The risk for psychological injury for paramedics in Queensland is not limited to the exposure to the traumatic cases they attend. Their exposure is compounded by not being adequately supported to perform their duties and, at times, being treated in an unreasonable way by their employer.
As outlined in chapter 2, the nature of first responders' work inherently involves exposure to trauma, which is known to be a risk factor for developing mental health conditions. This risk of exposure cannot be avoided, and human beings—even highly trained professionals—cannot be inoculated against the psychological effects of repeat exposure to trauma. This means that the exposure risk must be mitigated, and focus placed on prevention, harm minimisation and proper management when mental health conditions do inevitably appear.
This chapter looks at how Australian emergency services manage the duty of care they have towards their employees. What has emerged over the course of this inquiry is that a considerable discrepancy exists between the policies in place and first responders' lived experience. This fact is inextricably linked to the stigma attached to the reporting of mental health conditions by workers, with first responders in large numbers reporting being wary of disclosing their mental health struggles for fear of repercussions. Consequently, evidence provided by submissions suggests that mental illness in first responders is likely to be significantly underreported.
This chapter examines why first responders may be reluctant to report psychological problems to their employers, as well as how organisations manage mental health conditions in their workers when these are identified.
In late 2018, Beyond Blue released the findings of major research around mental health conditions in police and emergency service employees. The research found that first responders hold considerable levels of stigma around their own mental health, with 33 per cent reporting feelings of shame about their condition. Similarly, 32 per cent expressed shame about the burden their mental health placed on those around them, and alarmingly 61 per cent avoid telling others that they suffer from a mental health condition.
However, when asked whether they would support colleagues suffering from a mental health condition, a significant majority responded positively. Only one per cent of first responders hold the view that individuals are to blame for their own mental health conditions, and only two per cent believe mental health problems are a burden on others.
The research above also shows that in organisations where employees believe that organisational stigma is high, they are far less likely to report mental health concerns or seek help.
Stigma around mental illness exists throughout the community, perhaps nowhere more so than in professions which are associated with bravery, physicality and strength. This culture of silence is not new:
My father grew up never discussing his war service, never wearing his decorations that he was awarded as a war veteran and refusing to be a part of any celebration of war. I'm starting to understand, as a senior firefighter, that I'm seeing that kind of behaviour amongst a lot of people: when you put the uniform on, you're 10-feet tall and bulletproof; when you take it off, you're a very vulnerable person.
The Australasian Fire and Emergency Service Authorities Council (AFAC) highlighted that stigma is also related to career advancement:
Agencies are not immune to the stigma around mental health present within society. This has been evident through program evaluation that identified the level of stigma attached to mental health. There are also additional organisational and cultural factors impacting on the willingness of employees to engage with the preventative and support programs organisations have on offer. Feedback from workforces, including those championing mental health programs, has indicated that firefighters are concerned about reporting mental health or attendance at potentially traumatic events, on the basis that it will adversely impact on their careers.
Stigma was a common theme in submissions provided by individuals as well. An example is set out below:
Most of my mates feel replaceable, and most of my mates have some form of non-disclosed mental health issue, and I personally help them through issues every day or two, from debriefing to actually stopping “my best friend in ambulance” from killing himself. Thankfully he had the insight to ring me before he swung from that noose, and do you know what he said to me, “DON’T TELL WORK, PLEASE DON’T TELL WORK.”
Given this stigma, expecting first responders to report mental ill health may in many cases be unrealistic:
For somebody who has a mental health issue, they struggle sometimes to ring us and say, 'look, I need help'. They're hardly going to report it to the commissioner's office.
Beyond Blue described three types of stigma the organisation looked at in its large-scale national survey of mental health in first responders:
Self-stigma, an assessment of perceptions about one's own mental health conditions:
Shame surrounding their mental health (i.e. embarrassed about their conditions and seeking support).
Burden their mental health conditions placed on others.
Experiences with others, such as being treated fairly and not being avoided.
Personal stigma, views on others' mental health, assessed in two ways:
Knowledge or ignorance surrounding mental health conditions (e.g. “If someone is experiencing anxiety or depression it’s a sign of personal weakness”).
Burden an individual’s mental health condition places on others (e.g. “I would prefer not to have someone with anxiety or depression working on the same team as me”).
Workplace stigma, measuring perceptions of stigma in the workplace:
Perceived stigma—the extent to which an employee or volunteer feels others in their workplace perceive mental health conditions to be avoidable and the fault of the person experiencing them, and also a burden on others in the workplace.
Perceived organisational commitment—whether an employee believes the organisation they are a part of is committed to and capable of enhancing the mental health of their work force.
Structural stigma—to what extent an employee or volunteer believes their organisation should support someone with a mental health condition.
While the Beyond Blue study showed that many first responders exhibited feelings of shame about their own mental health condition and the burden it places on those around them, far fewer indicated they had negative experiences involving others, such as being avoided or treated unfairly. This is illustrated below:
Figure 3.1: Proportion of employees with a mental health condition who had experienced self-stigma relating to their mental health
Beyond Blue, Answering the call: National Mental Health and Wellbeing Study of Police and Emergency Services, final report, 2018, p. 88.
Data from the study also showed that self-stigma had a considerable impact on first responders:
A high number of employees indicated they avoid telling people about their mental health condition (61%), while a comparatively lower number indicated they feel embarrassed about seeking professional support (36%). A high number also indicated they should be able to pull themselves together regarding their mental health condition (61%).
Volunteers indicated lower levels of stigma surrounding their own mental health than employees. In particular, they noted less shame (23%), burden (26%) and negative experiences with others (13%).
The Beyond Blue study also showed that most first responders hold positive beliefs about the mental health of others. This fact notwithstanding, responses from a significant portion suggest that many would prefer not to work alongside someone with a mental health condition:
Employees held considerably less stigma regarding the mental health of others when compared with their own. A very low number believed that mental health conditions are the fault of the individual experiencing them (1%). In addition, only 2% believed that mental health conditions were a burden on others. However, while only 23% of employees were neutral regarding the extent to which mental health conditions are the fault of the person experiencing them, a much higher number were neutral regarding the extent to which they were a burden on the team (47%). This may indicate a lower desire to work with someone who has a mental health condition, although they don’t blame them for their experiences.
While 18 per cent of first responders indicated they would prefer not to work with a colleague who suffers from depression, very few (three per cent) held the view that anxiety or depression were signs of weakness, avoidable (five per cent), or something the sufferer can 'snap out of' by choice (four per cent).
This is possibly explained by the high-intensity nature of the work, where any constraint on the ability to make decisions calmly in stressful situations can have serious consequences.
The Beyond Blue report showed that most first responders do not hold positive beliefs about their agencies' commitment to supporting those with mental health conditions, which Beyond Blue concluded may be suggestive of working environments which are not conducive to people seeking support:
Roughly a quarter of employees believed others within their organisation perceive mental health conditions as the fault of the individual experiencing them and a burden on those around them (26%). Almost two thirds of employees were neutral on the matter (i.e. neither agreed nor disagreed).
