These are profound life experiences, I think they’re transformational. We see them as illnesses, and part of it is, but that’s not all of it. I think the whole picture is the transformation, so I say to anyone who’s been through it, advocate for that and have the courage to speak it.
Many first responders spoke of a deep regret at no longer being able to pursue their chosen career due to unresolved psychological injuries. Despite some horrific experiences and bleak times struggling with mental health conditions, the sense of community spirit and desire to help others was a striking feature of the large number of public and confidential submissions the committee received directly from first responders. Put simply, many of them are people who love their jobs and serving their communities, but are failed by a system incapable of providing the help which is needed when mental health is compromised.
This chapter looks at the support for first responders wishing to return to work and those who are retired.
Turning the corner
For some first responders, turning the corner towards mental health recovery means accepting that a problem exists and that it is at that point in time overwhelming. As put by one former first responder, Mr Peter Kirwan:
The two hardest conversations I have ever had relate to my mental illness. The first was when I sat my two children down and told them I was sick. My son was about 10 and my daughter was eight. I explained to them that I was unwell and that, if I was being unreasonable, just to walk away from me. I knew by that stage I'd become a bad dad.
My second hardest conversation was with my psychologist. The psychologist I clicked with was not my first psychologist; she was my third. My initial consultation was supposed to be 40 minutes, but it ran for an hour and 40 minutes. I walked out of the session both physically and emotionally drained, but it was the start of my recovery. I've also seen both sides of the mental health journey.
Some first responders, like Mr Kirwan, heal over time:
We would make allowances: if someone has to come back to work and they've got a crook leg and they need a wheelchair ramp, we make reasonable allowances for those employees. But sometimes people may come back and they may say, 'Well, for me to come back to work I need to work with a peer who is the same level as me. I don't want to be working with a graduate. I don't want be working with a volunteer. I need another advanced life support paramedic sitting beside me so I can build my confidence, and I know that I'm not going to take any action that's going to affect the patient,' or, 'I'd like to be working at my branch.' Things like that, reasonable allowances, things that we would say should be facilitated quite easily by the employer, seem to be very difficult. And it's, 'You're either coming back to work or you're not,' 'Are you fit to come back to work or are you not coming back to work?' And they get into a bit of a stand-off, where people even end up in a fitness for duty assessment and they are sent off for an independent medical examination. And that process, the return to work process—people actually tell us that that's often as stressful as the original incident that caused them harm.
Some first responders also receive support, including support from their employer. Mr Brendan Maccione, a police officer in Western Australia, spoke of his diagnosis and treatment, as well as the support he received from his employer:
In 2017 I was referred to a psychologist for management of my anxiety and PTSD symptoms—specifically, intrusive thoughts from attending multiple serious and fatal vehicle crashes in my capacity as a police officer. My referral was initiated due to my need and desire for additional care, independent from and external to the police force, that would help me progress forward from my PTSD symptoms of stress, fatigue, intrusive images, depression and anxiety… Through acknowledging my symptoms and my early intervention I've been well-supported by my immediate family, I've been well supported by my colleagues but I've been especially well supported by the Sirens of Silence Charity and Lyn and Ian Sinclair. I've lost long-term friends but, equally, I've made some amazing new friendships through peer support, the community network and trauma‑room mental health workshops that I've attended.
My symptoms have improved with treatment and I've linked some of my traumatic experiences to patterns of interpersonal relationships in my early life. The police have been extremely supportive of my recovery. I acknowledge the support of my colleagues, my supervisors and my officers in charge, both past and present, who've supported me through my duty so far. I accept that the story is different and you've heard differently from many others who have made submissions and spoken of the lack of support they've received.
In this context, the committee looked at return to work arrangements available to first responders who experience a psychological injury, receive treatment and feel able to continue working.
Return to work
In some situations, a first responder's mental health condition can leave them feeling unable to function:
I'm not a violent person. I never have been. I've always been a protector. That's the way I did my job as a police officer. Helping people, saving lives—that's the sort of work ethic I had. I was so stressed. When I walked into Civic station one day to start work, another police officer made a smart Alec comment to me. Not being able to get off my chest what I needed to get off, with everything that had happened to me, the urge to go 'bang' was so strong that it scared the living hell out of me. I walked into that office, put my paperwork in my briefcase and walked out. They sent another police officer after me: 'Stop, come back. Come back to work.' I said: 'No, that's it, mate. I'm finished. I can't do any more. I can't. That's it.' I went home and broke down.
