The scale of the problem
There is a growing recognition that First Responders themselves can become psychological victims of a disaster (Alexander & Klein, 2003; R Wraith & Gordon, 2001?). Eighty percent of disaster workers experience emotional symptoms due to their experience of the events, and their role as help providers dealing with death and injury increases susceptibility to stress reactions (Robbins, 1999). Emergency workers frequently identify with victims and can feel guilt as well as helplessness in the face of overwhelming trauma (Raphael, 1986; Robbins, 1999; Singer, 1982; Robert J. Ursano & Fullerton, 1990).
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The variety of psychological and behavioural symptoms that affect first responders matches the spectrum affecting primary disaster victims themselves and their friends and family (secondary victims). Stress may be experienced through any of the following specific symptoms, either in isolation or in combinations: insomnia, guilt, defensive psychological reactions (such as humour, disassociation, and focus on other events), worry, anxiety, elevated startle response, isolation and withdrawal, phobia, depression, alcohol and drug abuse. Work may suffer due to irritability and anger with colleagues, difficulty in assimilating new information or making decisions, memory loss and confusion (Butler, Panzer, & Goldfrank, 2003; Jane's, 2002; Singer, 1982).
The severity of symptoms ranges from mild distress through acute stress disorder (ASD), estimated to occur in 10 to 20 per cent of cases and lasting up to 4 weeks (R. C. W. Hall, Hall, & Chapman, 2004). However, anxiety and depression can persist for months (Butler, Panzer, & Goldfrank, 2003; Jane's, 2002).
Post Traumatic Stress Disorder (PTSD)
Long-term psychiatric illnesses, such as post traumatic stress disorder (PTSD), are the most severe outcomes of traumatic events, and are also the best researched. Full PTSD has been estimated to occur in 3 to 7 per cent of first responders (R. C. W. Hall, Hall, & Chapman, 2004; Robbins, 1999). However, there appears to be wide variation in the estimates, depending on the exact range of symptoms surveyed, the period of time between the incident and survey, the professional groups surveyed and their prior experience of such events, and other factors including the type and severity of the emergency.
Several studies report much higher levels, and that chronic stress experienced in their jobs exposes first responders to increased risk of developing PTSD as a result of a specific incident. In one study of over 400 professional fire fighters in Germany, 18% were found to be suffering from PTSD, with older, more experienced personnel repeatedly exposed to distressing missions most likely to be affected.
In the case of the Oklahoma City bombings, 20% of disaster workers experienced symptoms of PSTD after one month. Among Australian fire fighters, involved in a massive conflagration, 30% were suffering from PTSD after more than two years (R. C. W. Hall, Hall, & Chapman, 2004).
Causes of stress reactions
Stress in First Responders does not form simply as a consequence of the gruesome nature of their work, although that is clearly one major aspect of it.
Among rescue workers involved in removing individuals from an oil rig disaster, 24% evidenced PTSD nine months later (R. C. W. Hall, Hall, & Chapman, 2004). However, the Australian fire fighters, noted above were not exposed to grotesque stimuli or assisting in the removal of dead or injured people. Their stress resulted from their job and the personal risk to their lives.
In a 1993 article, Dr. E. McCloy, medical advisor to Greater Manchester Fire and Civil Defense Authority, identified three emergency event stressors: personal loss or injury; traumatic stimuli; and mission failure (McCloy, 1993). Other, more familiar sources of stress also bear down on the situation including: organization/management issues, interpersonal relations, uncertainty due to unfamiliar and difficult tasks, and the volume of work and overload.
In the case of CBRN-type disasters, many of these sources of stress may be amplified, and stress responses may be more prevalent although we have not identified any systematic comparisons in the literature.
Stress in CBRN disasters
There is conflicting evidence over whether stress is more likely to occur in response to human rather than natural disasters generally (Butler, Panzer, & Goldfrank, 2003 chap. 2), although the nature of the event itself—its duration, intensity, scale, and type—influences the degree of stress experienced by first responders (Butler, Panzer, & Goldfrank, 2003).
Nevertheless, CBRN incidents appear to be a major cause of concern among first responders. In a survey of 1900 first responders in the US conducted in the aftermath of the September 11th attacks, 26% listed potentially coming into contact with biological/chemical weapons as their major fear or concern (R. C. W. Hall, Hall, & Chapman, 2004).
The effects of CBRN agents bring additional stresses to the disaster situation. Unlike the damage and injuries caused by a natural disaster, many toxic substances are invisible to the senses. First responders may not be sure without instrumentation if they have been exposed to a toxin and to how much they have been exposed, and what the health implications are (Report of the expert panel workshop on the psychological response to hazardous substances, 1995).
The continued but uncertain level of personal risk to first responders from CBRN agents has been noted to be a stressor in several studies of disasters including the Three Mile Island nuclear accident and the Tokyo subway Sarin attack (Guillemin, 2004; R. C. W. Hall, Hall, & Chapman, 2004; Robbins, 1999).
In addition, the specific agent may be unfamiliar and unidentified initially, and the correct course of action may not be immediately understood. For example, familiarity with specific chemical or nuclear agents may vary between regions depending on the locations of plants (Gray, 1981). These factors increase feelings of uncertainty and loss of control which can cause increased stress (Butler, Panzer, & Goldfrank, 2003; Gray, 1981; , Report of the expert panel workshop on the psychological response to hazardous substances, 1995).
