What other job requires you to be in a constant state of hyper vigilance and alertness yet at the same time be a counsellor, a social worker, a lawyer, or a prison warden. What other profession authorizes you to take a person’s liberty, or potentially use deadly force, but then mandates that you attempt to save the person’s life that has just tried to kill you? What job causes you to wonder whether you will come home to your loved ones after you bid them farewell each and every day as you head off to work?
First responders are highly skilled men and women who deliver the initial response in emergency situations, interacting with people and the forces of nature in extreme circumstances. Incidents requiring emergency response often involve serious injury or death, or a threat to life, safety and property. The term 'first responder' most commonly refers to professionals such as paramedics, police officers, fire fighters and other emergency personnel trained to provide assistance in time-critical, often life-threatening situations. It may also refer to individuals who perform those functions in a volunteer capacity and emergency control centre workers.
There are over 80 000 full-time emergency workers in Australia. These professionals perform an indispensable function in the community, dealing with vulnerable people in urgent need who may be injured, in a state of heightened anxiety, shock or distress, in danger or deceased. They do this in circumstances where their own safety may be at significant risk. By definition, these jobs entail highly challenging working conditions and regular exposure to traumatic experiences, including both direct and vicarious trauma. They often work on irregular shift patterns, and face long hours, fatigue and the need to make often critical decisions under constant time pressure. They do this almost every day, for years on end.
The subject of mental health conditions in first responders is garnering growing interest in Australia and internationally. It is now widely thought that first responders are at increased risk of experiencing serious, ongoing stress which if left untreated may develop into mental health conditions including anxiety, depression or post-traumatic stress disorder (PTSD).
This chapter looks at the reasons for, and prevalence of mental health conditions in first responders.
Expectations and the hazard environment
Emergencies can be prepared for and personnel can be trained, but they do not occur at a time or on a scale of any organisation's choosing:
Whilst in some situations, such as issues of social disorder, floods and cyclones, it is possible to predict and prepare for the likelihood of an event, it is rarely possible to predict the degree of severity or damage, and in many cases incidents (such as road accidents, house fires and homicides) arise randomly and unpredictably.
In When Helping Hurts: PTSD in first responders, a report following a high-level roundtable, independent and not-for-profit think tank Australia21 finds that managing the expectations of a crisis environment as well as the wellbeing of staff 'has many of the characteristics of a wicked problem'. The challenges are considerable:
These include how to staff first responder organisations to accommodate some recovery time from the inevitable stresses of their role; how to prepare first responders for the psychological risks of the job without undermining the motivation and spirit that attracted them to the work in the first place; how best to provide in-service psychological counselling and training to maximise personal resilience while also enhancing the ability of the organisation to identify in good time people in need of help; how to honour the courage of those who do seek help in an organisational culture that also honours resilience and capacity to keep on responding in times of danger and crisis.
The University of Adelaide Centre for Traumatic Stress Studies reports that emergency service workers face particular occupational hazards which present a risk to their mental health, describing the high rates of mental health disorders in this cohort as a 'predictable phenomenon':
In essence, it is the cumulative exposure to horrific accidents and life‑threatening events, as well as the personal threat to the individual officers, that leads to a cumulative risk of developing a range of mental health disorders. It is striking that there is little actuarial modelling of this risk of mental [health disorders] in the course of the career of an emergency service worker in any of the emergency services.
This is borne out by other research, which suggests that first responders may be particularly vulnerable to sequential stressors due to the nature of their work.
Box 2.1: —The lived experience
An example of my early career was as a student I was tasked for “the baby run”. This is where I would go on my own to a midwifery home on a Monday morning. The task was to package up the still born babies born over the weekend. I would have to place each baby in a cardboard box then place them on the ambulance stretcher (on one occasion I remember there were 7 babies). I would then drive down to the Royal Hobart Hospital mortuary and place each box on a sand stone shelf in the mortuary fridge. At the time this did not impact me, but as the years and decades have rolled on I think about this often.
Mr Peter James, paramedic
Our work as First Responders is not a sterile office environment. We put our hearts and souls into our work. We constantly risk our lives at work. We have lost friends in our work. Our families risk losing a son, a daughter, a father, a wife when we go to work. We have had colleagues significantly burnt or injured, shot or wounded, beaten and bashed, fallen from heights and hit by vehicles. We have had colleagues take their lives because of their experiences at work. We have had colleagues suffer and sadly die from significant cancers because of workplace exposure. Our actions or inactions are something we must carry with us for the rest of our lives… It is an honour and privilege to help others, but just as we care for others we also need to be cared for.
Mr Andrew Picker, firefighter
I was in road patrol and we were called to a fatality. I had been to plenty and you learn too just ‘deal with it’. When we got there, we saw two fourteen-year olds lying dead on the road. It hit me like a brick. I was so overcome with emotion. I did what was needed to be done but I was emotionally numb and I can’t get the vision of those two lost lives out of my mind. I always just saw the bodies I never saw them as people. My mistake that night was I saw them as teenagers. Now my heart thumps every time we attend an accident. I just feel I will never be the same again.
Anonymous, police officer
I was really struggling and felt I just couldn’t go on. I was exhausted and just felt like crying. People were dying, how selfish it would have been for me to express what I felt in that context. I just kept going but by the end I was a wreck.
Anonymous, volunteer firefighter
During my career I have responded to over 2000 cardiac arrests which I was actively involved in resuscitation attempts, ages ranged from newborn, to the very aged persons… I have attended and managed over 2500 motor vehicle accidents, and have declared there to be no signs of life in many hundreds… In many of the above cases I personally have had to inform the parents of a deceased child that their child is deceased. That is very difficult to do (however it is part of the job), but it is even harder to inform a child that their parent/s are deceased… I have been assaulted multiple times… I have been shot at, involved in knife fights and feared for my life on numerous occasions, I have also had my family threatened on numerous occasions and witnessed a murder and suicide… I know that the above sound like a story but it is real and happens every day in the emergency services.