Such situations, where officers have to leave their job because of conditions such as PTSD, represent a failure of the system to deal with the injury in its earlier stages.
Conversely, helping first responders who have suffered from a mental health condition return to work is part of their recovery. A successful return to work indicates that treatment is working.
Often however, psychologically injured first responders who are on a workers' compensation return to work program are unable to access meaningful work while they recover. The committee heard that being able to engage in mentally stimulating, meaningful work is important:
'Meaningful tasks' are the two words that scream out to me. Anybody in the ambulance service—I can't speak for WAPOL or fireys—who is on a workers compensation return to work program at the moment, whether it's from a cut finger, a broken leg, surgery or mental health issues, are grouped together, put in a little office at the bottom of the building and if they're given any tasks they are given menial tasks of folding this, envelope-stuffing this, running an errand here or delivering medications and drugs to some of the depots around the metro area. They're not meaningful tasks. They're not engaging. They're not mentally stimulating at all and, for someone with mental health issues, there could be nothing worse. So, yes, some meaningful tasks and overseeing of that return-to-work process by professional people—and that immediately says to me that the professional people should be external to the relevant organisations so that people are getting the right help not only for their cut finger but for their mental health as well.
An absence of meaningful work can exacerbate a worker's psychological injury, as can expectations which don't take the nature and source of the injury into consideration:
The real danger here is the increased isolation and lack of meaningful work for that injured worker, which then exacerbates their injury… That broader scope of work has also already been cleared by their nominating treating doctor. This work needs to be meaningful. An example of that could be an activity that the worker has experience in outside of his or her paramedical expertise or even some accelerated training in another role. Also, there's pressure brought to bear—I don't know that it's overt—when the injured worker is expected to try to do things that may also exacerbate their injury in order to meet the conditions of a return-to-work plan, even if that activity doesn't appear on the plan.
The committee heard that trend of returning staff not being given meaningful duties can stem from managers' lack of awareness of how to handle mental health conditions.
One organisation aiming to address this, the WA Department of Fire and Emergency Services, described its approach to assisting returning staff, which involves ongoing education of line managers and supervisors about supporting injured workers for a favourable return to work.
The role of rehabilitation counsellors
The Australian Society of Rehabilitation Counsellors (ASORC) stressed the complexity involved in returning to work following exposure to trauma. Many organisations rely on return to work coordinators to facilitate the process of injured workers gradually re-engaging with their jobs, however these coordinators may not have sufficient training and expertise to deal with the complexities inherent to this process:
Most of the time a return-to-work co-ordinator is somebody who's participated in somewhere between two and nine days worth of training… I guess one of the things that I see a lot in practice is that a return-to-work coordinator doesn't necessarily have the inherent understanding of behavioural science and the knowledge and expertise to identify what the suitable duties are likely to be for a particular worker in their particular diagnosis with the particular triggers that they present with.
Rehabilitation counsellors are specialist health professionals who assist people experiencing a health condition, disability or social disadvantage to participate in employment and education. ASORC set out a series of broad factors which can impede recovery from mental health conditions in, and successful return to, the workplace. These are broken down into medical and treatment factors, workplace factors, health behaviours and personal patient factors.
ASORC advocates returning to work as soon as possible, stressing the need for maintaining daily activities (including work) whilst acknowledging that this must be balanced with symptom management and 'avoiding reinforcement of the belief that work is bad for the patient and should be avoided.'
This approach, ASORC submitted, is particularly challenging in the context of first responders due to the nature of their work:
If we consider the common mental health condition anxiety, which often forms part of a diagnosis when a mental health condition arises out of a workplace injury, (either as part of the primary diagnosis or as a comorbidity), many psychological treatment approaches or management tools are directed towards graded exposure/ or developing strategies to help manage the physiological manifestation which occur with anxiety. Some commonly prescribed psychological treatments are aimed at removing the threat value of stimuli and discourage avoidance. In the case of first responders, it can be difficult to gradually expose a worker to their pre-illness role and as such, many workers with diagnosed mental health concerns remain absent from the workforce to ‘recover’ and remove the triggering stimulus.