Ten per cent of employees believed their organisation was not committed to helping address stigma, and almost three quarters were neutral. Therefore, most employees were not positive regarding their agencies’ commitment to supporting people with mental health conditions. This is particularly problematic as it may indicate a working environment less conducive to the wellbeing of employees and may pose a barrier to seeking support.
The table below offers a breakdown of views across the services:
Figure 3.2: Employees’ perceptions of workplace stigma
Beyond Blue, Answering the call: National Mental Health and Wellbeing Study of Police and Emergency Services, final report, 2018, p. 92.
These findings are reflective of evidence received by the committee directly from first responders and the mental health professionals working with them. Many expressed the belief, borne of experience, that employees reporting mental health problems would be treated punitively instead of supported. Several excerpts from publicly available evidence are set out below.
Mr Ray Karam, former police officer:
We got told, in the early days when I left, 'You're paranoid. That's just your policing,' and that sort of thing. But we had a lady just present here—and she was very lovely in how she presented it and very honest—that her son said to her: 'They're going to come after me,' and she didn't believe it. People don't believe you. They will come after you. They do come after you. Police leave for different varieties of reasons and don't speak up because there's a hierarchy that will come after you. And I don't say 'hierarchy' as in, it's just the commissioner. I feel like there's an entrenched behaviour within the New South Wales police specifically that says: 'Mental illness does not have a part and won't have a part.' They won't recognise it for what it is. They won't see it for what it is. Do we even see it for what it is? I'm not sure.
Mr John Richardson ASM, former intensive care paramedic:
In the latter years of my career in my position as clinical support officer I was fronted with the situation of having my peers approaching me for assistance with psychological distress. They would often confide in myself of their fears and issues this sometimes including self-medication to manage their stress. I learnt early that sharing these problems with senior management in the Ambulance service resulted in targeting and subsequently getting rid of the staff rather than helping them. This caused me major psychological distress as my need to help my peers caused me to feel as though I had to support these staff in isolation and without informing senior management. This lack of Managerial support impacted on all staffs psychological wellbeing.
Dr Matthew Samuel, Consultant Psychiatrist:
The other issue we have is that the police have got a police psychiatrist and the St John Ambulance have got a psychologist, but how many people who are going to go openly and tell the police psychiatrist, 'Hello, I've got PTSD and I need to be stood down'? They will be horrified. So we have got this issue. So they come to see me as a private psychiatrist, and then they go and see a police psychiatrist and tell an entirely different story.
Dr Jann Karp, former police officer:
The problem with specialised squads is that, if you're a specialised officer, you have a particular skill that you particularly like doing, such as being a sniper shooter, and you're very good at it. Can you say, 'I can't sniper‑shoot today'? If saying that means you're off the squad, you're never going to declare it.
Mr James Watkins, paramedic:
It is worth nothing that I have not proceeded with the workers compensation claim, rather choosing to pay for treatment. Part of the reason for this is I was worried that Ambulance Tasmania would decide that I should no longer be working as a paramedic. Also, I volunteer with the State Emergency Service and I was worried that if I progressed the claim I would be told I was not able to volunteer with them. I volunteer with the SES not only for community involvement but this is also a social outlet and I find a lot of support in this environment, certainly it would be detrimental to my mental health to stop attending SES training.
Mr Bruce Perham, mental health social worker and director of Let's Talk Differently:
I feel very strongly that Mental Health conditions have a long history of stigma and even today are seen as being an inherent weakness in the individual. Clients who come to counselling are often very fearful of ‘being found out’ as not coping and subsequently judged by their organisation and their peers. This fosters a ‘bottling up ‘of psychological reactions to significant trauma experiences with a façade of I am okay. We need a paradigm shift in our thinking and to come to accept and understand that psychological reactions to First Responder work is inevitable and a natural response to the passion and commitment people bring to First Responder work.
Mr Peter James, intensive care paramedic:
Workers with career ambitions are very reluctant to put claims in or seek help within the agency, as it is considered a career killer.
Historically workers who have sought help have even been ridiculed by some members of the Ambulance Service Management and or treated as liars by co-workers, this is an injury that cannot be seen. I myself have experienced this. Sometime after Port Arthur, a training schedule for flight Paramedics was posted on the supervisor’s wall changed from transporting the Psychiatric patient, to “The psychiatric Flight Paramedic”.
The committee is extremely concerned about the prevalence of stigma around mental health conditions in the first responder environment. In one sense this is a reflection on how our broader community still views mental ill health. However, culturally-entrenched stigma in first responder organisations is particularly damaging given the heightened risk of psychological injury inherent in the job.
The committee notes that a significant number of submissions were received alleging bullying and deliberate punitive action being taken by management against first responders who report mental health conditions. While it is not the committee's role to investigate individual cases, the committee is nonetheless very concerned by the evidence received and believes that first responder organisations must dramatically improve their response to, and management of psychological injury in their workforce.
Evidence from first responder organisations
The committee approached first responder agencies around the country to discuss their approach to managing employees with mental health conditions, as well as to understand what steps these agencies are taking to reduce the risk of occupational trauma.
By and large first responder organisations indicated that they accept their duty of care towards their staff, responsibility for providing safe workplaces and, as put by one agency, that they understand the need to invest money into their people.
If these lessons have been learned by most agencies, however, their stated positions largely stood in stark contrast to the evidence presented by first responders themselves. The example below is from Mr Eric O'Rourke, a veteran police officer, whose description of the response from his employer suggests that this interaction was counterproductive at best and did not reflect an understanding on his employer's part of their duty of care:
Until you personally take this journey you cannot make a creditable call. It is the most painful and dreadful experience I have been through. I was fortunate in that I had accumulated years of untaken sick leave so whilst on leave my financial situation did not change. To have my credibility, my integrity and service questioned by many, many faceless, unemotional psychiatrists was below demeaning. It was a knife strike every time. This process continued for many months. Were they hoping for a different diagnosis, were they ‘shopping for agreeable diagnosis’ I don’t know, but it certainly did nothing to help me. In fact I am sure that my possible return to work was hindered at least or perhaps removed completely by this process. Had my initial call for help been treated more kindly who knows, I may have returned to work, I may have regained my self-respect, my family may have had their father, husband, brother return from the darkness of depression and anxiety. Instead, there I was, pensioned off, unable to work with a best case prognosis and guidance of no more than 2 days a week at some less stressful job.
Evidence from first responder organisations instead largely centred on positive aspects of their engagement with staff and policies which had been or were in the process of being implemented. However, none sought to understate the nature of the work first responders do. A few examples are below.
Mr Darren Hine, Commissioner, Tasmania Police:
The Department of Police, Fire and Emergency Management is committed to providing professional support and assistance to all Tasmanian police officers, firefighters, state emergency service workers and volunteers. All emergency service workers and volunteers perform tough roles that expose them to greater risk of mental health issues, such as post-traumatic stress disorders, stress and anxiety. This risks increases with lengths of service. Emergency service workers and volunteers deserve to work in a healthy, safe and productive environment and to return home to their family and friends in the same fit state that they attended work. This is why the mental health and physical health of all of our employees remains a priority for each and every one of us.