Mr Malcolm Babb, paramedic
The situations first responders witness and deal with vary, and may be psychologically challenging in a number of ways:
They may see revolting or otherwise confronting things at the job they are called to.
They may think that they are about to lose their own life when attacked by armed or otherwise dangerous individuals.
They may identify with the circumstances surrounding an incident to the degree that they become emotionally involved. (This may be evident when a first responder from an abusive family background gets called to a domestic violence scene or when a paramedic or police officer who is a parent attends the death of a child).
They may be impacted by the grief and distress of victims around them in a wide range of circumstances.
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) concurred that most first responders are exposed to trauma repeatedly:
Exposure to trauma or ‘critical incidents’, such as disasters, interpersonal violence, traffic accidents, and combat, forms an important part of the work of first responders and emergency service personnel. Research on Australian firefighters provides a valuable snapshot of trauma exposure in emergency services. A study on South Australian metropolitan firefighters found that 76% of the workforce reported exposure to 10 or more critical incidents throughout their career, and almost all those involved reported witnessing death on the job.
Mental health can be influenced in a number of ways in this cohort:
The mental health of non-operational and operational first responders and emergency service workers can be influenced by a number of factors, including traditional workplace risks such as large workloads, lack of control over work and demanding deadlines and targets. Operational first responders and emergency service workers face unique risks in addition to traditional workplace risks, including repeated exposure to trauma. Individuals recruited often have high expectations of their own performance and a low tolerance for failure.
Submitters distinguished between two different ways in which exposure to trauma, described by one firefighter as seeing 'things that no human should see', may affect first responders:
Particular cases which impact the worker profoundly.
The cumulative effect of repeat exposure to confronting situations.
The hazards and risks of exposure to trauma cannot be understated and, the Centre for Traumatic Stress Studies reported, this is supported by evidence:
There is an extensive body of literature documenting these hazards and risks. The combined literature would suggest that ambulance officers and paramedics are a group at highest risk. In general, the risk is highlighted by the positive linear relationship between the number of fatal incidents attended and the rates of posttraumatic stress disorder, depression and heavy drinking, independent of emergency service in which the individual serves.
These risks extend beyond emergency personnel who are directly exposed to trauma at the scene of an event or events:
This has been noted in emergency medical dispatchers who take calls from the triple zero hotline. While further research is required before secondary trauma is fully understood, it is important that it be considered with regard to emergency services personnel and to ensure that treatment and care are appropriately provided.
Ms Jeannie Van Den Boogaard, formerly a dispatcher for the Victorian Emergency Services Telecommunications Authority (ESTA) with 15 years' service, spoke of her lived experience going to work one day and coming home 'a different person':
I was employed by ESTA as a Dispatcher for the Fire Services for 15 years before having to reluctantly resign on the advice of my psychologist due to my mental health. I was diagnosed with PTSD and severe depression in February 2014. I was on night shift for Black Saturday (February 7th, 2009), I was subjected to almost 13 hours straight of the horrors of that event and was severely affected by what I had endured throughout that shift and the weeks to follow.
I, somehow, remained at work for the next 5 years. I was never the same person after Black Saturday. I knew that something was not right but I didn’t understand what I was going through. Directly following Black Saturday, I tried tirelessly to be heard by management regarding many matters, to have changes made to procedures and to have more support for the staff but none of those came to fruition.
Box 2.2: —The lived experience
I started my role as a superintendent with ACT Fire and Rescue on 13 February 2009. My very first job on that day was to approve a list of staff that were deployed to the 2009 Black Saturday bushfires. Amongst that list of staff that I approved on that day was a very good friend of mine and a family friend called David Balfour. David was killed in the line of duty, supporting the state of Victoria and supporting our staff. That took a very big toll on me, and it will stay with me for the rest of my life that I made the decision to send that man to Victoria.
Mr Pat Jones, firefighter
When three of my colleagues committed suicide, I was never given any counselling. I wasn't allowed to discuss it… I was expected to keep going—turn on the Superman switch, which doesn't work anymore. I don't know how I've summoned up the strength to appear here today to give this evidence. I don't need notes. It's all in here. Every day of my life, every night, is a living misery for me—for what has been done to me and what has happened in the police force without being allowed to get closure and to speak about the individual life-threatening incidents that I've been involved in.
Mr David O'Connell, former police officer
The point of no return for me all happened within a week in May 2012 where I was required to view over 1700 child pornographic videos over 2 days. I believed it was an unpleasant part of an otherwise great job. I felt I was saving others having to view this abhorrent behaviour. I couldn’t control my emotions, shocked at the cruelty & degradation I was witnessing. I had NEVER [had] such a response which confused me, because I’d seen so much I didn’t think there was anything which could shock me. Flashbacks & triggers still appear as a result of those 2 days to this day, though they have dissipated.
Ms Narelle Fraser, former police officer
Emergency service officers do not usually become unwell after a single traumatic event. Instead, it is often repeated exposure to trauma over time which results in building and gradually worsening symptoms:
In first responders and emergency service personnel it is not simply exposure to a single traumatic event but repeated trauma exposure that results in the neurobiological dysregulation that underpins the emergence of clinical disorder. Population studies show that the number of trauma exposures increases the risk for post-traumatic stress disorder and other adverse health outcomes.
The committee heard that it is doubtful whether training and conditioning can ever completely mitigate this risk. As put by the United Firefighters Union of Australia:
Firefighters are very well trained, and you can train a firefighter, and certainly this country has got great firefighters, but you can't condition them from the accumulated exposure to the trauma. We've looked at programs. Recruits get some education and promotional courses, but you cannot inoculate them from the accumulated exposure. You've got to remember that, when they knock off to go home to their own family, they may have just had to deal with a child passing away from SIDS or alternatively…with the hanging of a young girl. You've got to go home and pretend you're a happy father or a happy mother or a happy parent.
