Social Determinants of Mental Health in First Responders: Paid versus Volunteer Status and Related Implications

by Farah Hasan, November 18, 2021

First responders are celebrated for their selfless devotion to aiding civilians in traumatic events. However, as the first ones to arrive on scene, these responders often face the brunt of the immediate danger. Volunteer first responders may experience their work differently from the way occupational first responders do in regards to workplace culture and environment. As a result of these subtle differences, the mental health implications of responding to emergencies on volunteers differ from the mental health implications on paid responders. The experiences of both paid and volunteer responders must be improved and standardized to ensure that both types of responders are sufficiently prepared for high-stress work and are equipped to deal with common psychological outcomes.

Although career and volunteer first responders perform similar work, they face significant differences in terms of time commitment, recruitment/hiring processes, and training. Paid responders often devote anywhere between 56-72 hours per week to their work, while volunteer responders often dedicate their free time to providing service, resulting in them offering about half the amount of hours that paid responders give. Volunteer first responders are usually recruited on the basis of their completion of basic training (ie. EMT-B training for volunteer EMTs and training through probationary schools for volunteer firefighters), as well as hazardous materials (“Haz-Mat”) awareness training, AED-CPR training, and National Incident Management System (NIMS) training. Career first responders, on the other hand, may go through competitive interview processes and receive extensive training in addition to the basic requirements, including rigorous written and physical tests, as well as close to 200 hours of lectures, labs, and clinical experience (Ventura et al., 2021). Training and on-boarding processes may differ slightly from state to state. It is also important to note that while behavioral health and mental health programs for first responders are available, they are not a standard part of the majority of training processes for both volunteer and career responders. 

Due to the high-stress nature of their work, the prevalence of mental health disorders is significant among these trained heroes. First responders may experience irregular sleeping patterns, autonomic hyperarousal, and hypervigilance as a result of responding to traumatic and/or high-risk emergencies (Stanley et al., 2017; Skogstad et al., 2016). The severity of these symptoms and other aspects of mental health may be influenced by career or volunteer status. Distinctions between career and volunteer first responders arise in terms of cumulative time spent exposed to traumatic events, competing responsibilities (i.e. volunteers may have a separate job), and areas served (Stanley et al., 2017). In a study with a hybrid sample of firefighters (n=204 volunteer, n=321 career), career firefighters reported higher levels of substance use, particularly problematic alcohol use in comparison to volunteer firefighters (Stanley et al., 2017). On the other hand, volunteer firefighters reported elevated levels of posttraumatic stress, depression, and suicidal ideations compared to career firefighters (Stanley et al., 2017). After the 2003 Bam earthquake in Iran, the 2001 World Trade Center terrorist attack, and a 2011 vehicular bus accident in Norway, volunteer first responders were much more likely to exhibit symptoms of posttraumatic stress disorder (PTSD) than career and professional responders (Skogstad et al., 2016). Volunteers are also more likely to report higher perceived personal threat during an emergency situation (Skogstad et al., 2016).

In comparison to career departments, volunteer first responder programs may not provide adequate access to critical incident stress management (CISM), employee assistance programs (EAPs), or general stress reduction therapeutic programs. This may be due to inadequate funding and/or a belief that volunteer first responders do not require extensive resources, as their services may not entail work that is “serious” enough to necessitate them. This serves as a potential structural barrier to treatment for volunteer first responders and may contribute to increased risk of or exacerbated psychiatric symptoms (Skogstad et al., 2016; Stanley et al., 2017). 

Lack of prior training and exposure is another issue that confronts volunteer first responders. Nontraditional responders, such as construction and utility workers, electricians, and transportation workers, who assisted at the terror attack on the World Trade Center (WTC) on September 11, 2001 were in a similar situation in regards to lack of relevant training. Nontraditional responders at the WTC were twice as likely to develop PTSD compared to the police that were present (Bromet et al., 2015). Partial PTSD was also more prevalent among nontraditional responders than among the police (Bromet et al., 2015). This would suggest that lack of training is a contributing factor to the development of PTSD in volunteer first responders, who do not receive as extensive training as paid or professional first responders do. 