Our department promotes a positive culture for the awareness of and assistance in managing mental health conditions. This culture is championed by our senior leaders, who believe in a work environment where police are supported and are able to seek help when they need it. Our focus is our people, and we want them to be healthy and well. With that aim, we are talking one goal one step further to attempt to proactively prevent mental health conditions through the introduction of a wellbeing program to provide support for police officers, firefighters and emergency service workers, including Ambulance Tasmania. The wellbeing program will provide a proactive, preventative and holistic approach that addresses both physical and psychological wellbeing for emergency service workers; enhance the capacity for early identification of warning signs; and provide support to our emergency service workers.
Cognisant of the fears expressed by first responders in public and confidential submissions, the committee asked first responder agencies in Tasmania whether reporting mental health problems would have negative repercussions on a person's career. Mr Hine replied:
I disagree. I don't think it's career limiting at all. In fact, that's what we want to actually tell people so that people do come along to tell us if they're suffering from mental health issues. It's not career limiting at all. In fact, if someone comes forward to get help, the earlier we can actually provide that help and get them back to where they need to be to continue on with their career the better. But, if we had that attitude, I'd be really disappointed if that attitude prevailed within our organisation because it's not career limiting at all. In fact, we need to give that person the help that they need to continue on with their career, and that's what our aim is.
Mr Neil Kirby, Chief Executive Officer of Ambulance Tasmania, accepted that a stigma does exist, but was similarly of the view that reporting mental health concerns need not have adverse effects on employees' careers:
I acknowledge that there is often concern, and the literature says there's concern, about people bringing forward their mental health issues. The approach that Ambulance Tasmania has taken is to provide as many options as we can and as many pathways as we can for a person to bring that forward. We've put in place the peer support program, we have in place the Critical Incident Stress Management Program and they can access the EAP. I can tell you that officers have emailed me directly with concerns—and we've addressed those concerns—through their management line to convey it to a manager and get the support that they needed. I likewise would hope that our staff feel that they've got a number of options they can look at to bring it forward. I certainly am with the police commissioner. I don't regard it as career-limiting behaviour. I know personally of officers within our service who have a mental health issue, if I can use the broadest term there, who still work very productively for us. At times we've found specialised areas for them to work in to support us, so I wouldn't regard it as a career-limiting step.
Mr Dominic Morgan, Chief Executive of New South Wales Ambulance, detailed work his organisation has been doing since his commencement in the role in 2016. Mr Morgan stated that he undertook a listening tour around the state early in his time as Chief Executive, and was struck by the level of concern around mental health and wellbeing. A summit was subsequently held to inform a strategic approach to mental health and wellbeing, with over a quarter of NSW Ambulance staff submitting comments and suggestions:
Within six weeks of my return, I announced that we would hold the first ever Australian ambulance wellbeing and resilience summit, which occurred in July 2016. The summit was attended by every chief executive in Australia and New Zealand, and by more than 350 staff from all around the state. Many, in their own time, contributed to nearly 1,000 different ideas for the improvement of mental health and resilience for our workforce, and those ideas have been the cornerstone of our approach for the last two years or so. This has assisted in developing our strategic approach to these issues, and it may be worthwhile spending some time briefly describing the outputs.
Mr Morgan also reported that NSW Ambulance has consulted with staff, international colleagues and local industry experts, and has implanted a number of key initiatives with funding support provided by the NSW Government. Key initiatives include:
The first wellbeing workshop for all staff was held in March 2018. Since that day we've had over 913 staff go through our workshops. Over the next three years, all staff will have completed the workshop. Since August 2018, new staff—both paramedics and call-takers—have the workshop material included in induction training. The workshop is an integrated wellbeing training course, which includes an evidence based resilience and mental health component, complemented by RAW Mind Coach—an online program available to all staff which improves resilience at work. This workshop program also includes training in relation to health and fitness, manual handling and occupational violence prevention, all of which contribute to employee mental health.
A significant events register:
NSW Ambulance implemented the significant events register in July 2016, which requires all managers to record any event that may have a potentially harmful impact on the attending staff. The staff are actively followed up and offered support services. Senior managers are responsible for reviewing the register and ensuring follow-up has occurred. In May 2017, I personally wrote to all managers and educators and advised them of my expectations and their responsibilities to ensure that follow-up occurs and support is provided. I require any manager aware of any event to follow up, not just the employee's direct manager.
A staff psychology service:
In February 2018, we commenced our own staff psychology service and our chief psychologist was appointed. Two additional appointments have been made recently, and we wish to roll this program out to each operational work area. These registered health professionals are on the ground and will develop a good understanding of our agency and our work, which will enable them to deliver professional assistance in a timely manner. Importantly, by knowing the staff in their work area we're optimistic that this will build trust and facilitate earlier help seeking for mental health concerns.
At the beginning of 2018, 33 new peer support officers were trained, taking the total number to 209. A further 29 staff are on an eligibility list ready to commence training. In April this year , we recruited a further eight chaplains, taking the team to 48. We're planning to add another 19 to our team of Christian, Jewish and Muslim pastoral carers and more evenly distribute them throughout the state. Our intention in the next few months is to combine all these services in to a staff health unit, so it is easier for every staff member and every manager to have a one-stop shop where they can go to get advice and support.
Whilst the focus has been on what is directly in front of us, we're now turning our mind to those closest to them—the families. Since March 2017, the Supporting our Families program has been running. The program helps our paramedics' families to more fully understand what it is that the paramedic job entails, how they can recognise signs of stress or mental illness in their loved one and what they can do to assist them to get well, stay healthy and get appropriate help.
Notably, the service is also working to develop staff with management responsibility in order to ensure that they are equipped to deal with the complexity of mental health issues in the workplace.
The committee also notes NSW Ambulance's introduction of a therapy dog into its busy control centre. The idea, Mr Morgan informed the committee, stemmed from case studies in Canada:
There were some interesting case studies a few years ago, where the Canadians were moving to what I would describe as a 'superstation' model, and they noticed that having a dog in the workplace was really well regarded. It's very hard for people to stay angry at a dog, as you can imagine. Our Sydney control centre is the busiest Ambulance 000 call centre in the Southern Hemisphere, and it is a high-pressure environment for anyone to work in. The manager in that centre decided that it would be worthwhile to bring in therapy dogs, just for a visit, as it started. I was fortunate enough to be there the first day the therapy dogs were brought in. It was truly amazing seeing grown adults sitting on the floor in this high-pressure environment and absolutely engaging with these animals. The carers tell us that they're of the view that these dogs absolutely know the people who are in distress and know who to go for, and they target them.
The manager of the Sydney control centre is now going to care for that dog. We're going to reimburse her for the costs of that. They've organised the schedule within the Sydney control centre so that the dog will come to work every single shift and the staff will take turns caring for the dog and taking it for a walk. You can imagine what a great interrupter this is of the pressure of taking triple-0 call after triple-0 call. It's just one initiative that has been very, very successful in the eyes of the workforce.
Box 3.1: —The lived experience
We have never been satisfied with how Morgan was managed. From the first time our son, Morgan, began to experience psychological difficulties, and right up to the moment of his death from suicide in March 2009, he was comprehensively mismanagement by New South Wales Police, which led to his death. This includes how he was perceived and managed the year before his death and his management right up until the night he died... The police management of Morgan was always defended by New South Wales Police. No apologies for poor decisions or actions or inactions has ever been offered to us. Morgan's management by New South Wales Police was only ever investigated by the New South Wales Police themselves.