Dr Brian White, a consultant psychiatrist and member of the International Society for Traumatic Stress Studies, describes mental health conditions as being 'broadly proportional' to exposure to trauma, outlining a number of factors which can determine how individuals respond over time to these experiences. While training, support and general health are important and play a role, Dr White states that exposure to traumatic experiences is the key factor:
The most significant factor is the number and severity of these traumatic experiences. The second most significant factor is the management of people after they have had such experiences. Poor support and isolation if not outright aggression and intimidation will significantly aggravate these conditions. There are a number other factors which are important; including effective training, effective leadership, physical fitness, having a clear mission and positive community support are all important. However, in terms of the relative contribution to the production and perpetuation of psychiatric syndromes are less significant than the actual traumatic experiences.
The figure below, provided by the Black Dog Institute and based on data collected from a survey of fire fighters undertaken in 2016, clearly illustrates the relationship between the number of fatal incidents attended and mental health outcomes:
Figure 2.1: The impact of cumulative trauma exposure
Black Dog Institute, Submission 94, p. 6.
While reliable data was limited over the course of this inquiry, in late 2018 Beyond Blue released a report on its large-scale study of mental health and wellbeing in police and emergency services. The report is a valuable resource for agencies and policymakers. In relation to the prevalence of mental health conditions, key findings include:
10 per cent of employees have probable PTSD. The prevalence of PTSD in the general Australian population is estimated to be four per cent.
21 per cent of employees have high psychological distress, and nine percent very high psychological distress. Among the general population, those figures are eight and four per cent respectively.
39 per cent of employees reported having been diagnosed with a mental health condition by a mental health professional at some point in their life, compared to 20 per cent of the general population.
51 per cent of employees indicated that they had experienced traumatic events which affected them deeply.
The risk for psychological distress and PTSD increased with length of service. Two per cent of employees with less than two years' service have probable PTSD, while 12 per cent of employees with more than 10 years' service exhibit signs of probable PTSD.
The report also effectively illustrates the connection between the number of years in service and risk of PTSD.
Mr John Richardson, an intensive care paramedic for 37 years before being medically discharged due to a mental health disorder, captured the effect of cumulative trauma eloquently:
My belief is we all have a stress bucket and as we confront stressful situations the bucket accumulates stress and starts to fill. Most emergency service personnel are good at managing stress (empting some of the bucket) but sometimes we can’t keep the bucket from overflowing resulting profound emotional reaction. This continuing accumulation/emptying of the bucket over many years had a telling effect on me. Even though I thought I could handle everything this was not the case. This became apparent when dispatched to a choking child which I knew in my mind could either be something life threatening or something minor. As a single officer response on the way to the case I had a profound emotional reaction. After this event I was forced to acknowledge that I was burnt out so I took some sick leave. While on this sick leave my wife, family and friends convinced me that I needed help and it was the result of workplace injury.
The committee does note, however, that individuals can, and do, at times experience a single event which is so traumatic that their lives are upended in a short space of time. One such submitter, Ms Jeannie Van Den Boogaard, experienced this after the horrific Black Saturday bushfires in Victoria:
Unfortunately, I was rostered on for a 12-hour night shift on Black Saturday, 7 February 2009. I actually went in a little early and took over region 13's CFA radio dispatch. Not long after I slipped my headset on, the fires took off through the Kinglake region, and within about 20 minutes I was dealing with a horrific mayday call from a crew whose fire truck had become disabled, and they had the fire bearing down on them. That was only the start of my shift. To describe the whole shift to you and to have you totally understand what I went through for nearly 13 hours straight would take way too long, but, exactly a year to the day of Black Saturday, I wrote a story, called One year on. It is a total account of what I endured that day as a dispatcher. I did attach it to my submission... I left out the gory details, but it will give you a total understanding of the roller-coaster of emotions, the madness and mayhem in the control room and the anguish of those on the front line that day. Most people think of Black Saturday as a one-day event, when, in actual fact, it went on for weeks. I, like others, went back in, shift after shift, even on my days off during those weeks. Unfortunately, as a result, I now have PTSD, severe depression and anxiety. I went to work one day, and I came home a different person whose life has been changed forever.
Work intensity and resourcing
The committee also noted evidence supplied by the Ambulance Employees Association, South Australian branch, which urged a rethink of the pressure ambulance crews are placed under:
I've also seen a steady and relentless increase in work intensity from a time where some downtime as part of the job was assured, because of the number of crews and the workload, to now, where the workload is unmanageable. It creates risk for ambos themselves and the community they serve. This is compounded by chronic shortages in the health system generally. I've also seen over this time fatigue emerge as a significant and increasing concern for frontline ambulance first responders.
Shift work and intense rostering practices are also said to impact on both mental and physical health. These risks are discussed further in chapter 3.
This clearly goes to the question of resourcing. However, as with all sectors, tighter budgets impact on the amount of money available for staffing, as well as the expectations and pressure placed on staff:
Over time, it's become more difficult to gain funding from governments to ensure ambulance service delivery is properly resourced. Governments tend to skimp on funding as long as they can get away with it. This approach has led to poor response times and the trampling of ambos' rights for a timely meal break, to knock off on time and to get some respite from the job, as well as an alarming disregard for the impact of work intensity on ambos' mental health. All roles in the public service are important and all are busy, but the role of ambulance first responders has unique factors that are not accounted for in the demand-supply equation. Unlike other roles, trauma, distress and antisocial behaviour are encountered on an almost daily basis in an environment that is uncontrolled, unpredictable and which requires time-critical, adaptive and autonomous decision-making. People's lives depend on it. Human factors that should be considered are not in workforce planning.
The committee also raised the issue of ambulance ramping with witnesses.
Ramping refers to the time ambulances spend in a hospital emergency department while ambulance officers or paramedics care for and hand patients over to the care of emergency department staff.
Upon arrival at the emergency department, patients are triaged. Priority is given to urgent or life-threatening cases, such as those requiring resuscitation. Ambulance officers or paramedics stay with non-urgent patients until their care can be transferred.
The committee heard that in Tasmania for example ramping is a serious concern for first response organisations, whose ambulances and staff cannot provide a service to the next patient while they are on the ramp. However, a strategy to address this problem was not in place at the time of the committee's public hearing.
