Vol. 3, No.

1
June 2021

FIRST RESPONDER MENTAL HEALTH:

A LITERATURE REVIEW OF CURRENT INDIVIDUAL AND ORGANIZATIONAL
ISSUES.

Jordan Bolzon HBSW, School of Social Work, University of British Columbia Okanagan
[email protected]
Nick Halmasy MACP, Registered Psychotherapist; After the Call
[email protected]
Abstract: First responders are exposed to potentially traumatic events (Ricciardelli, Czarnuch et al. 2020; Carleton,
Afifi, Taillieu et al., 2019). Although, they may not be traumatized by said events (Yehuda et al., 1998). This paper
examines three themes emerging in the current literature surrounding first responder mental health. These themes are
individual mental health knowledge and exposure to trauma; stigma and resilience training; and mental health at the
organizational level. This review acknowledges that much of the current literature is flawed although still provides
valuable information and results. We conclude with recommendations on improving current and future research as
well as first responder mental health.

Keywords: first responder, resilience, stigma, mental health, review

Introduction be used as stand-alone interventions or as part of

broader CISM programs (Beshai & Carleton, 2016).
First responders are ninety percent more likely to Based on current literature, mental health
be exposed to a potentially traumatic event (PTE) training for first responders is severely under
more than eleven times in their lifetime, whereas the achieving and cultivating a piece of the current stigma
general population is likely to be exposed to much in the workplace. There are minimal preventative
fewer (Ricciardelli, Czarnuch et al., 2020; Carleton, programs, and most interventions are completed after
Afifi, Taillieu et al., 2019). PTSD is classified in the critical incidents and retention and learning is minimal
fifth edition of the Diagnostic and Statistical Manual (Beshai & Carleton, 2016; Carleton, Korol et al., 2018;
of Mental Disorders (DSM-5) as a Trauma- and Ricciardelli, Andres et al., 2020). There is also a
Stressor-Related Disorder (American Psychiatric disconnect between supervisory or management staff
Association, 2013). It is estimated to affect first and frontline workers regarding mental health training,
responders at an estimated rate of ten to twenty-two stigma, and a lack of acceptance of potential mental
percent (Carleton, Afifi, Taillieu et al., 2019; Carleton, health issues among both groups (Knaak et al., 2019;
Korol et al., 2018; Skeffington et al., 2016; Szeto et Ricciardelli, Andres et al., 2020; Ricciardelli,
al., 2019); however, PTSD is no more probable than Czarnuch et al., 2020). An overhaul of mental health
major depression or other mood disorders following a and resiliency training needs to be conducted with
traumatic exposure and there are substantial numbers programs that involve check-ins, refreshers, and
who do not develop PTSD or other mental disorders preventative measures for all mental illnesses. There
(Yehuda et al., 1998). are three fundamental areas of focus these trainings
Current interventions and trainings include the should cover: individual mental health knowledge;
Road to Mental Readiness (R2MR) program, Critical stigma, and resilience training; and mental health at
Incident Stress Management (CISM), Peer Support the organizational level.
Training and Programs, Crisis Intervention Stress
Debriefing (CISD), defusing, Psychological First Aid, Individual Mental Health Knowledge
psychoeducation, the NOVA program, the Raphael, and Exposure to Trauma
and Dyregrov Models of Debriefing, Group Stress
Debriefing (GSD), emotional decompression, A key theme that emerged from a study on
Multiple Stressor Debriefing (MSD), and attitudes and practices for hiring first responders was
Demobilization (Beshai & Carleton, 2016). There is that many current employees found that many new
split evidence on whether these interventions should hires would be unaware of the mental health issues that

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CSHR Vol. 3, No. 1 June 2021
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 FIRST RESPONDER MENTAL HEALTH:
A LITERATURE REVIEW OF CURRENT INDIVIDUAL AND ORGANIZATIONAL
ISSUES.