Mrs Janet and Mr Barry Hill, parents of Morgan Hill, police officer
I believe the management of my rehabilitation was appalling. I believe the management hindered any chance of recovery & actually exacerbated my condition. I believe that an independent person should oversee the process & assist in liaising between all parties whenever there are issues. The primary focus of the NSW Police & the Rehabilitation Consultant were to return me to Policing duties regardless of my condition, symptoms & medical reports that indicated I was not fit to return. My experience would have been less stressful & managed more efficiently if there was someone to make sure that my best interests were taken into account & that all parties followed Policy & Procedure.
Mr Alex Cooper, police officer
In my personal experience, they just didn't care. There was no-one from welfare who came around to check on me or my family. When I was pensioned out of the police force, that was it. I was isolated, I was alone and I had to try and survive.
Mr David O'Connell, former police officer
Approximately 5 years ago I started to display signs of PTSD. I started having nightmares about cases that I attended. Many nights awaking standing in the bathroom trying to wash brain matter off my hands from a job that I attended. This didn’t get any better, but worse. My personality changed with my family, I began drinking heavily, became withdrawn, but when at work continued to put on the face, be the respected Paramedic that I always have been. On September 11, 2016 I had reached the end of my road…I had decided that I couldn’t go on any longer and had planned to end my life at the end of the shift. I took one vial of Fentanyl from the station safe, and at the end of the shift started to inject myself intramuscular. As to why I did this, I still am unclear but I knew that I was ending my life that day…I was investigated for the missing vial of Fentanyl, and in the investigation meeting I was very candid about what had occurred on the day. I gave full disclosure about the events. I realised that I needed help, and had started to see a phycologist for assistance. I honestly believed that by being honest and open about what had happened then the QAS would assist me with my PTSD and help me move forward. I could not have been more incorrect…I was asked to show cause as to why I should still be able to work as an Advanced Care Paramedic. I was given time to put together my case’ I think it was about 2 weeks. I sent my show cause response in on a Monday, and I had a reply sent back on the same day that I was being terminated after “careful consideration”. The letter that was sent through was scathing and stated that they did not believe my excuse of PTSD was a contributing factor. I remember still the despair I felt on that day. To this day I am grateful for the support of my family, psychologists, and close friends who supported me through this time. If I did not have those people around me I know I wouldn’t be here now.
Mr Chris Arnol, Chief Officer, Tasmania Fire Rescue, was of the view that the days when reporting mental health concerns would jeopardise a first responder's career were, although legitimate, a thing of the past. He did however acknowledge that stigma is pervasive:
I think there is still a stigma attached to reporting, and our reporting is showing that we're not getting the reports from, perhaps, the trauma-associated psychological concerns. For example, we've currently got three people on workers comp for psychologically related issues and another 18 who are not—so it's for trips and falls and so on. But I think there is a stigma attached to it still. Whilst we're encouraging people to come forward and say, 'I've got a concern'—particularly, in SES and fire, in road crash rescue, where we see so much more trauma now than we did with just pure fire and fire death—I think it sits there and people are still hesitant. Whether it's a general societal position or not, they're still hesitant to say, 'Yes I've got a psychological issue or a stress issue,' because stress, I think, has had a bad name over time as well. So I can't say I've got research, but I've certainly got anecdotal evidence from career firefighters that they have concerns but they're not reporting them. As much as we have tried to do that—including in collaboration with the UFU, with which we are working together on this—we've had difficulty having people come and say that. We've actually got a lady firefighter that's resigning today. She's been on leave for 12 months, but I don't think she's been quite as frank as she should have been about what her issues were.
Noting that a considerable appetite for change appears to exist at the top of first responder organisations, the committee sought to understand why this did not appear to be having a marked effect, one that would be palpable for employees themselves. Mr Craig Atkins, representing Code 9 Foundation, provided valuable insights into the culture of first responder agencies:
[P]olicy is one thing, but culture overrules policy—culture trumps policy—at all times. There is a good commitment at the top. I think what's happened in Victoria Police lately, in the last 12 months, has been a been fantastic move. And I think a lot of the agencies are really having a decent look at their mental health policies now, but there's a long-entrenched culture, so it will take a long time to filter through all ranks and all lifelines, basically. That will take a lot of changing—some of those middle areas where people enlisted into the agencies in the eighties when our culture was quite stoic. It will take a long time to have that new culture filter through and change… [W]e are all of an ilk: the first responder mentality is very alpha and very stiff upper lip. We don't need help; we provide help. So it will take a long time for that culture to change. It is changing at the recruit level, in all the agencies, but there is that middle section that's going to take a long time to bust through, I think.
The Police Association of Tasmania described this phenomenon as a 'culture clash' in which long-embedded ways of thinking were at odds with the current cultural shift towards accepting the validity and importance of mental health:
Unfortunately, there is a cultural clash where the old meets the new. Again, as stated in the PFA submission, the old culture has been historically male dominated and encourages brute endurance and a denial of mental trauma, which leads to a fear amongst police that acknowledging distress will result in damage to their careers. The words 'Go away, drink a nice big cup of concrete and harden up' have been used many times in the past. Pockets of bullying and harassment sadly still exist in society and in workplaces in general. Policing is no different and promotion to a position of power does not necessarily make one an expert in the field of everything, particularly around mental health issues. Merely acknowledging that PTSD and/or work related mental health issues may exist means absolutely nothing if there is no real action to address the issues.
The committee sought evidence on this point from Victoria Police. Asked whether they accept that there is enormous resistance and stigma attached to reporting mental health problems and mental illness itself, as well as what the service was doing to ensure that change filtered through middle management to employees, representatives of Victoria Police stated:
I'm not sure that I accept that that is as prevalent as I guess is suggested. A mental health review, as you would be aware, was initiated in 2016, and there were 39 recommendations made as part of that mental health review. All of those recommendations have been accepted, and we are in the process of systematically working through the implementation of those recommendations. Those recommendations are also being implemented in conjunction with the VEOHRC [Victorian Equal Opportunity and Human Rights Commission] review which was undertaken in 2015 into sexual harassment, sexual discrimination and predatory behaviour in the workforce. Both of those reviews highlighted management and leadership practices as an area of concern and an area requiring further work and focus. Certainly there have been a number of initiatives that have come out of both of those reviews that are addressing the concerns raised. I think there has been significant progress made. A recent pulse survey that we have conducted as an ongoing means of monitoring the implementation of the mental health review recommendations suggests that there is improvement in people's willingness to speak up and ask for help, and there is reduction in the notion of stigma. Although I would say that we certainly still have a long way to go, we are certainly making progress in the right direction.
Victoria Police representatives added that the organisation monitors workplace culture, engagement and issues around wellbeing through a survey, 'People Matter'. The results of this survey, the committee heard, suggest that improvements have been made. Recommendations are implemented on a regular basis, and the process is managed through a dedicated office:
We've also developed a Mental Health Strategy and Wellbeing Action Plan with significant governance around the implementation of the actions that are in the plan, which are aligned to the recommendations of the review. We've also worked through systematically to look at the content of many of the training modules that we offer, both in terms of foundation training for recruits and promotional and managerial training programs. We've aligned a lot of the content that we're delivering with partners like beyondblue, Black Dog Institute and Phoenix Australia—so we're working very much in partnership with them.