Mental health injuries
The mental health conditions first responders report include depression, anxiety and post-traumatic stress disorder (PTSD). Co-morbidity including a number of conditions simultaneously is not uncommon in this cohort, nor is self-medication with alcohol or other forms of substance abuse.
Safe Work Australia (SWA) has commissioned four reports relating to mental health and the workplace in Australia:
Work-related mental disorders in Australia – April 2006
Psychosocial safety climate and better productivity in Australian workplaces: Costs, productivity, presenteeism, absenteeism – November 2016
The Australian workplace Barometer: Report on psychosocial safety climate and worker health in Australia – December 2012
The relationship between work characteristics, wellbeing, depression and workplace bullying: Summary report – June 2013
The first of these, Work-related mental disorders in Australia, summarised available data on both the severity and magnitude of mental health conditions, as well as the evidence on approaches to prevention and their effectiveness. The report drew a distinction between PTSD and other psychiatric disorders, noting that the condition carries with it a raised risk of developing other mental health disorders. Three categories of stressors leading to PTSD were identified:
time limited stressors – high intensity events the victim is unprepared for
sequential stressors – cumulative effect of multiple events, and
long-lasting exposure to danger – such as repeated abuse which can remove inner sense of security.
The most prevalent mental health condition reported by first responders and health professionals who treat them is PTSD. Mental health professions first recognised PTSD as a syndrome in the 1980s. It can be a debilitating and chronic condition:
It is usually triggered by exposure to traumatic situations where an individual may be placed in a life or death situation that can also challenge their emotional resources, beliefs and values.
Evidence from RANZCP points to the significant risk emergency personnel have of developing PTSD, as well as complex manifestations of mental illness which may not reach diagnostic criteria but may well be damaging to the individual:
Particularly well studied in this field is post-traumatic stress disorder (PTSD), with systematic reviews of the evidence indicating that emergency service personnel have a significant risk of developing PTSD in the course of their working career. This is particularly concerning when the numerous physical comorbidities of PTSD are considered, acknowledging that it is a systemic disease that can have a significant impact on a number of areas of life. Approaches to this issue must also consider the issue of suicidal ideation and behaviour with lower levels of mental distress, known as sub-syndromal PTSD. With sub-syndromal PTSD individuals report levels of symptoms that a just below the threshold required to reach the DSM [Diagnostic and Statistical Manual] diagnostic criteria. Sub-syndromal PTSD has been identified as being a significant risk factor for the later emergence of PTSD.
The committee heard that PTSD is by its nature difficult to diagnose, and often takes time to formally diagnose. While most people would meet the necessary criteria for PTSD immediately following a traumatic event, it is those who do not recover in coming months that can be accurately diagnosed:
In the initial weeks after trauma most people meet the criteria for PTSD, then over the next three months 50% recover, with recovery continuing over time. Full diagnostic criteria for the 10–15% who develop PTSD are not met until six months have elapsed, yet early intervention gives the best prospects for recovery.
Furthermore, first responders affected by PTSD may display problems with behaviour and performance at work that are not unique to sufferers of the condition, meaning that their PTSD may exist undetected or mischaracterised. Submitters recognised that while employers need to be compassionate towards workers, they must also manage the risk of spurious claims designed to avoid accountability for underperformance.
The Centre for Traumatic Stress Studies pointed to emerging evidence indicating that PTSD is a systemic disease, emphasising the need for those managing the mental health of first responders to understand this and the complex neurobiology involved:
While trauma exposure is the critical precipitating event for conditions such as PTSD, and psychosocial risk factors play a significant role in the onset of the condition, the role of neurobiology cannot be under estimated. PTSD impacts a multiple of biological systems, including inflammation, endocrine and metabolic function. Brain circuitry and neurochemistry are also significantly disrupted in a progressive manner with repeated trauma exposure. Generic factors and the switches that activate genetic mechanisms are also increasingly being understood to play a significant role in the onset and maintenance of the condition. It is important that any consideration of both prevention and intervention carefully considers the neurobiology of posttraumatic stress disorder. This is increasingly the case because of the emerging evidence that PTSD is in fact a systematic disease carrying with it significant physical comorbidities such as autoimmune disease, hypertension, metabolic syndrome and decreased life expectancy. This extensive literature cannot be reasonably summarised in the course of this submission but it is a critical body of knowledge that needs to be understood by any occupational workforce managing the mental health of emergency service workers.
This, the committee notes, highlights the importance of early intervention:
With the passage of time these symptoms tend to remain and then escalate with further trauma exposures. This highlights the substantial opportunities for early interventions. It is also the case that a significant percentage of emergency service workers who develop a PTSD remain within the workforce in the earlier stages of developing the condition. Subsequent exposures to traumatic stress lead to the increasing severity of their PTSD. It is in the context of the increasing disability that they finally are no longer able to keep functioning. Presenteeism is common problem rather than individuals taking excessive sick-leave. The continued presence in the work place when they are unwell leads to a worsening of their prognosis and a decreased probability of having a positive outcome from treatment.
Dr White submitted that while PTSD is prominent, it is not the only mental health condition generated by exposure to trauma, which can lead to a range of depressive and anxiety disorders as well. He also noted that the conditions suffered by an individual have a major impact on their families.
The Australian Counselling Association concurred, adding that mental health conditions may not be immediately obvious:
First responders, emergency service workers and volunteers have been shown to be at risk of a number of mental health problems; which could include alcohol abuse, depression, posttraumatic stress disorder, fatigue, suicide and others. The preponderance of mental health disorders increases the risk of death by suicide. There is no blanket term or single diagnosis that encompasses all potential mental health conditions experienced by first responders/emergency service occupations. Mental health conditions can manifest quietly and have significant implications on the individual’s overall health and wellbeing.