Rather than helping aid a person's recovery, for some people extended absences can have a counterproductive effect:
…extended periods of time away from work may inadvertently confirm the belief that work is dangerous and should be avoided by the patient. The longer the period of incapacity the more difficult it can be to challenge this belief. Therefore, we suggest that it is imperative that goal-oriented therapies be employed by clinicians in order to prevent long term disability and worklessness. Much like medical practitioners educate their patients as to their diagnosis, we believe that this education should extend to patient’s recovery for all activities, including returning to work in a timely and safe manner.
To address this, ASORC suggested that qualified rehabilitation counsellors should be used to assist workers, employers and treating practitioners with:
psychoeducation, in terms of recovery and the importance of maintaining activities of daily living, including work;
supporting adherence to medical and other recommended treatment regimens;
identification of suitable duties preferably within the pre-injury employer;
return to work, and where this is not possible initially, arranging suitable work placement for the purpose of:
Graded exposure to work relationships / situations
Opportunities to practice treatment management techniques
Note: This strategy should be monitored closely and return to pre‑injury employment should be implemented as soon as practicable (i.e. ensuring that it is safe, durable and sustainable);
assisting the worker with helpful ‘patient centred’ strategies to manage return to work obstacles, as required;
education for employers, as necessary, on what is required from them;
management of relationships between the stakeholders;
assistance with complex communications, as required, and
acknowledge the unique nature of the work first responders undertake as part of any recovery process.
ASORC added that rehabilitation counsellors are impartial, and their role is to support both the injured worker and the employer through the return to work process.
The referral process differs from state to state, and impartiality may be maintained when referrals are made by general practitioners, rather than the employer or insurers:
Depending on the state or territory, the scheme that you operate in can depend on where the referral actually comes from. There are not many states in Australia or jurisdictions in Australia where a GP can actually make a referral to rehabilitation services, which amazes me. I've worked in Western Australia and South Australia for most of my career. In WA a GP can make a referral. In South Australia a GP cannot make a referral to our services. The only person with the authority to make that referral is the insurer, which is essentially a third-party administrator of the regulator. So, that's how referrals will come.
Just on that note, I should say, going back to my experience in Western Australia, where the referrals are coming through the GP, that one of the things that does is remove any sort of question about whose side we're on.
Once a referral is obtained, rehabilitation counsellors typically allow the affected worker an opportunity to share as much or as little of their situation as they are comfortable with, letting the person know that background information has been received. From there, individual obstacles to returning to work may be identified:
So, we look at the trauma history. We also look at some of the psychosocial risk factors—how they're functioning and their activities of daily living, how they're interacting with their family, what their sleep routines are like—a whole raft of different things—and what the barriers to return to work are, and that will be partly from discussion with the person and partly our own formation in terms of what we feel is happening. Part of that process will also then be meeting with the employer to talk about what their experience is as well, because our role is very much, as I touched on before, impartial. We're supposed to be there to help support the worker—the person experiencing the mental health condition—but also the employer in terms of making sure that they can meet that person somewhere that's reasonable. So, we'll meet with the employer and talk to them about what we have found through our assessment, obviously with the person's consent. Part of that conversation will be what sorts of work accommodations you can provide, what alternative duties might be available within the particular service that the person comes from.
The process of gradual return to work is an important facet of recovery from mental ill health. The committee is of the view that engagement with health professionals with expertise particular to the return to work process would be of benefit to all first responder organisations around Australia. However, the committee notes that early intervention and engagement of rehabilitation counsellors is pivotal yet, as seen in chapter 3, extremely difficult while ever people fear for their jobs if they report concerns about their mental health. In the committee's view therefore, a noticeable cultural shift will need to occur in most first responder organisations in tandem with early intervention strategies devised to minimise the impact of mental ill health on individuals and their ability to work.
The committee is however cognisant of the importance of impartiality, particularly of the perceived biases associated with professionals appointed by employers or insurance companies. For this reason, the committee supports referrals to rehabilitation counsellors to be solely made by independent general practitioners.
The committee recommends that a consistent approach to referrals to rehabilitation counsellors be developed across states and territories, requiring referrals to be made by general practitioners not associated with employers or insurers.
The committee also notes the importance of early intervention in terms of PTSD prevention, and calls on first response agencies to collaborate in identifying and developing effective strategies to mitigate the risks inherent to their workplaces.