Other factors that may contribute to volunteer first responders’ increased risk for psychiatric disorders include lack of role clarity, perceived obstruction of services provided (Skogstad et al., 2016), and education level (DePierro et al., 2021). Role clarity pertains to the idea that volunteers may not fully understand what their task or role(s) are in an emergency, as delegation of roles may not be as efficient and definitively assigned to them as they are to paid professional responders. Perceived obstruction of services provided may arise when volunteers feel that their work is hindered or overshadowed, thereby feeling remorse over perceived inability to provide adequate service in a time of need. Additionally, first responders with a high school diploma are more likely to endorse symptoms of both PTSD and partial PTSD, compared to first responders with graduate or postgraduate degrees (Motreff et al., 2020). Lower education levels can be compared to lack of exposure/training for volunteer first responders, who are also more likely to endorse stigma surrounding psychiatric disorders, thus leading them to attempt to cope with their mental health stressors on their own (DePierro et al., 2021). Despite perceiving a greater stigma around psychiatric disorders and mental health resources, interestingly enough, DePierro et al. also found that nontraditional responders and volunteers were more likely to endorse higher perceived need for mental health resources (DePierro et al., 2021). Lack of education and lack of training both constitute a potential barrier to gaining a deeper understanding of mental health and realizing the importance of seeking professional help when needed.

As both volunteer and paid first responders are typically on the front lines during emergencies, it is important to ensure that the mental health of both types of responders are addressed. Volunteer first responders should be trained to provide the greatest role clarity possible and provided with CISM services as often as possible. For both volunteer and paid first responders, the importance of getting help from mental health professionals when necessary should be emphasized, and the contact information for such services (if they are not already provided by the corps) should be explicitly provided. Research by Jeff Thompson and Jacqueline Drew at Columbia University Irving Medical Center’s Department of Psychiatry show that resilience programs such as warr;or21, which incorporate practices such as controlled breathing and showing gratitude, have potential in alleviating mental health outcomes for first responders (Thompson & Drew, 2020). Additionally, reducing the stigma around mental health using training such as the Road to Mental Readiness (R2MR) program and reforming the workplace culture in this manner will encourage healthy dialogue (Szeto et al., 2019). These steps will pave the way for healthier and better-informed volunteer and paid first responders, which will ultimately enhance the quality of their work and services.


References

Bromet, E. J. et al. (2016). DSM-IV post-traumatic stress disorder among World Trade Center responders 11-13 years after the disaster of 11 September 2001 (9/11). Psychological Medicine, 46(4), pp. 771–783.

DePierro, J. et al. (2021). Mental health stigma and barriers to care in World Trade Center responders: Results from a large, population-based health monitoring cohort. American Journal of Industrial Medicine, 64(3), pp. 208–216.

Motreff, Y. et al. (2020) Factors associated with PTSD and partial PTSD among first responders following the Paris terror attacks in November 2015. Journal of Psychiatric Research, 121, pp. 143–150.

Skogstad, L. et al. (2016) Post-traumatic stress among rescue workers after terror attacks inNorway. Occupational Medicine (Oxford, England), 66(7), pp. 528–535.

Stanley, I. H. et al. (2017) Differences in psychiatric symptoms and barriers to mental health care between volunteer and career firefighters. Psychiatry Research, 247, pp. 236–242.

Szeto, A., Dobson, K. S., & Knaak, S. (2019). The Road to mental readiness for first responders: A meta-analysis of program outcomes. Canadian Journal of Psychiatry, 64(1_suppl), 18S–29S. https://doi.org/10.1177/0706743719842562

Thompson, J. & Drew, J. M. (2020). Warr;or21: A 21-day program to enhance first responder resilience and mental health. Frontiers in Psychology, 11, 2078–2078. https://doi.org/10.3389/fpsyg.2020.02078

Ventura, Denton, E., Court, E. V., & Nava-Parada, P. (2021). The emergency medical responder: Training and succeeding as an EMT/EMR. Springer. https://doi.org/10.1007/978-3-030-64396-6

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