The committee noted that, while clinically important for individuals and the professionals treating them, breaking psychological disorders down into different categories may be counterproductive in terms of gauging their prevalence in the first responder population. This salient point was made by Mr Ray Karam, former police officer and founder of Police Are People, a community project which offers support to police and other first responders and works to build awareness of the impact of high intensity work:
As to figures, I don't know if you've had any luck in getting accurate figures, but they break things up. So I'm watching now to see how they break up PTSD, because it'll be post-traumatic stress disorder under this heading, and there'll be different levels of it. So they'll break it all up, so you won't have how many people actually committed suicide here, how many were on the job here, how many were this or that. They break all the figures up for a reason. Scatter it across and it doesn't look as bad.
Noting this key point, the next section looks at available data on the prevalence of mental health conditions.
Prevalence of mental health conditions
At a public hearing on 5 September 2018, the committee heard that Australia was lacking a national dataset or baseline measurement of mental health conditions in Australia's first responders. The prevalence of mental health conditions in first responders is difficult to establish with accuracy, but is widely considered to be considerably greater than that found in the broader community. A number of submitters and witnesses sought to provide estimates.
Statistics on the number of mental disorder claims, provided by SWA, offer some insight. SWA stated that an average of 711 serious workers' compensation claims were submitted per year from 2011-12 to 2015-16, equating to about 10 per cent of serious mental disorder claims:
Of these claims, Police account for the vast majority (an average of 566 serious claims or 76 per cent), followed by Ambulance officers and paramedics (an average of 120 serious claims or 17 per cent), and Fire and emergency workers (an average of 53 serious claims or 7 per cent.
SWA provided a table comparing select statistics for mental health claims among first responders and others from 2011-12 to 2015-16:
Figure 2.2: Selected statistics for serious mental disorder claims among first responders compared with total serious mental disorder claims and with all serious claims (2011-12 to 2015-16)
Safe Work Australia, Submission 30, pp. 3–4.
The table shows that both the frequency rate and incidence rate are more than 10 times higher in the first responder cohort than the general population, and that the median claim payment for first responders is also nearly double that of the general population. Furthermore, first responders' claims lead to significantly more time off work. The figure below, also supplied by SWA, depicts a rise and fall in the number of claims made by first responders and others from 2006-07 to 2015-16:
Figure 2.3: Number of serious workers’ compensation claims for mental disorders among first responders compared with all mental disorder claims (2006-07 to 2015-16)
Safe Work Australia, Submission 30, p. 4.
While the numbers of claims follow a similar pattern, it is important to note that trends may reflect more than just the prevalence of mental disorders. They may also reflect 'changes made within jurisdictional schemes with respect to the compensability of mental disorders.'
The following figure, also supplied by SWA, shows that while claim numbers for police, fire and emergency service workers follow similar trends to those depicted above in Figure 2.2, claims for ambulance officers and paramedics followed a different pattern over the same period:
Figure 2.4: Number of serious workers’ compensation claims for mental disorders by first responder occupation
Safe Work Australia, Submission 30, p. 5.
Tellingly, the highest proportion of claims for first responders was due to mental stress, followed by exposure to trauma. As could be expected, the level of first responders' mental disorder claims due to exposure to traumatic events was three times as high as amongst the general claimant population.
Figure 2.5: Proportion of serious mental disorder claims by mechanism of incident
Safe Work Australia, Submission 30, p. 6.
Caution must be exercised in extrapolating too much from the above figures, however. Considering the extensive evidence received on the stigma associated with the reporting of mental health conditions, which is discussed in the next chapter, it is probable that the number of claims does not reflect the true instance of serious, potentially debilitating mental health conditions experienced by first responders.
Other submitters also provided evidence on the prevalence of mental health conditions among the first responder cohort. Behind the Seen, for example, notes that part-time and volunteer workers are often not included in research into the prevalence of mental health conditions, even though they are also exposed to the same traumatic experiences and stressors, may be on call and may have other jobs to balance with their work as first responders. Noting this, Behind the Seen quotes statistics looking at suicide and posits that these may not accurately reflect the real incidence:
National Coronial Information System 2015 statistics indicate that one first responder takes his/her life every six weeks. This figure however is based on primary occupation and does not include part time or volunteer emergency services nor retired or medically discharged members therefore the rates of suicide are likely to be much higher.
Mr Peter Marshall, National Secretary of the United Firefighters Union of Australia, related findings from commissioned research looking at the prevalence of PTSD in firefighters:
[I]n 2013 we were so worried about this particular issue we engaged the Centre of Full Employment and Equity at the University of Newcastle... They found that studies of overseas and Australian firefighters showed PTSD affecting 17 to 26 per cent of all firefighters. More critically, this study was into the Metropolitan Fire Brigade in Melbourne; there's another one in relation to the South Australian fire service, which we're going to take you to also. It identified that 68 per cent of firefighters had scores indicating moderate levels of PTSI [post-traumatic stress illness] symptoms—that's 68 per cent of your workforce.
A submission from the Queensland Government, representing the Queensland Fire and Emergency Service (QFES), Queensland Police Service (QPS) and Queensland Ambulance Service (QAS), recognises the impact working as a first responder may have:
Given the nature of their duties, first responders are more likely to be exposed to potentially traumatic and distressing incidents that may contribute toward suboptimal mental health.
However, the Queensland Government submitted that this does not appear to translate to higher than average rates of mental health conditions:
First responders and emergency service personnel, like the general population, may experience a range of mental health conditions from time to time. Approximately 1 in 5 Australians each year will experience mental health related issues, and the incidence within the first responder population in Queensland appears to be similar. Conditions may range from acute stress reactions, mild anxiety and mild depression to more severe conditions such as adjustment disorder, severe clinical depression, or Post Traumatic Stress Disorder.
In this context, the Centre for Traumatic Stress Studies notes that 18 per cent of the broader Australian workforce is believed to have suffered from a mental disorder in the last 12 months. While the centre states that known figures for the rate of psychiatric disorders among first responders is not dissimilar to the broader workforce, comparison between the two groups may not be straightforward:
While the rates of psychiatric disorder in the emergency services are not dissimilar to the Australian community, in reality they should be healthier because of the recruitment standards and the subsequent discharge of those who are injured.