Appearing at a public hearing alongside representatives of the Code 9 Foundation, Ms Debra Purnell, from the Australian Association of Social Workers, added that as well as not filtering down from the top, policies generated by management may not necessarily be in tune with the actual needs and experiences of employees:
Our members have also suggested that often, while there may be training provided or there may be counselling or services available, sometimes it doesn't meet the needs of the people in the workplace. So it's not good enough to say, 'Let's just get this package off the shelf and deliver it, and that's ticking the box and it's meeting people's needs.' I think the feeling is that you actually need to find the response that's going to work for the individual and for their situation, and I don't think it's good enough to just say, 'Go along to a session on how to deal with trauma or how to deal with difficulties.'
The committee broached this with Victoria Police, noting that while the Code 9 Foundation had acknowledged that improvements were being made, membership numbers for Code 9 have been growing, suggesting that increasing numbers of first responders are accessing support groups for mental health conditions. Victoria Police suggested that this may not necessarily mean that mental health conditions were increasing in prevalence, and that instead people might feel more comfortable reporting a problem:
With the release of the mental health review and us beginning work on implementing the recommendations, we did anticipate that we would have increased reporting and that there would be more complaints made, more issues raised et cetera. In many ways, if your numbers are going up, you might consider that to be not a good sign. But in the sense of people feeling safe to speak up and as an indication that stigma is beginning to reduce we actually took that initial increase as a sign that progress was being made.
This is supported by other evidence, such as that pertaining to NSW Police. Although NSW Police did not wish to engage with this inquiry and declined opportunities to make a submission or appear at a public hearing, the committee noted witnesses' scepticism about policies being put into place by the service. As put by Mrs Janet Hill, whose son, a police officer, died by suicide:
[R]egardless of present welfare policies—and apparently the New South Wales Police organisation has introduced 90 welfare policies—we have observed that there still is a particular culture in the New South Wales Police organisation that has entrenched the stigma of psychological injury of post-traumatic stress in their own force. And we can elaborate anecdotally because people still come and talk to us. In the Police Force they feel that they can talk to us privately, secretly—and you heard that from some of the other people. We still hear those stories, and one of the reasons we are here today is that most of those people find it extremely difficult to give a voice themselves. We feel that, while we are being a voice for Morgan, we are at the same time being a voice for all of those whose voices are silenced for one reason or another. Because they are suffering, they cannot come to something like this and speak about what is going on. And it is not just because of the triggering effect, but also because they fear management.
Mr Ray Karam, a former police officer with NSW Police, concurred:
We're great at recreating things and making it look like we're doing something, but I'm looking at mates around my home town that aren't doing well, still. And how can we have post-traumatic stress on the rise? If we've had 90 policies implemented just in the last few years, that shouldn't be happening. If there are more people committing suicide, that can't be happening, because we're over it, aren't we? Police will be saying—and I'll just speak about New South Wales—'No. We've got 90 policies here. We're over it. We have to be handling it.' But if it's increasing, then they're missing it.
This suggests that, in some services at least, the policies in place do not add up to produce results for people on the ground. The committee notes a salient point made by Mr Rosario (Ross) Fusca, a former AFP officer and current welfare officer assisting firefighters in Victoria. Mr Fusca observed that the ability to report mental health problems in a work environment has a lot to do with trust:
Another issue that needs to be addressed is: employers need to gain the trust of their employees so that there's a relationship to provide the appropriate support.
A submission from the United Firefighters Union of Queensland (UFUQ) collated members' responses when asked about lack of trust in their employer's willingness or ability to manage the reporting of psychological injury. The lack of trust was found to be based on a number of factors, including:
lack of progressive, proactive capacity in QFES [Queensland Fire and Emergency Services] to handle the management of psychological injuries, and
lack of confidentiality within QFES management and a repeated inability to handle the sensitive nature of psychological injury in a reasonable and appropriate way, and
a zero-tolerance approach to any type of injury within QFES firefighting and fire communication centre employees, with a total focus on reduction of employer risk and a risk averse attitude to managing employees with injuries, and
the over-reliance by QFES on referral to assessment of fitness for duty as the first step in their injury management processes, drawn from the availability within the Queensland Fire and Emergency Services Act 1990 for forced medical retirement of employees who are assessed as unfit for duty, and
assumptions about the cause of injury and the defensive risk averse approach of QFES and an unfortunate focus on minimisation of that risk to the detriment of true consideration of the duty of care to employees, and
many other factors, such as QFES regional variability in the organisational maturity and capacity to handle injury management.
The committee notes that the issue of trust has not escaped senior management in some organisations. Notably, representatives from QFES acknowledged the failures of the past and the hard work required to rebuild trust:
We're very careful, more so than ever before now, to make it a human intervention and not a bureaucratic, heartless, clinical interaction. That's a move that I think is happening right across our industry. It's the hardest thing to actually get large organisations to not immediately act heartlessly, so that's a work in progress for us. What goes hand in hand with that is the notion of people trusting the system and that if they do put their hand up they're not going to end up being thrown out. In our earlier history—we're probably not the only agency in our industry around the country—you were either good to go 100 per cent or you were asked to go.
These sentiments were echoed by the Queensland Police Service (QPS):
They're good people; they're very, very good people [QPS staff]. We have pockets of incredibly good practice across this state. We have some pockets of very poor practice. We're on a journey. I don't profess for one moment that we're perfect, but we're very, very committed to making a difference and changing in this space. There are people who would say they've been treated appallingly—and they have been, obviously and usually through the ignorance of the person they're speaking to it about. But you will also see some incredibly positive stories of genuine support. In the latest union journal, which has never been backward in criticising the QPS more generally when it's not agreed with things, there is a letter to the editor that made my heart sing. It was an officer telling his story of sitting in a car crying, hidden away from his colleagues, because the impact of his psychological demons had just taken its toll on him. He was so fearful of going back to his officer in charge because of his traditional notion and perhaps because he feared that he would not be listened to… The wonderful letter showed the sympathy, the empathy and the support that he got from his officer in charge. That's what we're planning as our future. We've got a long way to go. We've had some horror stories of what some people have experienced. But, if you then start looking at the statistics, they're a relatively small number compared with the 15,000 that are there. But I'd be the first to say that even that small number is probably a very big underrepresentation of the people who suffer with these conditions.
In contrast to this frank and honest account, the committee again notes that the New South Wales Police service declined the opportunity to engage with this inquiry.
Privately owned first response organisations
A number of submitters expressed serious concerns about the management of employee wellbeing by St John Ambulance (SJA), a not-for-profit organisation not part of the state government, but instead contracted by the state government to provide ambulance services in Western Australia. One such submission, from Sirens of Silence, described breaches of confidentiality by management, bullying and intimidation, as well as the practice of performance managing mentally ill staff out of the organisation.
