Five years ago, Matthew Carlson responded to the call of a house fire. It was a relatively routine part of his job. A certified firefighter and medical first responder, Carlson was no stranger to trauma, but the tragedy he witnessed that day would stand out from all the others.

As Carlson was providing CPR to one of the victims, he glanced around the lawn to see several children lying near him unconscious. The fire would claim the lives of four children and a woman who was pregnant. Carlson calls the experience the straw that broke the camel’s back and an event that eventually led to a call of another kind — becoming a counselor.

Soon after the fire, Carlson started noticing signs of posttraumatic stress disorder (PTSD). He decided to take a step that many other first responders hesitate to take and sought counseling. “I had lost who I was and felt I had to reach out or I was going to self-destruct,” he says.

“I purposely sought out a faith-based counselor because I wanted to work with someone who held the same worldview,” Carlson says. “He first took inventory of all the traumatic events that had been particularly bothersome over the years. This was good because many of these events I had not talked about or to the extent necessary to provide insight. He used a faith-based form of guided imagery where I imagined the incident. He helped me discover core beliefs I held about the incident. We concluded each incident by praying and asking God, ‘What would Christ say in this moment? About this scene? What would he say to you?’”

Carlson was affected so deeply by the counseling he received and by how it helped him overcome his PTSD that he decided to seek a degree in counseling and focus his research on firefighters. After earning his master’s degree, he also started Resilience Consulting, through which he offers training and education on psychological resilience to first responders.

Carlson describes working with one firefighter client who was struggling with PTSD, just as Carlson had in the past. The client and his partner had fallen through the floor during a house fire and almost died. “Before we could get to the heart of [the client’s] PTSD, I spent hours and hours listening to his war stories and letting him unload years and years of the trauma he saw but never talked about,” says Carlson, a member of the American Counseling Association. “You see, he was taught to ‘suck it up,’ and he was a pro. He refused to say the word feelings, which I then dubbed the ‘F-word.’ As he described how he fell through the floor, became disoriented, injured and separated from his partner, he cried for the first time in 10 years. He briefly looked at me and saw tears rolling down my face. It was at that moment that he knew I understood and it was OK to ‘F.’ We spent our remaining sessions using a combination of guided imagery and systematic desensitization to bring about incredible healing and growth.”

Carlson was a limited licensed professional counselor in Michigan, where he was also still working as a firefighter, before relocating to Colorado. He is now employed by an area mental health center while working toward licensure in his new state and pursuing his doctorate in advanced human behavior from Capella University. “I am dedicating myself to emergency service counseling full time and have decided not to pursue firefighting again until after I finish my doctorate,” he says. “However, it is unlikely that I will work full time as a firefighter [again]. I will most likely volunteer in my local community, wherever that may be.”

Not a pro-counseling culture

Carlson says his motivation is to break down the barriers between first responders — such as firefighters, police officers and EMTs — and mental health treatment. He says first responder culture is characteristically resistant to discussing mental health or seeking treatment for it. “There’s an understanding that, ‘Hey, we don’t talk about this,’” Carlson says.

According to Carlson, when traumatic experiences are encountered on the job, first responders historically have been encouraged to get over them quickly because they have duties they need to continue performing. “It’s a sign of weakness to bring anything up,” he says.

It’s little surprise then that first responders fear “losing face” and may avoid counseling, Carlson says. “There needs to be a way to get help without fear of reprisal,” he adds.

Brian Chopko, an associate professor in the Department of Sociology at Kent State University at Stark, is a former police officer who began conducting research on police officer mental health while earning his master’s and doctorate in counseling. The stigma surrounding mental health treatment is prevalent within police culture, Chopko asserts. He points out that officers worry they might be skipped over for promotion if word gets out they have sought counseling.

There is an element of secrecy and insulation to the police culture that also serves as a barrier to seeking outside help, says Chopko, who also works as a reserve deputy sheriff and is an instructor with his county’s crisis intervention team. Part of that insulation stems from the distrust that sometimes seems to exist between police officers, the public and the media, he says. Chopko explains that police officers often find themselves in “damned if you do, damned if you don’t” situations in which they anticipate facing public criticism or other negative consequences regardless of their actions.

For instance, Chopko says, if a police officer encounters someone with a gun and doesn’t react quickly enough, the officer risks being killed. But if the officer shoots too quickly, the media might portray the police as being unnecessarily brutal. It makes sense then that police officers sometimes maintain an insular mindset and believe that the rest of society, including counselors, don’t truly understand what they go through, says Chopko, a member of ACA.