The assertion that rates of mental health conditions in first responders are comparable to the wider community was vigorously disputed by a large number of submitters. One of these, Australian Paramedics Association Queensland, noted that employers such as QAS may have a distorted view of the problem, due largely to a problem with organisational culture which leads to serious underreporting of mental illness:
APA submits that it is dangerous for QAS to assume that the rate of mental health conditions experienced by QAS employees is less than other ambulance services across Australia. After supporting hundreds of paramedics over the years, APA knows that is unfortunately not the true position.
APA submits that what QAS has is a cultural problem, which impedes the reporting of mental health conditions. Paramedics have communicated to the association that they feel as though they are treated by their employer as a disposable resource. They believe if they report that they are psychologically injured or suffering from a mental health condition or battling alcohol or drug abuse, they will be removed from their workplace one way or another.
Beyond Blue informed the committee that the organisation was undertaking large-scale research on mental health and wellbeing in police and emergency services:
Beyondblue is undertaking a major piece of research, incorporating the personal experiences of employees, volunteers and their families. That research has been in the field for some time. Over 21,000 current and former employees and volunteers in the police and emergency services agencies have participated. We believe this makes it one of the biggest, if not the biggest, survey of this kind certainly in Australia and potentially even the world. The research is funded by beyondblue with a significant contribution from the Bushfire and Natural Hazard Cooperative Research Centre.
At the time of Beyond Blue's appearance at the Melbourne hearing, the final results of the survey were not complete. Preliminary findings discussed at the time provided insights which may be useful in the development of prevention and management strategies. One of these involves self-awareness levels among first responders:
We also found a really interesting finding. The survey methodology that we used did require individuals to create their own responses. However, it had some psychometric validated measures incorporated into it, which individuals wouldn't have necessarily realised when completing the survey. What we found using those measures was that there were high numbers of survey respondents who were found, based on those measures, to have probable PTSD or to have higher levels of psychological distress. However, then when they were asked subjective questions they didn't relate that. What that tells us is that people may have a diagnosis but not have strong enough mental health literacy to understand the signs and symptoms, and that mirrors what happens in the general population but is possibly even higher here. Then that means if you can't do that you don't know that you need to seek support. Then if you add stigma on top of that that's a real barrier to seeking support. We think that is a really important finding around mental health literacy and improving awareness of signs and symptoms. That correlates with what we found in the Ambulance Victoria work that we did. Where we improved mental health literacy they got much greater uptake of their support services, which was a good outcome because then people are getting support early.
The Ambulance Employees Association, South Australian branch, spoke of disturbing data emerging from research:
I've provided a research paper—it's not quite released yet but it's complete—from Griffith University, Improving people management systems in emergency services. I'm going to cite some figures from that document and I'm also going to cite some comments made in other submissions. That Griffith University research, Improving people management systems in emergency services, has produced some concerning but not surprising information. Substantial levels of anxiety and depression are reported by ambulance first responders. In that paper, almost 40 per cent of those surveyed by Dr Townsend's team in South Australia, Queensland and the Northern Territory reported severe and extremely severe anxiety. The figure increases to 55 per cent when moderate anxiety is included. So 55 per cent of the workforce experience anxiety of some kind while 40 per cent—which is a significant portion of the 55—have severe anxiety... About 17 per cent of respondents report extremely severe depression.
RANZCP also provided the committee with a valuable overview of some of the existing evidence gathered to date on the occupational health of first response professionals. This is set out below.
A study looking at South Australian metropolitan firefighters found that:
17.1 per cent meet the criteria for anxiety, affective or alcohol disorder (in the past 12 months), the highest disorder group being anxiety at 12.7 per cent;
10 per cent reported suicide ideation in the preceding 12 months;
23 per cent reported moderate psychological distress; and
10 per cent reported high or very high current psychological distress.
Further research indicates that experiencing multiple sources of trauma is a significant predictor of the development of PTSD in firefighters. Retired NSW Fire and Rescue firefighters had PTSD prevalence rates of 18 per cent, depression of 18 per cent and heavy drinking at 7 per cent:
This study also found the rates of PTSD and depression for current firefighters were 8% and 5% respectively, while 4% reported consumption of more than 42 alcoholic drinks per week.
RANZCP submitted that an August 2017 report following a review of Victoria Police employees showed that the most common presenting issues were:
personal relationship problems;
mental health issues such as depression and anxiety disorders;
The review suggested that a prevalence study would be required to establish the extent of mental health problems in Victoria's police officers.
A more recent report, looking at the Australian Federal Police (AFP), found that almost a quarter of respondents reported current mental distress:
Of the respondents, 14% reported clinically significant symptoms of depression, 9% reported symptoms consistent with PTSD diagnosis, 6% reported clinically significant anxiety, 9% reported problematic alcohol use and 9% reported suicidal thoughts.
Other reports, however, have found even higher levels of mental health conditions, ranging from 37 to 66 per cent of police officers. RANZCP submitted that this underscores the need for further research:
Whilst research on Australian police is limited, it must be assumed that mental health problems associated with their work will be similar to overseas police or Australian military cohorts and is therefore considerably higher than civilian rates, under-reported due to stigma and organisational/cultural barriers, and poorly managed within such organisations. Further research is required to better understand the prevalence of mental illness, and the incidence of suicide in police and ex‑police.
To assess the rates of mental health conditions in paramedics, RANZCP pointed to research looking at compensation claims in Victoria, which indicates that this population faces higher risks of mental injury than other healthcare workers. A number of factors could be at play:
International studies suggest that ambulance personnel have the highest prevalence of PTSD among all occupational groups of rescuers. Reasons for this could include that ambulance personnel are exposed to greater pressure and stress at work than other rescue teams, that they respond to more emergency calls and have closer contact with the victims.
This trend is borne out in research looking at Australian paramedics:
Australian paramedics have reported significantly higher levels of fatigue, depression, anxiety, and stress, and significantly poorer sleep quality than reference samples. Particularly concerning is that over 10% of paramedics reported severe or extremely severe levels of depression. Researchers conclude that paramedic shift workers are at particular risk for increased levels of fatigue and depression.