The committee recommends that early intervention mental health support services be made available to all employees of first responder organisations with the aim of preventing, or reducing the severity of mental health conditions.
Lack of support is a significant struggle facing retired first responders and those transitioning into retirement. Mr Pat Jones, a senior firefighter in the ACT, described his feelings of uncertainty about his upcoming retirement:
For me, what I do as a firefighter defines me. I don't know what I'm going to do when I retire in 16 months—I really don't know. There's no process or system or anything that employs second-hand, broken down firefighters or paramedics. What do I do? I can't go to another jurisdiction's fire service and work there. I've made a really conscious career decision, putting 30 years into becoming the best firefighter that I can be for the territory that I work for. But when that ends, there's nothing at the other end; there's nothing at the end of the tunnel.
For some, even the timing of that process is taken out of their hands when recovering from psychological injury requires them to end their career prematurely and abruptly:
I joined the police for what reason? To be a police officer. Was there any thought of retirement or getting out? No way! I was in there for the career. That was it. That was my job. All I wanted to do was to be in the police. So I was there for the long term. It got me 13 years in. I was probably busted up about five years in. I don't know how I squeezed another eight years out of it; I'm not sure.
Box 5.1: —The lived experience
In mid-2015 I identified I was struggling with day to day work and home issues, the issues included:
Heightened irritability with peers/family
Withdrawn from peers/family
Constant anxiety heightened at emergency responses and in day to day function
Graphic reliving of case workload (smells, sounds and visual) over past 40 years
Inability to get proper sleep due to all of the above
Depressive moods and thought patterns
Unfortunately I did not identify these signs (I had been informed by the management a noticed personality change in the previous 12 months, no action pursued by them)… I felt I needed to take extended leave… I approached my immediate manager and pleaded for my leave owing e.g. long service leave, accrued leave and annual leave. My manager took my request to the Director who refused my request for leave stating that if I “gave a firm resignation date, he would approve” (I had not intended to resign in the immediate future) the leave… I refused to submit a resignation date and the leave was refused… I appealed to my industrial body that also failed to act on my behalf… I appealed to a relief Director some weeks later who then approved my leave, prior to my taking the allocated leave I attended my G.P. who insisted I take some sick leave as I was not fit for work… I commenced leave in June of 2016 and remained on leave until April of 2017 where I still had ongoing issues, my G.P. referred me to an in-service counselling service and again placed me on sick leave… I was diagnosed with P.T.S.D. and remained on sick leave informing the organization of the same… I was not offered any support and was directed to retirement, with no post resignation support and was regarded as a problem to the organization.
Mr Malcolm Babb, former Ambulance Officer and Critical Care Paramedic
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.
Mr Eric O'Rourke, veteran police officer
Professor Samuel Harvey, Chief Psychiatrist with the Black Dog Institute, told the committee that little is known about what retirement means for first responders:
We don't know enough about retiring first responders and what that process of retirement means for their mental health. Those are research questions that we could absolutely answer with funding, but it's very difficult to get funding for a group like first responders through those standard research schemes, because one of the responses you get is: 'Well, this is a very focused research question on a very focused group of workers. Is that really the role for a general scheme?' So I suppose I would conclude by raising the prospect of whether your committee may be able to think about ways in which we can try to get some targeted research funding to answer some of those unanswered questions that I've tried to summarise in our submission.
However, anecdotal evidence cited by the Black Dog Institute suggests that retired emergency workers may be at particularly high risk of developing mental health conditions, such as PTSD.
The committee received a submission from the Australian National Audit Office (ANAO), which makes reference to a recently published report titled Managing Mental Health in the Australian Federal Police. While the ANAO report did not make specific reference to post-retirement support, witnesses representing the agency at a public hearing discussed potential areas of improvement:
The Comcare data [examined in the ANAO report] highlighted…that since 1989 there have been these sorts of periods where psychological claims from former employees have increased and then been addressed, but most recently they've increased to a substantial high of around 12 per cent of the total. We recommended that the AFP look at its exit interview or departure processes. This was a key theme that came through in the submissions as well. We got a number of submissions through the public facility from former employees saying that as part of their exit process they would have loved to have received information on what they can access post their AFP career. The AFP provides ongoing services that that these individuals can access post their career.
The ANAO found that, although the AFP does have services that former employees may access, these did not reach the level of support provided in, for example, the Defence environment.