That said, Chopko and Carlson think the tide is slowly turning and more light is being focused on the importance of mental health care within first responder culture. Part of that is attributable to the growing awareness and discussion of mental health in the media and society at large, Carlson says, and part is due to first responders waking up to tragic happenings such as firefighter suicides within their own culture. In fact, Jeff Dill, a licensed professional counselor and professional firefighter, has been working since 2010 to collect firefighter suicide statistics (read a Counseling Today online exclusive article about Dill here).

Within police culture, Chopko says, there is a push to pay more attention to mental health issues among officers because administrators have come to see that neglecting mental health care ends up being more costly in the long run. “Officers missing work and being off on sick leave costs the department,” Chopko says. “Also, the department spends a lot of money training officers over many years. So, if the officer retires early or quits due to mental health issues, the agency has to spend more money to train new officers.” Chopko adds that the growing awareness may also come from the officers themselves, who tend to be better educated than in past years, including on the topic of mental health.

Chopko believes the focus on mental health care among first responders will continue to expand in the future because researchers and mental health professionals are showing a growing interest in the community. Chopko says this may be partly influenced by the increased attention being given to the effects of stress among military veterans.

Making a connection

A significant element of reducing stigma within first responder cultures, Chopko says, is to educate this population early on about how people experience stress and emphasize that what they are feeling, or may one day feel, is completely normal. In Chopko’s experience, it is rare for police officers to share their feelings and symptoms of stress with one another. So, when officers do feel stressed or overwhelmed, they may regard it as an indication that they are weak or unable to do their job. “Other officers go through similar things, but [they] don’t talk about it,” he says.

For counselors interested in working with first responders as clients, offering trainings at a police station or firehouse, with the administration’s approval, can be a win-win. Trainings offer the counselor an inroad to finding potential clients, while providing first responders an opportunity to learn about mental health symptoms and issues without initially having to go against their culture and seek out counseling.

Chopko conducts police officer trainings on PTSD through his county’s crisis intervention team, which offers another access point for reaching first responders. Chopko says each time he does a training, officers pull him aside and ask questions about how to deal with the stress they are under. Counselors can find out about working with crisis intervention teams in their area by contacting their local police department or sheriff’s office, local board of mental health or local chapter of the National Alliance on Mental Illness, all of which may know about or be directly involved with the teams, Chopko says.

Working as an employee assistance program provider for a firehouse or police station is another option for connecting with first responders, he adds.

Because first responders typically won’t show up at a counselor’s office without having heard about the counselor ahead of time, Carlson emphasizes that counselors must be proactive and intentional about building their reputation within this particular client population. “Meet them where they are,” he says. “Visit the local firehouses, police stations and ambulance bays. Request to ride along to get a feel for the culture. Immerse yourself in their world for an afternoon once a month and let them know you just want to understand what they go through.”

Ride-along programs are fairly common in public safety departments, Carlson says. “I suggest calling the station and inquiring directly by asking if they have a ride-along program,” he says. “Don’t be alarmed if they’re a little skeptical about you doing ride-alongs. It’s nothing personal. It takes time to establish trust, and that’s your mission. Tell them you would like to find out what their job is like. That’s what a ride-along program is all about. You won’t need to overemphasize that you’re a counselor. The point of riding along is to take that first step and [allow] the first responders to check you out and see that you’re a safe person, while you observe firsthand how they operate.”

As a next step, consider offering resilience training or educational sessions on stress, adrenaline and psychological performance enhancement, Carlson advises. “If your intent is to offer training with a dual goal of making yourself available for counseling, be up-front about it. Don’t secretly hope they will come see you. Tell them what your motives are.”

Carlson also emphasizes that counselors shouldn’t overlook volunteer-based departments, which he says make up more than 75 percent of fire and emergency medical services departments nationwide. “I would … make the case that the volunteers need more intervention, especially if they serve in a rural area, due to the low call volume and underexposure to traumatic incidents,” he says. “They don’t run enough calls to become resilient. They need our help. It has been my experience that the lower the call volume, the more receptive the department is to openly addressing mental health issues.”

Thinking ahead

If first responders do begin seeing a counselor, they may be afraid of their colleagues finding out. Counselors can take steps to make the process more comfortable for these clients, Carlson says. For instance, he recommends having a separate entrance and exit. That way, when first responder clients leave the counselor’s office, possibly in uniform, they won’t have to go back through a lobby where other clients might be waiting.

