the workplace that can lead to job stress:
• Management style: Lack of participation by workers in decision making, poor communication in the organization, lack of knowledge of resources available to management and employees.
• Interpersonal relationships: Poor social environment and lack of support or help from coworkers and supervisors.
• Work roles: Conflicting or uncertain job expectations, too much responsibility, uncertainty of job requirements.
Poorly trained supervisors exposed to an employee exhibiting the early warning signs and symptoms of stress often begin disciplinary actions as their first tool. The trained supervisor and fellow coworkers usually easily recognize the early signs of stress. But, the effects of job stress on job performance and chronic diseases take a long time to develop and can be influenced by many factors other than stress. Some employers assume that stressful working conditions are a necessary evil and that organizations must turn up the pressure on workers and set aside health concerns. Research findings challenge this approach. Studies show that stressful working conditions are actually associated with increased absenteeism, tardiness, and workers’ intentions to quit their jobs. (1)