Sirens of Silence cited no less than six reviews of SJA conducted in eight years, once of which concluded:
The Independent Oversight Panel (IOP) review released August 2016 ‘St John Ambulance WA Health and Well Being and Workplace Culture’ revealed that the panel reported that “submissions and hearings illustrated a culture where bullying appears to be systemic, if not condoned, and that it does not appear to be consistently addressed. One officer in a management position reported being told they need to be more aggressive when dealing with Paramedics.”
Another witness, Mr Patrick O'Donnell, Assistant Branch Secretary of United Voice WA, pointed out that part of the problem is that ambulance services are not legislated in WA. As a result, SJA's contract with the state government does not specifically set out the employer's responsibilities in terms of staff health and wellbeing:
[T]here is no ambulance legislation in WA. Many states do have legislation or their service is legislated. There's no recognition of ambulance as an essential service, there's no policy you can point to that just talks about the service in WA as an essential service. Essentially it's run between a contract between St John and the state. That contract is really very simple and it sets very basic KPIs around attendance at jobs, but that's about it. It doesn't go on to put into the contract the responsibilities that we would expect the employer to have, or the government to take, on service provision to the community, the quality of care provided and the health and wellbeing of the workforce, and we think this is something that needs to be addressed.
The committee raised these concerns with SJA. Representatives of the organisation told the committee that SJA had accepted 26 out of 27 recommendations made by three reviews:
The organisation's been very transparent—developed an operational plan and shared that with the organisation.
The committee noted, however, that SJA did not accept a key recommendation around key performance indicators relating to psychological risk and care of the workforce operating under SJA's contract with the state government. SJA did not explain why this recommendation was not agreed.
The committee notes that oversight of outsourced first responder organisations is necessary to ensure that these comply with standards to be defined by the Commonwealth-led national action plan and recommendations contained within this report.
The committee recommends that federal, state and territory governments work together to increase oversight of privately owned first responder organisations.
Work with external organisations
Beyond Blue established a police and emergency services program in 2014, with the objective of promoting mental health for both current and former workers in the emergency services, volunteers and their families. The purpose of the program was to reduce these individuals' risk of suicide:
Our first significant activity in this space was really finding out what was going on, looking across agencies and across each of the particular disciplines of the sector to really see what they were doing to protect mental health and prevent suicide. That led to the development of a good practice framework for mental health and wellbeing in first responder organisations, which we launched in 2015. As with all of our work in the space, we partnered with police and emergency services agencies and their staff to develop the framework. It has now been applied in several agencies as they develop their own mental health strategies. We also worked very closely with Ambulance Victoria last year to develop their training program, Mental Health Matters @AV. The program has been delivered to over 6,000 operational and non-operational staff. An independent evaluation found that it had a significant impact on knowledge and attitudes among Ambulance Victoria staff and extremely high levels of satisfaction.
Noting this initiative and the work done by organisations such as Beyond Blue and the Black Dog Institute, as well as a range of smaller support organisations, the inquiry revealed considerable inconsistency across agencies around the country.
Services in some states reported noticeable shifts in culture and practice following the rollout of projects intended to improve the response to mental health problems. In South Australia, for example, the South Australian Fire and Emergency Services Commission (SAFECOM) has sought out training through Mental Health First Aid Australia. The organisation reported positive feedback from employees:
Culturally, I think we are getting somewhere. It's early days still, but in some of the feedback that's come through—if you'll allow me to read it out—one person said: 'Very good course that will improve over time. Mental health is such a diverse subject, but what was covered was worthwhile. I certainly feel more compassionate towards people with mental health and also now equipped with basics to assist people in need.' Other comments we've got are: 'very important that the officers of the emergency services, especially the volunteers, are aware of these issues', 'very informative and valuable to both personal and CFS operations', 'useful', 'recommended that all CFS brigade officers undergo this training', 'excellent value for people who are managing people in high-stress environments', and: 'I was excited to tell my brigade and workplace about it, encouraging people at both places to do it. It opened my eyes and gave me a deeper understanding. Thanks.'
Work done by SAFECOM is revealing that greater numbers of first responders may be feeling comfortable enough to disclose mental health concerns to other, colleagues at least:
The other interesting thing is that we are doing our own evaluation of the program. As part of that, we are doing a pre and post survey to see if there are any changes in people's attitudes. Preliminary data is that there is a shift, but what was really interesting is that 56 per cent of our people are actually recording that they're having access to or they're dealing with fellow brigade members or unit members who they believe possibly have a mental health condition. That's actually been quite surprising for us and something that we probably need to explore further because that's quite a high number coming through already.
Some, however, take the issue very seriously yet lack the resources required to implement optimal mental health strategies. SAFECOM for example, pointed to recent studies the South Australian Country Fire Service has taken part in which identified links between first responder occupations and mental health conditions:
Group critical incident stress debriefing and emergency services personnel, 2014;
Prevalence and predictors of mental health in firefighters, 2016; and
National mental health and wellbeing study of police and emergency services, 2017 (report 2018).
Witnesses speaking on behalf of South Australian fire services were cognisant that more needed to be done, but noted that limited resources force the prioritisation of critical areas:
As a service, we need the resources to implement the recommendations resulting from the findings of these studies. We need to track our brigades and units who have had high exposure to trauma, and put strategies in place to support these people. We need to talk to our volunteers more to educate them on mental health and provide them with strategies to increase their health and resilience in their volunteer career. We've already started this process, but we need to continue that. We need to continue to provide mental health first aid training to our senior volunteers and staff, as these are the people who are dealing with volunteers experiencing mental health issues, and they are often under a lot of pressure themselves. We need to increase the capacity of our volunteer peer support team to assist in providing stress and trauma education to volunteers and their families. We need to promote our services more broadly through online programs, including information that increases awareness through various mediums such as our training modules, posters, pamphlets, et cetera. We need to also promote our mental health and wellbeing message to rural and remote volunteers.
However, our largest barrier to providing the full complement of necessary mental health services to our volunteers is staff resourcing. As mentioned in the submission, we have one full-time equivalent position, which is mine, and there is no capacity to implement the additional initiatives required to provide volunteers and staff with a broader program. With only one position, much of the mental health response is primarily focused on those areas considered to be critical.
Available research suggests that prolonged shift work can in itself be detrimental to health and wellbeing. The committee noted that better rostering has also been identified as a significant opportunity for mitigating the risk inherent in shift work for first responder agencies.
Improved rostering practices which foster a healthier work-life balance, however, require more funding:
The areas that we believe are of most importance and relevance to PAT [Police Association of Tasmania] members, and that provide relief and proactive responses to PTSD, include roster reforms—roster reforms that provide a greater work-life balance for all shift workers. These have been resisted historically by police management, as they require more police to run these types of rosters. Better rosters equals more police, which equals more funding. If we were to go down the path of looking at some of these rosters, we believe that the money spent on recruiting more police would be offset in the long term by the reduced sick leave and higher productivity which comes from a happier workforce. Flexible work arrangements have also been mentioned in the PFA submission. These should be available to police in all areas. Sadly, all police officers at this stage can't avail themselves of these flexible work arrangements, for a number of reasons.