Rural, regional and volunteer first responders
First responders based in rural and regional areas face additional pressures not experienced by their metropolitan counterparts. These pressures—including a small number of trained staff spread across a wide geographic area, and closer personal connection to the local community—were effectively demonstrated by Mr Patrick O'Dal, an ambulance paramedic from regional Western Australia:
[I've] recently worked in country WA as a community paramedic, and my job in that role is to look after quite a big area of the country. I had an area spanning about 250 kilometres east-west and about 150 kilometres north‑south, looking after 10 ambulance centres and 235 volunteers. On top of the normal stressors of ambulance work…our position description as community paramedics factors in a whole lot more…
Mr O'Dal explained that because he is the only community paramedic for that large area he gets little respite:
Everyone else is a volunteer. So you go for any job that is above what a volunteer would normally be expected to handle. You get calls 24 hours a day, seven days a week. You never have any downtime…
There's not one community paramedic place in WA that has two community paramedics working back to back so that you can have some downtime.
Mr O'Dal also highlighted the challenges posed by living and working in a regional community:
You live in the community. You're usually personally affected by all the jobs that you go to or there's some sort of personal connection, not just at the time but ongoing…
RANZCP pointed to volunteer first responders and those in rural and regional areas as being vulnerable for specific reasons:
A 2015 study found that rural and regional ambulance workers face unique issues, including treating personally-known patients, working alone and long response times. This study also found that rural and regional ambulance personnel experience high levels of fatigue and emotional trauma at work while an earlier study reported increased levels of fatigue and depression, anxiety and stress, and poor quality sleep. Rural and remote communities also have a widely acknowledged disadvantage when it comes to accessing mental health services, due to geographical barriers, maldistribution of medical professionals and unique circumstances surrounding stigma in such communities. In particular, access to specialists, such as psychiatrists, may be limited.
A submission from Code 9, a peer-to-peer online support group for first responders with PTSD, agreed:
Country service is incredibly difficult. With less staffing, there is a higher incidence of every street intersection to be a reminder of an incident, every member of the community knowing the victims, possibly being called to an incident involving your family or friends. In cases of incidents involving multiple locations, debriefing with all the necessary members is near-impossible and often isn’t conducted.
Mr John Richardson, a former intensive care paramedic from Tasmania, recalled one such incident, which occurred when he started out as a volunteer:
I still vividly remember my first night on road as a volunteer with very limited training where I was called out with an ambulance officer to a single vehicle crash. Five young people from my local community had rolled their car several times and the occupants were all ejected from the vehicle. Four of the patients were critical with head injuries and one with serious injuries. Due to limited resources I spent the next hour at the scene attempting to manage two of these patients before back up arrived and we moved the patients to hospital. The long term outcome of this crash is three of the patients died and the two remaining recuperated after extensive hospital stays. It wasn’t just being at the crash site which was distressing it was also being part of the grieving community and knowing these people and their families. This was the first of many cases that had a profound long term effect on my psychological wellbeing.
The Australian Counselling Association described a 'distinct lack' of services for first responders in rural and regional areas. The submission pointed to over 5000 registered counsellors Australia-wide who the organisation believes could be a valuable support and resource for first responders in rural and regional areas.
Others highlighted the particular difficulties faced by volunteer first responders. Mr Richard Elliot, a Unit Manager with a Tasmanian State Emergency Service (SES) comprised entirely of volunteers, set out a number of factors which compound the effect of traumatic experiences for volunteers:
Volunteers are called upon from rest. When volunteers are called to attend call outs they are undertaking their usual daily activities as well, they may be at work or at home with their families or perhaps asleep. They are then asked to attend a high stress scenes when moments ago they were at rest. They are not given the opportunity to mentally prepare for a traumatic event.
There is a lack of training for SES volunteers on how to deal with potential traumatic scenes that may affect their mental health. There appears to be an effort in initial training to down play the responsibility that lies with being a first responder, while the management of this unit try and minimise the exposure to new members to traumatic scenes there is none the less some degree of exposure. This practice of course exposes the more experienced members to more traumatic scenes, this may also be harmful.
Volunteers are called to assist people they know. The nature of volunteering for emergency services is that volunteers are used where there is insufficient workload to justify full time responders, this generally means volunteer first responders are from rural areas. As a result of sourcing first responders from a small community there is an increased likelihood of having to respond to incidents involving people known to volunteers. It is common place for this to occur, particularly for road accident rescue call outs. Kentish SES volunteers have had to respond to fatal motor vehicle accidents where members of the unit have been killed.
Volunteers are treated as replaceable. While I work hard to keep as many volunteers in the SES unit I manage there is a general culture within the Tasmanian SES that volunteers are replaceable. That is, volunteers do leave the organisation for a number of reasons and sometimes this is unavoidable, however, because of this some volunteers feel undervalued and that they do not play an important role in the organisation. This can result in a feeling of worthlessness when couples with a traumatic event this can be enough to cause mental health problems for volunteers.
Mr Elliot pointed out that a notable difference between volunteer first responders and paid staff is the volunteers' ability to leave the service if they feel they are developing mental health problems. While this is an advantage, it also means these individuals do not receive support once they leave.
The committee notes the findings of Beyond Blue's large-scale study on mental health and wellbeing in police and emergency services, which found that volunteers generally have lower levels of psychological distress and probable PTSD than employees, and their levels are comparable to those found in the general population.
Personal background vulnerability
RANZCP submitted that individual psychological risk factors linked with childhood and family origin may impact how first responders manage the stress and trauma inherent in their roles:
An individual’s experience of a potentially traumatogenic stressor may vary according to a range of factors including genetics, developmental stage, previous life experiences, cultural beliefs and available social supports.
RANZCP stated that consistency in pre-employment testing varies among organisations.
An individual's susceptibility to mental illness may also be impacted by personal stressors such as relationship or family problems, however this is 'difficult to manage from an organisational perspective'.
