By Cynthia Ross Tustin
For decades, many first responders have suffered in silence with post-traumatic stress disorder (PTSD). It is only recently that we have adopted a more open-minded approach to admitting that we need help, thanks in part to the brave men and women who opened up about their personal mental health issues and, sadly, in part because of the soaring suicide rates among our colleagues and peers. The floodgates have now opened, and information and programs abound.
Like most fire service leaders, we want to help our people, and taking care of their mental health is as important as their physical wellness. In Ontario, for example, PTSD is now recognized as a compensable work injury for firefighters, and the provincial government has mandated that fire departments are required by law to have a workplace mental health program in place. But what is any concerned fire chief to do with the sudden onslaught of information and experts? What program or approach is best? Can choosing the wrong program do more harm than good?
In an effort to sort the wheat from the chaff or, more accurately, the experts from the charlatans, my research led me to Dr. Edna Foa. She is renowned in North America for her expertise in the subject, and her list of credentials gave me a certain piece of mind that can only come from an expert. I contacted her late last year and she graciously answered my questions. I found the information and insight that she offered into PTSD treatment and recovery extremely helpful. In fact, it was too good to keep to myself. Dr. Foa agreed to allowing the conversation to be turned into an interview, and what follows are excerpts from that discussion.
The Background
First, let me provide a bit of background about Dr. Foa and why I found her to be such a credible expert. Dr. Foa is a professor of clinical psychology in psychiatry at the University of Pennsylvania and the director of the Centre for the Treatment and Study of Anxiety. She has dedicated her entire academic career to the study of the psychopathology and treatment of anxiety disorders, primarily obsessive-compulsive disorder (OCD), PTSD, and social phobia. She is currently one of the world’s leading experts in these areas. Dr. Foa is the author of Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences (Treatments That Work), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies, and Mastery of Obsessive-Compulsive Disorders: A Cognitive-Behavioral Approach Therapist Guide. Dr. Foa, long recognized for her expertise in this field, was appointed to chair the committees that worked on the PTSD and OCD chapters in the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (DSM-IV and DSM-V). The DSM-V, published by the American Psychiatric Association, offers a common language and standard criteria for the classification of mental disorders.
The Interview
Chief Tustin: How is PTSD diagnosed? Is it a purely from a psychological assessment or are there physical symptoms that can be tested/assessed? Are we closer to any biological markers?
Dr. Foa: A physical exam is conducted to rule out a medical reason for a person’s problems. This is followed by a psychological exam to assess the person’s signs and symptoms and a review of events that led to them. Psychologists and psychiatrists use the questions and criteria that are outlined in the DSM-V for the assessment and to make a diagnosis. The diagnosis is not based exclusively on the questions. The interview includes many questions about daily functioning.
The criterion also requires an evaluation of the event, as it is equally important. The person’s traumatic experience is generally a near-death injury, a life-threatening event (often with an element of violence), or some sort of sexual abuse. A person could also experience PTSD if he or she witnessed any of those events. Finally, the last criterion for the diagnosis is it also must be interfering with the person’s life.
There are currently no biological markers available to test for PTSD. However, doctors closely monitor for physical reactions during the interview (elevated heart rate, pallor, tremors, emotional outbreaks).
Tustin: How does a healthcare professional differentiate between PTSD and a cumulative stress problem?
Foa: The thoroughness of the questions within the DSM—V helps to differentiate between the two; the person’s reactions during the assessment; and, of course, the presence of a serious traumatic event. You must also be experiencing the signs and symptoms for a prolonged period of time.
Tustin: What is the prognosis for someone with PTSD? Do you have it for life? Or, can you be completely cured with the proper treatment?
Foa: If people can get help quickly, and if PTSD can be diagnosed within the first month, the rate of cure is extremely high. Some people may have some residual symptoms left, but they are easily dealt with. For the majority of patients with early treatment, all the symptoms go away. Unfortunately, if PTSD goes undiagnosed for a year or more, treatment takes much longer. You can be completely cured with good treatment. Currently, 40 percent are completely cured and then 40 percent have virtually no symptoms. A final 20 percent may never get better, even with treatment such as prolonged exposure therapy.
Tustin: Recently, there has been a flurry of programs (Road to Mental Readiness, First Responders First, TEMA, Heroes Are Human) aimed at first responders to assist them with identifying and dealing with PTSD or with building resilience. Can you help me differentiate between some of them? Or, if not, what are the components of good programs?
Foa: There is evidence from other areas of study that these types of programs are working. But I am not specifically familiar with these. Generally, though, programs that assist with mental preparation work very well. Critical incident debriefings do not seem to be helpful, as they can cause secondary victims. But the part of critical incident stress management that uses pretraining to focus on talking/seeking peer support, advocating the value of professional assistance, getting adequate rest, avoiding alcohol and stimulants, ensuring proper nutrition, and exercise is quite helpful. But after a month or so, if symptoms don’t go away, then it’s time to see a professional.
Tustin: So stress is normal for people to experience after traumatic events; it’s just not normal for it to persist. Then I’ll steal a quote from Dr. Jeffrey Mitchell, clinical professor of emergency health services at the University of Maryland in Baltimore County, “This is a normal response, by normal people, to an abnormal event.”
Foa: Yes. When it persists, that’s when treatments like prolonged exposure therapy work really well; for many, as little as five sessions are all that’s necessary. It’s important to know that 90 percent of people do not develop PTSD after a traumatic event. The majority of people recover naturally after an event. They don’t necessarily forget, and they may be more cautious, but they don’t have a disorder.
Tustin: If I have a firefighter returning to work after a prolonged absence because of PTSD, how can I help that person be successful in reintegrating back into the fire department?
Foa: What’s important to remember is that, when they do come back, they’ve had treatment and no longer have PTSD. Gradual integration is helpful; so are compassion and a stigma-free workplace. PTSD doesn’t discriminate. People should be aware that it could have happened to them just as easily.
Tustin: What can you tell me about the term post-traumatic growth?
Foa: Individuals will tell you that they’ve learned a lot from PTSD, and this is what they mean. This is a brand-new area and still being studied. Generally, though, my patients don’t talk about growth; they’re here to talk about suffering and loss. Post PTSD, each person is mentally a different person, but that is from an experiential perspective. They have overcome something that was seriously affecting their life.
Tustin: If you could tell first responders one thing that would help them to avoid PTSD, what would it be?
Foa: Understand the facts and the preparedness. Be tolerant of yourself if you have symptoms, especially immediately after. Don’t isolate yourself; stay connected. Talk to the one person you really trust. Your mind is processing a terrible event; this is normal. They should also know that for it to be a compensable injury, you must have it for at least a month or more, and it must meet the criteria of DSM-5. Benzodiazepines are not good for PTSD, and antidepressants aren’t necessarily helpful either.
Prolonged exposure therapy and cognitive processing therapy are generally the most effective treatments. But these treatments should be done by trained professionals who are certified in these treatments. The fire service needs to make sure that the mental health professionals your department is dealing with are trained in the evidenced-based diagnosis and treatment of PTSD.
Cynthia Ross Tustin is a 31-year fire service veteran and is the chief of the Essa Fire Department in Ontario, Canada. She is a member of the Fire Department Instructors Conference (FDIC) International Advisory Board, a vice president with the Ontario Association of Fire Chiefs, chair of the Ontario Home Fire Sprinkler Initiative, and the co-chair of the Home Fire Sprinkler Coalition—Canada. Tustin has worked as a critical care nurse, a volunteer firefighter, and a deputy chief. She has been published in fire service magazines and journals throughout Canada and the United States.