As put by another witness, resourcing is a big problem and may be influencing organisational attitudes towards healthier rostering practices:
[Y]ou can run out training programs and you can have barbecues and you can have R U OK?, and you can do all that, which is really useful, but it just doesn't alter the structures that these people work in. The systems are so regimented in terms of rosters and delivering services to high-needs clients that, if you actually step back and say, 'Okay, we're going to provide psychologically what first responders need,' the resources it would take would be astronomical. I hear, 'Well, if in the real world we had a bucket of money, we could do that.' But the psychological recommendations go into this—'Well, we have no resources. So, yes, it would be great if we could provide certain things, but we don't have the resources to do it.' So we're at a stalemate. An example is that often first responders will tell you how ineffectual they felt their management was; they either went to them or didn't feel they could go to them or were told: 'That's a part of the job. You knew you were going to have that when you signed up, so what are you wasting my time for?'
Dr Brian White, a consultant psychiatrist, noted that emergency services should also actively rotate staff to better manage the amount of exposure individuals have to trauma:
There is a pressing need for all emergency services to look at ways of restructuring the amount of exposure and to improve the level of support and understanding that is given to their operational personnel. This may need to include consideration of significant limitations on the number of years and the intensity of experience in operational employment. Ideally, this means that there should be an active program of rotating staff.
Over the course of the inquiry it became apparent that collaboration and discussions were taking place between different first responder services around the country. The committee noted that police and fire services are generally governed by state emergency services, while ambulance services fall under state health portfolios (noting that in Western Australia and the Northern Territory, ambulance services are outsourced from the health portfolio to a private provider).
As part of a wider discussion around the work Beyond Blue is doing to help organisations looking to develop a mental health strategy, the committee questioned whether there was merit in establishing national guidelines on how strategies could be implemented across various emergency services. Ms Georgina Harman, Chief Executive Officer of Beyond Blue, saw potential in that approach:
I think there's something in that. As we work our way through the very, very large volume of research evidence that we're working through at the moment, we're thinking about what kinds of recommendations we should make—not only industry specific, but also things that can be progressed predominately by states. We're also asking, 'What is the Commonwealth's role?' That's an active kind of thought process for it. We haven't quite landed on a particular view yet, because, as I said, we need to let the evidence tell us what those recommendations are. But I think there is a role that the Commonwealth can play in bringing people together.
Such an approach would focus on the commonality between various emergency service providers rather than their differences and, the committee heard, could be a valuable way of bringing together and benefitting from data and experience collected nation-wide:
I think there is a role the Commonwealth can play, in a strong leadership sense, in binding those findings together and actually promoting and potentially even monitoring—not monitoring in a Big Brother type of way, but actually bringing people together in communities of practice, for example, to find out what's working, what didn't work so well, what we learnt from that and so what do we do next.
We're also potentially thinking about—there is lots of research and lots of research data. There's nothing yet at a population level, and we believe our research will fill that gap, but there are lots of really significant pieces of research, both qualitative and quantitative, across those sectors. Some is at a state level; some is at a service level. Bringing that together in one place so that there's a sort of evidence hub and then using that as the single source of truth, it could be a useful role for the Commonwealth to play.
Creating mentally healthy workplaces
When its Answering the call report was finalised, Beyond Blue pointed out that while the first responder agencies inherently operate in a context involving particular risk factors, they are also workplaces. This means that:
…the core components of an evidence-based approach to a mentally healthy workplace are just as relevant to them as any other workplace.
Furthermore, while different agencies differ in the type of work they perform, Beyond Blue's research highlighted common themes—many directly associated with workplace factors—which in themselves should give first responder organisations valuable insight into how best to tackle the problem:
In all agencies there was a concerning number of employees with poor mental health. All agencies had high rates of psychological distress and probable PTSD in their employees. All agencies had personnel with mental health conditions who were not seeking or receiving adequate support. All agencies had staff who perceived stigma—particularly adverse career impacts—which impacted on seeking support for mental health conditions. These themes indicated that many of the issues identified in the survey are relevant across all police and emergency services agencies. In addition, the results showed that these issues are strongly and directly associated with workplace factors.
The figure below from Beyond Blue depicts features of a resilient workplace:
Figure 3.3: A resilient workplace
Answering the call: Beyond Blue's National Mental Health and Wellbeing Study of Police and Emergency Services, 2018, p. 108.
The Black Dog Institute stressed the importance of high quality research when it comes to managing mental health problems and implementing workplace strategies to address them. Professor Samuel Harvey cited the example of psychological debriefing, which is often cited as an important aspect of mitigating the risk of exposure to trauma:
I suppose I also wanted to make note of the fact that history gives us a warning about the risk of ignoring some of the research evidence when we think about how to respond to this problem, and I make mention in our submission of psychological debriefing… [In] brief, psychological debriefing became very popular in first responder agencies in the 1980s and 1990s. By the late 1990s there had begun to be concern amongst some academics and clinicians that it may not be helpful, but by that stage it was almost ubiquitous amongst first responder agencies around the world. By the time we did randomised control trials that looked at it and were able to bring all those together in 1998, in a landmark systematic review, what had become clear was that debriefing wasn't helpful and that there was some research evidence that suggested that, rather than preventing PTSD, first responders who got debriefing were actually at increased risk of PTSD. So really it's a salient lesson, I think, about how rolling out things that seem like a good idea and are well intentioned can have unintended consequences.
Professor Harvey informed the committee that the institute has been developing a program of research in partnership with first responder agencies. Equipping agencies to deal with mental health conditions has been at the forefront of this work, which has clearly shown the importance of managers and leaders in setting the culture of a workplace, as well as in responding when staff are unwell:
The problem we had was that no-one was clear about whether you could train managers to do that role better and, if so, what that should look like. We partnered with Fire and Rescue NSW to develop a new four-hour training program for their managers, where, based on those research studies that we had in there, we really focused on giving managers the confidence to have those discussions earlier, because that seemed to be one of the key things that was holding them back from doing that.
As pointed out by Ms Simone Haigh, Vice-President of Paramedics Australia, it is important to remember that managers in first response organisations may themselves be affected by the nature of the work and environment:
I think that managers—an on-road paramedic talking about managers—are probably forgotten in the mental health space as well. Some of this culture may also be that they're broken as well. We have to remember that this is a whole organisation thing, not just the frontline staff.
The training program benefitted from a randomised control trial in which all Fire and Rescue NSW duty commanders were split into two groups—one which received the management training and the other which did not. The results clearly supported the strength of the training course:
We followed them up for six months. What we found was that the managers who had got that training had significantly increased levels of confidence after six months, that their behaviour had changed and, perhaps most importantly, when we looked at the impact of that on the firefighters that they were managing—and the measure we had from them was their sickness absence records—that there was a substantial reduction in sickness absence amongst the teams with managers who had got that training. That helped to make the economic argument about how there was a 10-to-one return on investment for that type of manager training.
The committee notes that the Black Dog Institute has been working with the ambulance services in NSW and Victoria to roll out an online version of this manager training so that it is more broadly accessible.