An additional complication is the difficulty in health terms of distinguishing between some of the symptoms of anxiety and stress due to exposure or possibility of exposure to an agent, and the symptoms caused by actual exposure to the agent. For example, shortness of breath, confusion, and cognitive impairment, can be produced by some agents as well as by anxiety (Butler, Panzer, & Goldfrank, 2003).
Intentional CBRN incidents such as terrorist attacks may be seen as particularly reprehensible and unjust, and their effects more indiscriminate increasing the chances of encountering child victims, increasing psychological identification with victims, feelings of helplessness and lack of control, and stress levels—just as they are designed to do (Butler, Panzer, & Goldfrank, 2003).
Large-scale disasters
Additional stresses emerge from the scale of the disaster which can be much bigger in CBRN, and moreover can grow seemingly uncontrollably depending on weather conditions.
One early review suggests that the destructive potential of chemical and nuclear agents tends to be overestimated by the public and emergency officials alike, and controllability frequently misjudged (Gray, 1981). Faced with a large disaster first responders can feel overwhelmed by the scale of the tragedy, while the apparent randomness of victims can be an additional stressor (Paton, 1990; Raphael, 1986; Robbins, 1999).
Large scale events bring additional complexities to the situation that further raise stress levels. For example, large-scale CBRN events are more likely to involve a multi-agency response, and toxic agents can cross geographical and hence operational boundaries, complicating the inter-agency response (Gray, 1981). As organizational complexity and communication and coordination demands are all increased, there is a much greater volume of work, leading to overload and organizational stress (James, 1988).
Recommendations for building resilience
A number of recommendations appear in the literature for reducing first responders' stress responses and increasing their coping abilities, although in some cases there is doubt and controversy about their efficacy. The recommendations concern four areas: incident management; pre-incident training, post-incident training and debriefing; and support during and after the event.
Disaster management
The management of the disaster and emergency response will influence the degree of psychological impact upon first responders. This includes not only decisions made during the event itself but also the degree to which the feasibility of different response options have been explored and prepared for. Critically examining the capabilities of mental health crisis intervention teams that might respond to the event, and the range of other psychological support services can increase the level of preparedness for adverse psychological responses (DiGiovanni).
Training
In general the need for pre- and post-trauma training is seen as important for increasing psychological preparedness and ameliorating stress responses in emergency workers. Training can increase their sense of control over the event as well as their efficiency in responding to it (Gibson, 2003).
Pre-event training should therefore aim to increase knowledge of CBRN agents, their destructive effects and controllability, and appropriate responses (Gray, 1981). Improved knowledge of the health implications for first responders of dealing with CBRN agents may help to reduce anxiety over personal health concerns.
Training should also include knowledge and awareness of the psychological effects of emergency work, including symptoms of trauma in themselves and their colleagues, and the range of physical, emotional and behavioural responses that can occur in the immediate situation or over a longer period (Jane's, 2002).
Pre-event training needs also to prepare first responders for the possible scale of a CBRN-type incident, for example by viewing films of previous tragedies. These procedures are sometimes referred to as stress inoculation training (Paton, 1990). Training also needs to be extended to mental health service personnel who might be called on to respond.
Debriefing
Appropriate debriefing of first responders can act to create a psychological “jigsaw” whereby each individual can fit his or her role into the overall picture of the disaster event. Debriefing helps remove fears among first responders about job competency and encourages the return to normal behaviour patterns (McCloy, 1993). However, the form of debriefing can be critical since inappropriate or mistimed debriefing can itself become a source of secondary trauma (Robbins, 1999).
Caveats
For example, the Critical Incidence Stress Debriefing method of peer intervention used by US fire and rescue services for their responders (Mitchell, 1983) has been criticised, as well as telephone hot lines and crisis intervention centres more generally. Gist & Woodall (1999) argue that the empirical evidence of a demonstrable preventative effect from CISD is unreliable and that any palliative effect obtained is no greater than that obtained by more traditional venues of discussion and social support (Gist & Woodall, 1999).
Similarly, the evidence that brief, early cognitive-behavioural interventions work is far from certain, being based on the results of relatively small trials (J. e. a. Bisson, 2003). These kinds of interventions may be more beneficial if primarily aimed at individuals with acute symptoms, rather than all those responding to the traumatic event (J. e. a. Bisson, 2003).
Gist & Woodall (1999) argue that treatments and interventions can be responsible for causing or at least increasing some symptoms among first responders, for example by impeding psychological distancing as a coping strategy and creating group contagion effects. They argue that interventions should instead focus on building individual and collective resilience which stems from organizational culture, effective partitioning of incident components and responsibilities, and family, peer and professional support systems.
Social support
While adequate social support is a moderator of stress reactions (Fullerton, McCarroll, Ursano, & Wright, 1992), establishing peer group support that is coherent with the organizational culture (through e.g., the Fire Service “Watch”) may be more effective (see Section 4.3) (McCloy, 1993). At the same time adequate support and de-briefing needs to be provided for mental health workers treating first responders since they too will be subject to stress (Talbot, 1992; Veer, 1992).
Supporting the family
Finally, it is recognized that psychological disturbances associated with exposure to disaster situations, coupled with the additional uncertainties and fears associated with CBRN incidents can also affect the families of first responders. For example, alcohol and drug dependence increase with PTSD, and spousal abuse and personality changes have been noted in affected first responders with inevitable impacts upon family life (Fullerton, McCarroll, Ursano, & Wright, 1992; R. C. W. Hall, Hall, & Chapman, 2004).