Also worth thinking about, Carlson says, is where these clients can park if they are driving a first responder vehicle. A parking lot around the back of a building might be preferable to parking on the street, where others are likely to notice an emergency or police vehicle. The point, Carlson says, is to make it as easy and comfortable as possible for first responder clients to enter and leave the counselor’s office unnoticed.

For that matter, he says, “If your practice allows it, be willing to go mobile for sessions. For many first responders, the thought of being seen at a mental health clinic is enough to keep them from coming.”

Unfortunately, Carlson says, even when first responders take the bold step of seeking help, they too often encounter mental health professionals who don’t understand what these clients do for a living or grasp the day-to-day challenges they face. “This requires the client to first explain the job and then explain the problem,” he says. “This has to change.”

“Don’t think you have to be a first responder to help a first responder, but do take the time to understand the culture,” Carlson says. Among the elements he says are common to the culture of first responders is a high level of cohesion and trust within their respective departments, a requirement to perform in extreme circumstances and take calculated risks, a belief in the power of personal sacrifice and a connection to the local community. Counselors can seek training to learn more about what it means to be a first responder and how to work with them, Carlson says. One such training he recommends is offered through Helping Heroes at helping-heroes.org.

Chopko also suggests that counselors read the revised 2006 edition of Ellen Kirschman’s book, I Love a Cop, published by Guilford Press. Although the book was written for families and loved ones of police officers, Chopko says counselors can learn about police culture by reading it.

Relationship first

When counselors work with first responders as clients, Carlson suggests putting treatment planning aside in the beginning in favor of a focus on building rapport. Building rapport will go a long way toward establishing trust in the therapeutic relationship. This is key, Carlson says, because based on the work culture in which they were groomed, first responders may initially be less trusting of the counselor’s services than the average client.

Chopko echoes Carlson. “Trust is a very important thing,” he says. “If someone feels they’re going to go to you and someone else might find out, that will prevent them from coming back.”

Once trust and rapport are established, Chopko and Carlson say counselors can move forward to address whatever issues are at hand. Given the nature of what first responders spend their lives doing, signs and symptoms of PTSD may be a common issue.

Carlson is no stranger to it, having experienced PTSD himself. It is a significant issue for first responders, he says, because although many are at risk of experiencing it, a substantial number don’t understand it.

Carlson says when he begins talking about the signs and symptoms of PTSD in trainings, firefighters often nod their heads in recognition. “It’s giving it a name,” he says. “It’s like, ‘OK, now I know what I’m dealing with.’”

Chopko points out that police officers are exposed not only to a greater frequency of traumas but also to a greater variety of trauma types than is the general public. They not only experience situations in which they are at personal risk of death or physical harm but also regularly find themselves in situations where they witness others being killed or seriously harmed. Additionally, Chopko explains, firefighters don’t normally experience intentional violence that is directed at them, whereas police officers often do. In his research, Chopko has explored posttraumatic stress among police officers who have been seriously injured during an assault versus during an accident. He says the rates of posttraumatic stress tend to be higher if the injury was incurred during an intentional assault.

Being exposed to those traumas, regardless of their nature, can lead to PTSD among police officers, but developing PTSD should not be regarded as a given, he cautions. When thinking about PTSD, mental health providers need to realize that people react to the same situations in different ways, he says. So, some police officers may be deeply affected by what they see and experience, while the impact will be less disturbing for others.

Chopko points out that the common cluster of symptoms for PTSD in the Diagnostic and Statistical Manual of Mental Disorders includes reexperiencing, hyperarousal and avoidance. On the basis of the research he has conducted, Chopko adds guilt and shame as symptoms that may be related to potential PTSD.

Giving the ‘warrior’ a way forward

Working on resilience training with clients who are experiencing trauma or PTSD can be helpful, Carlson says. First responders can’t leave their jobs, so the stimuli will continue. Therefore, the
only option is teaching them how to bounce back and be resilient after each traumatic situation. Having a purpose larger than one’s job, building self-reliance and developing a support system are all elements to increasing resilience, Carlson says.

In his research, Chopko is looking at the effectiveness of mindfulness-based treatments with police officers who are dealing with PTSD. “In theory, [mindfulness] could be helpful because avoidance is such a big part of PTSD,” he says. “[If] you were involved in a traumatic experience, when you think about it, talk about it or see people who were there, it makes the symptoms go up. So, you avoid talking about it or thinking about it. That doesn’t work in the long run. It actually intensifies the symptoms.”