The return on investing in mental health programs is considerable. In developing its national workplace mental health program, 'Heads Up', Beyond Blue engaged Pricewaterhouse Coopers to conduct an independent analysis of the cost to business and employers of not doing anything. Lack of action on mental health in Australian workplaces, the analysis found, translates to almost $11 billion in lost productivity per annum. Furthermore:
We know also from that research that every $1 invested in an effective, evidence based mental health workplace initiative, action or strategy returns on average $2.30. That ratio changes between industries—that's the average. So it is a no brainer. If organisations and employers are not doing this, they are losing money. They are losing good people.
Considering the cost of training first responders, money invested in mental health provides a positive return on this investment. The committee received evidence on research conducted internationally:
The IAFF [International Association of Fire fighters] has done an awful lot of research into the benefits of the Wellness-Fitness Initiative [North America].
Within the Wellness-Fitness Initiative it also includes mental health, and what we find is that for every dollar you invest in it it's around $2 to $3 you get returned. That return is from—you have less sick time, you have quicker time for individuals being able to get back into workforce and, overall, the morale of the department goes up. So you find that there is a financial winning by putting money into the health and safety of your employees… It's an absolute tragedy when you lose a firefighter or paramedic. But when you look at it from an educational standpoint, if you have a firefighter or a paramedic who has 20 years of education that they've put in there, and they're an officer, and then you lose that person, tragically, you've lost all that funding that you've put into that person, because he still has 10 years left to be an officer. So that is a cost in itself.
In terms of the effect of investment in mental health on workplace morale, the committee heard the benefits are incalculable:
I would suggest it even contributes to the esprit de corps of the department. The women and men of the fire service are the greatest asset of the fire service, and they're willing to go above and beyond whenever they're called upon. The very right thing to do is to be there for them when they need assistance. That goes a long way to establishing this tremendous esprit de corps within the service. I think you can't put a price on that.
The committee similarly notes that the Black Dog Institute has put forward a proposed model of how various factors at work, which are not directly related to exposure to trauma, may overlap and intersect with one another. This model is based on a meta-review the institute published in 2017, which looked at all available international literature linking work situations to mental ill health:
Figure 3.4: Black Dog Institute proposed model of the interaction between non-trauma workplace risk factors for mental health
Black Dog Institute, Submission 94, p. 6.
The figure above shows that the level of perceived value and respect in the workplace can be a predictor of workers' mental health. The Black Dog Institute submitted that this was demonstrated by a survey looking at military veterans returning from deployment in the 2003 war in Iraq, which found that both morale and senior support in units were strong predictors of the likelihood of veterans developing PTSD.
A recent study looking at paramedics' experience of leadership and its influence on staff mental health, also conducted by the Black Dog Institute, clearly shows that paramedics who feel supported by management report fewer mental health problems.
This is illustrated below, where manager behaviour (MB) and manager psychological safety climate (MPSC) are plotted, showing the link between the level of support and mental ill health symptoms as measured by the K6 score on the left.
Figure 3.5: Data from Black Dog Institute study of ambulance personnel showing links between management behaviour, psychosocial safety in the workplace and symptoms of mental ill health
Black Dog Institute, Submission 94, p. 7.
Mental health management overseas
The committee benefitted from a submission from Executive Fire Chief Officer Ken Block, based in Edmonton, Canada. The submission outlines the Edmonton Fire Rescue Services mental health program, a joint program between the service and the Edmonton Fire Fighters Union. The program is confidential, voluntary and non-punitive. Its aim is to improve fire fighters' quality of life whilst demonstrating the value of investing resources into wellness:
With the positive engagement from preliminary mental health programming efforts, a Mental Health Coordinator was hired in 2016. At the time, Edmonton was the first major municipal fire department in North America with a full time Mental Health Coordinator.
Once the Edmonton Fire Rescue Services mental health task force was formed, it was delegated with three initial areas of focus:
To increase awareness of and educate staff members on issues related to mental and behavioural health specifically affecting those within the emergency services.
To lead a shifting of the organizational culture within Edmonton Fire Rescue Services with respect to dealing with issues related to mental and behavioural health.
To research best practices regarding mental health training programs suitable and appropriate for emergency services personnel.
This work has led to the development and rollout of two training programs for Edmonton Fire Rescue Services staff in 2016. Both of these were endorsed by the Mental Health Commission of Canada.
The first program, Mental Health First Aid, teaches staff how to recognise the signs and symptoms of a mental health condition, how to provide initial help and how best to guide the affected person towards appropriate professional help. It is not intended to transform staff into therapists. The second program, Road to Mental Readiness, aims to reduce the stigma of mental illness and increase awareness of mental health and resilience. A number of other programs and initiatives are in development.
A submission was also received from Mr Alex Forrest, a Canadian firefighter and health and safety advocate with 15 years' experience on the issue of PTSD and related legislation, as well as the International Association of Firefighters (IAFF) Canadian Trustee.
Mr Forrest's submission sets out treatment programs in place internationally, such as the IAFF Centre of Excellence located in Maryland in the United States. The centre is a residential rehabilitation centre purpose-built to treat firefighters:
[The centre] is a 60-bed unit that delivers treatment programs backed by scientific research and is headed by qualified clinicians with a wealth of experience in behavioral health and health care.
Located in Maryland just outside Washington DC, the facility is designed like a fire house and builds on the comradery that firefighters experience and value when at work with each program unique to the firefighter’s needs. The center includes a fully equipped gym, volley ball and basketball courts, reflection areas, outdoor walking trails, yoga and writing therapy spaces.
The submission also provides valuable insight into how presumptive legislation can be introduced to help first responders suffering from PTSD. This topic is addressed in the next chapter.
In the immediate future, the committee is persuaded that greater oversight needs to be applied to ensure that first responder organisations make the mental health and wellbeing of their staff a priority. Most first responder organisations fall under the jurisdiction of state and territory governments, with the Commonwealth Government only having jurisdiction over the AFP. However, given that the common mental health challenges faced by first responder agencies across the nation, the committee sees considerable opportunity for the Commonwealth to play a valuable leadership role in a long-term, nationally coordinated commitment to addressing and protecting the mental health of our first responders.
The committee recommends that a Commonwealth-led process involving federal, state and territory governments be initiated to design and implement a national action plan on first responder mental health.
Evidence strongly suggests that many first responders resist reporting concerns about their mental health due to pervasive stigma around mental illness in the community broadly and within first responder organisations specifically. There is a genuine fear—in many cases supported by first hand or anecdotal experience—of being subjected to ridicule, bullying and discrimination if problems are reported. The committee believes that it will take dedicated and proactive work by first responder agencies to change this organisational culture.
The committee recognises the importance of providing evidence-based training packages to first responders aimed at reducing workplace stigma, improving self-identification of symptoms and supporting colleagues.
The committee recommends that compulsory first responder mental health awareness training, including safety plans, be implemented in every first responder organisation across Australia.
The committee also notes the work already underway in some first responder organisations. In particular, the committee recognises that managers and leaders in these workplaces are primarily responsible for workplace culture, and must therefore be adequately trained to ensure they are equipped to manage the people they lead in a healthy way.
The committee recommends that compulsory management training focusing on mental health, such as that developed by the Black Dog Institute, be introduced in every first responder organisation across Australia.
The committee is also of the view that management training and mental health support services should be extended to all volunteer first responders and services as well.
The committee recommends that mental health support services be extended to all first responder volunteers.