Some submitters added that physical health plays a part in mental health. As put by Ms Caoimhe Scales, an exercise physiologist, the nature of the job impedes first responders' ability to lead a healthy lifestyle:
It is important to note that mental health and physical health go hand in hand. There is an expectation that emergency service workers are physical healthy and have high levels of fitness in comparison to that of other occupations, however this is often not the case. First responders and emergency service workers experience extended periods of sedentary time (sitting, driving, lying down, low-activity), with intermittent bouts of vigorous physical tasks. They can also have difficulty ‘winding down’ or ‘switching off’ and may experience inconsistent sleep patterns or sleep disorders.
Due to their variety of working hours, inability to predict the duties of the day ahead, and inability to have planned meal times, first responders may also have poor eating habits. In isolation and combination, poor eating habits, poor sleep quality, and sedentary behaviour can contribute to poor physical health. Poor physical health is strongly associated with poor mental health. Equally, those with poor mental health, or mental illness, are likely to experience poor physical health.
Furthermore, RANZCP also noted that first responders appear to have inadequate social support when they are no longer working in their profession, whether that is due to sick leave or being medically retired:
The police in particular, feel isolated from the community and once they are no longer operational or are retired, often become extremely isolated from community support and the support of colleagues.
Likewise, first responders are known to have little support from the broader community while in service:
Emergency services personnel often have poor support from the general community, poor understanding from their command and poor support from their ultimate employers, the various state, territory and Federal governments.
This social isolation is heightened when first responders are not working, whether they are on sick leave, restricted duties or retired:
The police in particular, feel isolated from the community and once they are no longer operational or are retired, often become extremely isolated from community support and the support of colleagues.
Research from Beyond Blue, however, indicates high levels of two-way social support between first responders working together.
Figure 2.6: —Level of two-way social support in employees and volunteers, by sector
Answering the call: Beyond Blue's National Mental a Health and Wellbeing Study of Police and Emergency Services, 2018, p. 71.
Beyond Blue notes that the prevalence of probable PTSD is significantly higher among first responders who receive low levels of social support from others. Thirty per cent of this cohort is believed to have probable PTSD.
The committee sought evidence on training provided to assist first responders in building mental health resilience. A representative speaking on behalf of the Australian Paramedics Association of New South Wales, Mr Stephen Pearce, Secretary, acknowledged that the ambulance service has made progress in recent years. However, the nature of the job means that it is difficult to prepare trainee workers for what they will experience with their own senses on the job:
It is the kind of role, though, that you have to do. I neglected to tell you my background; I started as a paramedic in 1989. There really isn't anything that can prepare you for what you do. However, there are support programs in place now when you begin whereas they really didn't exist way back then. That's a very good thing. Managing the staff's resilience is a subject of work that New South Wales ambulance started a couple of years ago with this health and wellbeing initiative—and that's a great thing—it's just that we see it as moving along very slowly. We are really hoping that some of the bureaucracies will fall away with the higher prerogative of putting that in place so that people can work in a safe way.
The committee heard that work to prepare trainees takes place while student clinicians are still studying:
There's also a hope, aspirations, that student clinicians through their university studies are being forewarned of the type of intense workload and psychologically challenging work they're about to enter into. They do get ride-along sessions with operational paramedics reasonably regularly. I'm hoping that paramedics go into it with eyes wide open.
While this is useful, it is nonetheless difficult to tailor resilience training before trainees begin working. This is because individuals have different trigger mechanisms, meaning that it is not possible to predict with accuracy what can or will precipitate a mental health problem:
Unfortunately, the rigours of operational workload and the variability of a dynamic working environment can sometimes be significantly challenging to process psychologically. What some people may seem to think are going to be the most psychologically damaging jobs as a paramedic can sometimes be the least damaging. Every individual has different trigger mechanisms of what's going to provide the psychological stress that's going to precipitate a mental health condition over time. I think that's a real concern for us—that those little triggers aren't being picked up on as they take place because operational workload dictates how much time a manager can spend with somebody who is ticking a box that says they're not well.
Mr Bruce Perham, a mental health social worker and director of Let's Talk Differently, a group of counsellors who provide support and training for first responders and correctional workers, submitted that psychological preparation for the job is currently inadequate:
While these Organisations offer training on how to manage the practical side of First Responder work history is telling us the emotional or psychological preparation required to integrate these work place experiences into everyday life are sadly lacking. As a counsellor I get to witness firsthand the psychological complexity of First Responders trying to cognitively process what ‘they see’ and ‘what they experience’ and integrate this into living a balanced life. First Responders tell me that repeated exposure to people in traumatic situations ‘does wear you down’ and that their view of the world can become a ‘dark place’. I have to emphasize that many First Responders see things that are really hard for most of us to even imagine let alone having the task of cognitively processing it.
The committee is of the view that, at present, it is not possible to accurately gauge the prevalence of mental health conditions in first responders. This is primarily due to constraints and deficiencies in reporting, which lead the committee to conclude that a large number of first responders may be suffering in silence. It is worth noting that a considerable number of confidential submissions were received by the committee, highlighting the fact that many people are not comfortable disclosing their mental health struggles for fear of the repercussions.
What is known, however, is that exposure to traumatic experiences impacts on mental health. It is also an inescapable fact that first responders are exposed to trauma on a regular basis and far beyond that experienced by the general population. These two facts together, along with the comprehensive research conducted by organisations such as Beyond Blue, are enough to convince the committee that this cohort of workers is at a heightened risk of mental illness as a direct consequence of their work day in, day out, over time. Confronting experiences which most of us may be exposed to on a handful of occasions through life, if that, are regular events—even daily—for first responders. The committee is therefore of the view that more must be done to establish the number of first responders who suffer from mental health conditions, as well as the number who take their own lives.
The committee recommends that the government work with state and territory governments to collect comprehensive data on the occurrence of mental health injuries and suicide in first responders.
The committee recommends that the federal government work with state and territory governments to collect data on the cause of death for first responders who die while employed or die within 10 years of leaving their service.