If avoidance intensifies PTSD symptoms, Chopko’s thinking is that mindfulness might have the potential to decrease symptoms. Mindfulness is the ability to accept without judgment, he says, and is thus the opposite of avoidance.

Chopko adds that counselors who are going to treat first responders or any other clients for PTSD should be specially trained and be using empirically validated treatments such as cognitive processing therapy and prolonged exposure therapy.

Because stressful situations are an inevitable part of a first responder’s life, teaching these clients relaxation techniques, such as breathing techniques for stress reduction and progressive muscle relaxation, can be helpful, Chopko says. “To account for some officers viewing this as ‘wimpy’ and not taking it seriously, counselors can present breathing relaxation techniques as something commonly practiced by kung fu warriors,” he suggests. “Also, breathing exercises are taught to our military special forces to handle the stress of going into life-threatening combat. They are taught this as ‘combat breathing.’ So, counselors can present breathing exercises as something that elite warriors do so it does not distract from the tough exterior mindset common among officers.”

Chopko also introduces the idea of elite warriors in another way — by incorporating a “compassionate warrior” concept in his work with police officers. He originally created the concept for use in training officers through his local crisis intervention team. It combines the ideas of serving a larger purpose, treating those who are vulnerable with compassion and empathy, and yet still remaining tough in “battle.”

“My hope is that facilitating a sense of purpose in life — [the idea] that being an officer is more than a job, it is a calling — will help officers better cope with, or act as a buffer against, occupational stress as well as physical harm,” Chopko says. “Officers often receive more negative than positive sentiment from the people they come into contact with on a daily basis as well as the larger community. So, to emphasize that they are part of a proud warrior tradition and highly valued may be important.”

 

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When the ‘protector’ is gone

First responders’ roles and responsibilities aren’t tough only on first responders themselves. They’re also tough on first responders’ loved ones. Lisa Jackson-Cherry, professor and chair of the Department of Counseling at Marymount University in Arlington, Va., serves as a counselor during National Police Week, which occurs each May in Washington. She grew up with close family members in law enforcement, her husband is a police officer, and the first master’s degree Jackson-Cherry earned was in criminal justice.

Jackson-Cherry, a member of the American Counseling Association, first got involved with National Police Week seven years ago. During the week, she and her colleagues provide two days of group counseling to children and adolescents whose parents have died in the line of duty as police officers. Jackson-Cherry is the lead counselor for the “returning survivors” groups, which are composed of children and adolescents who have been to National Police Week at least once before.

When a family loses a parent who was a police officer, Jackson-Cherry says, there is sometimes a simultaneous loss of identity because the family no longer feels as much a part of the greater “police family.” Negative stereotypes concerning police officers can also complicate a family’s grief. Some of the kids with whom Jackson-Cherry has worked have told her their peers have expressed less sympathy for them, saying things such as, “Well, your father shouldn’t have pulled that person over.”

Many police officers work long shifts or even extra shifts, and that can lead children who have lost a parent in the line of duty to feel some anger, Jackson-Cherry says. Children might harbor thoughts that their parent should have been safe at home instead of working long hours and getting caught in a situation that claimed the parent’s life.

Children may also feel like they have lost a “protector” after a parent who was a police officer dies, Jackson-Cherry says. “Children of police officers often grow up thinking their mother or father is a good person — the one who protects good people from bad people,” she says. “When a police officer parent dies, they may think, although it may be exaggerated due to the profession of the parent, ‘Who is going to protect me from bad people since my protector is no longer here and was killed protecting [other] people?’ Often, these children have intense fears of losing the other parent,” especially in cases in which both parents are on the police force.

Because Jackson-Cherry’s time with the children during National Police Week is short, she says her goal is “planting the seed that counseling is OK.” She tries to normalize the grief process and the children’s feelings, raise awareness to the likelihood that they may reexperience some of those feelings in the future and suggest support options, such as visiting a school counselor, should they need them in the future. Jackson-Cherry and her colleagues also remain on the lookout for any child or adolescent who needs immediate and more significant help and work to ensure that help is in place after National Police Week.

To contact Lisa Jackson-Cherry, email LJackson@marymount.edu.

— Lynne Shallcross

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To contact the individuals interviewed for this article, email:

• Matthew Carlson at matthew@resilience-training.com
• Brian Chopko at bchopko@kent.edu

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Letters to the editor: ct@counseling.org