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

The Impact of Gender Discrimination in the Workplace on Women’s Mental Health

by Farah Hasan, April 3, 2021

Perhaps the most defining moment of the Women’s Rights Movement to date was the passage of the Nineteenth Amendment in 1920 following the valiant efforts of those who spearheaded the project, such as Susan B. Anthony and Elizabeth Cady Stanton, and those who fearlessly backed the movement as a novel mark of progressivism. This momentous occasion is regarded as the single largest extension of democratic enfranchisement in the history of the United States (“The woman suffrage movement”). Despite such enormous strides having been accomplished for the advancement of women in a society where men had always dominated the government, the economy, the workforce, etc., women are far from seeing gender equality in the United States. Although the right to enfranchisement has contributed to the virtual elimination of overt prejudice, implicit bias against women still pervades. Evidence of such implicit bias is seen in numerous places including pop culture, educational institutions, and the workplace. Particularly in the workplace, despite making gains in the labor force participation rate over the last several decades, women working in male-dominated fields have significantly different experiences at work than their counterparts in fields with more female representation (Parker, 2018). Gender discrimination stands as an impediment to many women’s success in their professional and occupational lives, and often deters them from seeking promotions/leadership. Thus, perceived gender discrimination in the workplace has profound negative effects on women’s mental health regarding clinical depression and anxiety, especially in comparison to men’s mental health when faced with the adverse stimuli of gender-based prejudice. 

Gender discrimination in the workforce manifests itself in various forms and is thus perceived in varying extents of severity. One of the most pronounced forms of gender discrimination is the wage gap between men and women, with women earning about 80% of every dollar that a man makes for the same or similar job. Particularly in male-dominated fields, a toxic workplace culture is developed in which job performance and commitment are measured solely by the number of hours dedicated to work, the number of weekend shifts taken, etc. This takes away any hope for having flexible hours, which many women need in order to balance family commitments (as women are often primarily charged with keeping up with familial responsibilities). Consequently, many women are unjustly perceived to be lazy, not dedicated, and not committed to their job role. The lack of female role models in senior roles and leadership positions is also quite disheartening when it comes to female empowerment and promotion. Without figureheads for reference, women are more likely to undervalue themselves, be modest in talking about their accomplishments, and forgo opportunities to seek promotions (Agarwal, 2018). Women with a bachelor’s degree or higher report experiencing higher levels of workplace discrimination than women with lower levels of education. 57% of employed women with postgraduate degrees report experiencing some form of gender discrimination, compared to 40% of working women with a bachelor’s degree and 39% of women who did not complete college (Parker & Funk, 2017). Similar trends are seen when it comes to receiving support from senior leaders, being passed over for promotions, feeling isolated at work, and being paid less than their male counterparts. 30% of women with family incomes of over $100,000 say they’ve been paid less than a man doing comparable work, compared to 21% of women with lower incomes (Parker & Funk, 2017). Regarding the workplace environment, women employed in majority-male workplaces are more likely to see their gender as a limiting factor to their professional advancement, are less likely to report fair treatment in personnel matters, and experience more gender discrimination. 49% of women working in male-majority workplaces report sexual harassment as a problem in their workspace, compared to 32% of women who say the same about female-majority workplaces. Lastly, only 49% of women in male-dominated workplaces report that their workplace is putting enough effort into increasing workplace diversity, compared to 78% of women working in places with an even gender mix and 71% of women working in female-dominated places (Parker, 2018). 

The manifestation of gender discrimination and implicit bias against women in different forms and at so many different levels often translates into adverse consequences on women’s mental health. In a study titled “Perceived discrimination and health: A meta-analytic review,” Pascoe and Richman defined gender discrimination as a “behavioral manifestation of a negative attitude, judgment, or unfair treatment toward members of a group” and included studies that discussed poor service and treatment of women in public situations, derogatory comments, and harassment (Pascoe & Richman, 2009). It was found that perceived discrimination plays a role in increasing the incidence of depression, psychological distress, and anxiety. Experiencing discrimination on a regular basis causes more frequent activation of the body’s natural stress response, resulting in a perpetual negative mood state. Chronic stress and discrimination may also diminish one’s level of self-control, leading to increased use of and reliance on smoking, alcohol, and other substances to relieve the negative mood state. This may also decrease engagement in healthy habits, such as cancer screening and diabetes management (Pascoe & Richman, 2009). Risk of depression, in particular, is increased by stressful life events such as the loss of a loved one, a chronic disability/illness, or a business failure. Rejection, social exclusion, and embarrassment/humiliation also contribute to increased risk of depression. Gender discrimination in the workplace increases the odds that women will develop depression, regardless of the type of discrimination faced, whether it be regarding hiring, promotion, assignment of job-related tasks, wages, and firing. Women under 40 years old are particularly susceptible to developing depressive symptoms due to workplace gender discrimination compared to women over 40, adjusting for socio-demographic factors (Kim et al., 2020). 