could arise from repeated exposure to PTEs low perceived resilience and the exposure to traumatic
(Ricciardelli, Andres et al., 2020). events during training uniquely predicted the risk of an
Results from an Australian-based firefighter episode of depression (Wild et al., 2016).
study collected results of PTE exposures with 90% of A longitudinal assessment of the R2MR program
participants having at least one exposure and less than in Canadian police found results that imply that the
40% using adaptive coping strategies (Skeffington et program may not be as effective as hoped (Carleton,
al., 2016). These results imply that there is more at Korol et al., 2018). The study found no significant
play in preventing mental wellness issues due to changes in mental health knowledge nor resiliency
repeated traumatic exposure than knowledge, training, scores across time (Carleton, Korol et al., 2018).
and positive coping strategies (Skeffington et al., Furthermore, there was a decrease in stigma
2016). immediately following the training, but the decreases
Moreover, a study on the potential pre-trauma were not significant at the six- and twelve-month
risk factors for PTSD and major depression (MD) in markers (Carleton, Korol et al., 2018); yet a different
paramedics conducted in London U.K. indicated that study on the R2MR program for all first responders
the paramedics at risk of developing PTSD or MD found improvements in resiliency and stigma in a span
could be identified within their first week of training of three months (Szeto et al., 2019),
and that these paramedics could benefit from increased Results from a study on mental health knowledge
mental health training to boost resilience (Wild et al., stigma and service use intention for Canadian first
2016). responders indicated that higher mental health
A study on Canadian first responders exploring knowledge was associated with lower stigma and
the relationship between PTEs and positive screens for higher willingness to seek professional help with
mental disorders found positive screens can occur for exceptions being found in firefighters and paramedics
many kinds of trauma exposures but never found that regarding stigma and service use intention
one mental disorder could be a result of one type of respectively (Krakauer et al., 2020).
trauma exposure and the opposite was also indicated A study on mental health training and screening
in that no singular traumatic event could be the cause positive for mental disorders found that when
of a singular mental disorder (Carleton, Afifi, Taillieu participants were given some form of mental health
et al., 2019). training their chances of screening positive for any
A study conducted on paramedics in Switzerland mental disorders declined (Carleton, Afifi, Turner et
found that most participants did not report PTSD al., 2020). The study also found that any mental health
symptoms (Streb et al., 2014). They attributed this to training increased perceived access to mental health
having available psychological help at work, high support (Carleton, Afifi, Turner et al., 2020).
resilience, and a sense of coherence with others (Streb Current research is being done on resiliency
et al., 2014). This is indicative of the importance of building, and evidence from that research is being used
having peers help support you to minimize mental to build better programs that need to be implemented
wellness issues (Beshai & Carleton, 2016). as preventative measures to help others understand the
In 2018, a study on Canadian first responders’ hiring practices of first responders (Ricciardelli,
likeliness of exhibiting suicidal behaviours found Andres et al., 2020). Resiliency training should be
police and firefighters were least likely to exhibit included before exposure to trauma, and refresher
suicidal behaviours whereas, paramedics had the resiliency training that target modifiable predictors of
highest rates in both past-year and lifetime prevalence PTEs should be compulsory (Wild et al., 2016).
categories (Carleton, Afifi, Turner et al., 2018). The
researchers attributed this to rates of trauma exposure, Mental Health at the Organizational
mental disorders, and organizational stressors Level
(Carleton, Afifi, Turner et al., 2018). This concept
In first responders’ organizations, organizational
leads to implications of organizational barriers and
stressors may be causing poor mental wellness among
questions the importance of workplace relationships in
frontline staff. A study found that a higher sense of
preventing first responder mental wellness issues.
coherence within the workplace led to less severe, if
Stigma and Resilience Training any, PTSD symptoms among paramedics (Streb et al.,
2014). Another study suggested that the likelihood of
First responders need to be resilient and need to suicidal behaviours among first responders could be
know that exposure to trauma is a regular occurrence attributed to organizational stressors (Carleton, Afifi,
and be able to manage that (Ricciardelli, Andres et al., Turner et al., 2018).
2020). A 2016 study concluded that paramedics with

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 FIRST RESPONDER MENTAL HEALTH:
A LITERATURE REVIEW OF CURRENT INDIVIDUAL AND ORGANIZATIONAL
ISSUES.

A study that explored the balance between There was a mix of qualitative (Knaak et al.,
individual and organizational issues when it comes to 2019; Ricciardelli, Andres et al., 2020), quantitative
hiring first responders identified a need for (Carleton, Afifi, Taillieu et al., 2019; Carleton, Afifi,
organizations to be clearer about what is expected on Turner et al., 2018; Carleton, Afifi, Turner et al., 2020;
the job when hiring (Ricciardelli, Andres et al., 2020). Carleton, Korol et al., 2018; Krakauer et al., 2020
Many participants said their organizations need to be Skeffington et al., 2016; Streb et al., 2014; Szeto et al.,
better at hiring people who can manage the job stress 2019; Wild et al., 2016), and mixed method
and that there are discriminatory practices in place for (Ricciardelli, Czarnuch et al., 2020) studies with more
when first responders need to take time off for a mental emphasis on quantitative studies, which provides clear
illness (Ricciardelli, Andres et al., 2020). A 2019 statistical analysis opportunities and allows for
study identified perceived or real lack of support from generalizability. Diagnostic screens were often basic
leadership, poor recognition of mental health issues, standardized tests which do not prove diagnoses.
and poor workplace culture among tri-service as
primary issues (Knaak et al., 2019). Changing these Conclusion
perceptions would be useful in reducing the mental This literature review has drawn many
wellness issues within policing organizations (Knaak conclusions for first responder mental health.
et al., 2019). Primarily, there needs to be more research done with
Some participants stated that organizational stronger methodologies and better sampling methods
issues were more stressing than the traumatic incidents to gain more conclusive and generalizable results.
they regularly faced (Ricciardelli, Czarnuch et al., Furthermore, fixing some organizational issues such
2020), more participants said that there was unequal as changing and enforcing poor policies and practices
treatment of colleagues by supervisors, harassment, to prevent harassment and improve workplace culture
and general mistreatment of employees by supervisors will reduce first responder mental wellness issues.
and administration, and workplace bullying both by There also needs to be changes regarding stigma and
colleagues and supervisors trying to push personal resilience training such as implementing better
agendas in a Canadian study (Ricciardelli, Czarnuch et evidence-backed training programs with refresher
al., 2020). The authors address the lack of human courses to ensure retention and continuing to reduce
resources in these organizations as another issue stigma. There also needs to be more education at an
(Ricciardelli, Czarnuch et al., 2020), and suggest that individual level about mental health and trauma
organizations need to examine the accessibility of their exposure effects on the individual so new hire first
policies and practices to create a more positive work responders are better prepared and able to get support
environment, provide better training programs, and for their mental health if needed so they can stay in the
lobby for more budget allocations to provide the field. More research needs to be conducted for better
necessary resources to first responders (Ricciardelli, education, training, and organizational supports to be
Czarnuch et al., 2020). evidence-backed and useful in the long term.
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