While gender discrimination often puts women at a disadvantage, it is important to recognize that men could also be subject to such discrimination in the workplace. Due to the salience of historical instances of gender-based discrimination impeding women’s social advancement, most empirical research has focused exclusively on the impact of gender discrimination on women. This may be due to the fact that women have been entering male-majority fields at accelerating rates over the past several decades, but men’s entry into female-dominated fields has been largely stagnant. Regardless, research into gender discrimination may also apply to men entering female-dominated fields. Francesca Manzi of the Department of Psychology at New York University reviewed congruity models of gender discrimination (CMDs) to determine if men in female-majority fields face the same challenges as women in male-majority domains. It is important to note that while it is possible for men to be subject to gender discrimination, they may not be perceived as victims because they do not belong to a group that is commonly discriminated against, and discrimination of an “upper-class group” by a “lower-class group” (in this case, women discriminating against men) is usually not perceived as such. Female-majority occupations are often devalued and perceived to require less skill and intelligence, and thus do not come with significant status or monetary rewards, so exclusion from these occupations on the basis of gender is not seen as socially or economically hindering, and thus is not seen as discrimination. A potential source of stress, however, could be the incongruity of gender identity and occupation. Men may feel increased rates of depression and anxiety after perceiving a conflict between their gender and their job, which may lead to lower job satisfaction, dedication, and commitment. This is largely tied to the stereotype threat that comes from gender norms, where men’s quality of performance in female-dominated jobs is impaired when their gender is made salient (the stereotype threat also affects women in  male-dominated jobs). Conversely, it has previously been reported that men do not face gender discrimination in female-oriented jobs and actually experience facilitated upward mobility on the organizational ladder due to their gender (gender-based male advantage in female-dominated jobs is known as the “glass escalator” phenomenon). Unlike in the case of women being seen as incompetent in a “man’s” field, a man’s gender is seen to be a positive attribute that he brings to an otherwise female-dominated field, and thus the male stereotype works in his favor. Ultimately, this suggests that men have the advantage over women, even in female-dominated professions. Accordingly, men report receiving workplace support and report low levels of workplace inequality and/or mistreatment. Compared to the anti-female sentiment in male-dominated jobs, the anti-male sentiment in female-dominated jobs is insignificant (Manzi, 2019). 

The existing literature shows that both men and women can experience gender discrimination in the workplace. Due to the relative recency of the Women’s Rights Movement, the #Metoo movement, etc. women still have a long way to go in terms of equality and unfortunately bear the brunt of workplace gender discrimination. Women are subject to lower wages, fewer promotional opportunities, workplace isolation, sexual harassment, etc. On the other hand, it is important to recognize the barriers that men may face upon entry to female-majority professions, although further research must be done on this topic. Men face challenges associated with workplace gender discrimination, but on a much smaller scale than women, as they are less likely to report lower wages, be regarded as incompetent due to gender, receive less support from senior leaders, and be passed over for important assignments (Parker & Funk, 2017). Regardless, both men and women may experience some extent of psychological distress, depression, and negative mood state as a result of gender discrimination and/or incongruity between gender and occupation. Most men (67%) and women (68%) report that their gender has not played any role in hindering their professional success, but some workers are still experiencing the challenges of gender-based prejudice (Parker & Funk, 2017). Actions can be taken to counteract implicit bias and gender discrimination by encouraging diversity in workplaces (especially in occupations that are either male- or female-dominated) and normalizing the presence of other gender(s), allowing flexibility in work schedules, promoting female leaders, having strict disciplinary policies against sexual harassment, enforcing equal pay laws, and researching occupational barriers impeding men. Eliminating workplace gender discrimination may be a slow process, but with time, dedication, and sincere activism, it is an immense stride toward achieving true gender equality in America. 


References

Agarwal, P. (2018, August 31). How you can encourage more women into your workforce. Forbes Magazine. Retrieved from https://www.forbes.com/sites/pragyaagarwaleurope/2018/08/31/how-you-can-encourage-more-women-into-your-workforce/

Kim, G., Kim, J., Lee, S.-K., Sim, J., Kim, Y., Yun, B.-Y., & Yoon, J.-H. (2020). Multidimensional gender discrimination in workplace and depressive symptoms. PloS One, 15(7), e0234415.

Manzi, F. (2019). Are the processes underlying discrimination the same for women and men? A critical review of congruity models of gender discrimination. Frontiers in Psychology, 10. doi:10.3389/fpsyg.2019.00469

Parker, K. (2018, March 7). Women in majority-male workplaces report higher rates of gender discrimination. Retrieved August 2, 2020, from Pewresearch.org website: https://www.pewresearch.org/fact-tank/2018/03/07/women-in-majority-male-workplaces-report-higher-rates-of-gender-discrimination/

Parker, K., & Funk, C. (2017, December 14). Gender discrimination comes in many forms for today’s working women. Retrieved August 2, 2020, from Pewresearch.org website: https://www.pewresearch.org/fact-tank/2017/12/14/gender-discrimination-comes-in-many-forms-for-todays-working-women/

Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: a meta-analytic review. Psychological Bulletin, 135(4), 531–554.

The woman suffrage movement. (n.d.). Retrieved July 31, 2020, from Womenshistory.org website: https://www.womenshistory.org/resources/general/woman-suffrage-movement