Witnesses speaking on behalf of the AFP admitted that more needs to be done to support retired former employees:
In terms of retired members, and particularly those who are medically retired, I think it's fair to say we've got a lot of work to do towards improving our transition processes… In the last 12 months, we've recognised that our retired members need more. We've opened up our employee assistance provider to provide support to all former members.
A submission from the Australian Paramedics Association of Queensland (APA Qld) informed the committee that the Queensland Ambulance Service (QAS) offers peer-support counselling services for 12 months following a paramedic's retirement or medical retirement. This was echoed by the Council of Ambulance Authorities Australia:
Employees and their families can access the free, confidential counselling before and after retirement. Members of the QAS Retired Officers Association (ROA) can make strong connections and have access to free confidential counselling through the Peer Support and Resilience Advisory Committee, a subset of the ROA.
However, APA Qld explained that this does not apply when employment is terminated due to certain conditions, including mental illness:
APA Qld is informed that with respect to paramedics who are terminated from their employment as a result of mental health and drug conditions (including paramedics who have attempted suicide) or for any other disciplinary matter, QAS does not provide those employees with any mental health support or counselling beyond their termination date. For employees who find themselves in this situation, they feel incredibly isolated as they identify as a paramedic and their support network are quite often other paramedics who they then feel ashamed to be in contact with.
In South Australia meanwhile, the SA Ambulance Service has programs featuring seminars on the transition to retirement and ongoing support through its Retired Officers Association.
The committee sought input on support available for retired officers from other witnesses, such as the Police Federation of Australia (PFA). Witnesses informed the committee that while some services do have limited programs in place, a nationally coordinated strategy does not exist:
There's nothing nationally consistent. In our own state of South Australia, the police association which I run has put together a police support group for serving and retired officers and their families. It meets monthly for people who need to come and talk and get clinical advice. It's convened by a psychologist and other people involved in the mental health space. It's to get people to try to talk about their experiences, try to understand them and try to move on from them. There is a real bitterness and depression with a lot of officers who leave after 30 or 35 years because we haven't addressed the issues for them during their service. So we as unions are all aware of it, but I think the police departments across Australia have got a bit of a way to go to catch up.
In New South Wales there is a program called BACKUP for Life which is run by New South Wales Police Legacy and being funded by the New South Wales government. But, again, this is where it comes back to COAG to coordinate. These programs in New South Wales have started being evaluated. If they are best practice, they should roll them out across the other states. BACKUP for Life solely looks after retired police officers or those officers who are just about to retire and makes sure they have a long retirement or that they can find another job if they have to progress somewhere else.
The committee notes recent efforts to support retired first responders, such as 'NSW Ambulance Legacy', a program created in 2017 to support retired NSW Ambulance staff:
Its role is to assist members who have separated, retired or are retiring by providing support, enduring social connections and events, an ongoing sense of belonging and real, continuing involvement with NSW Ambulance colleagues. Peer support officers and chaplains will also be available to NSW Ambulance Legacy members following the official launch later this month.
It is clear that first responders around the country would benefit from a less haphazard approach to adequate support in their retirement if required. Due to the nature of their jobs, longer service is not the answer:
I think they have a use-by date. The difficulty is telling them that. I see police who've had multiple traumas who are, for all intents and purposes, limited functionally in a very limited way. I always talk to them, and the term I use is: 'You need a plan B. What are you going to do next?' The other thing is that typically we hope they're going to retire. Most of our police in Queensland and NSW retire at 60. What are they going to do for the next 25 years of their lives? They can't even conceive it. Part of that is, again, down to this double bind: they're extremely well remunerated and they don't see any other area where, with their skills, they can match the remuneration. I agree: it was said earlier, whether it's for paramedics in health, for police or for the public service elsewhere, we need transition plans for them, but we don't have those and we've never had them. I agree that they can't do 35 years. They are burnt out at that point.
Notably, Mr Jim Arneman, speaking on behalf of the National Council of Ambulance Unions, saw that retiring first responders have a valuable role and critical skills which may go to waste unless harnessed in the later part of their service:
I see it as an opportunity actually to be using people with advanced skills and experience to mentor and coach in those later years. One of the things which I liked was a paper from Griffith University in which Professor Townsend talked about reliability-seeking organisations. He was talking about changing the focus of how ambulance services set themselves up. There has been this ongoing focus on performance; it's all about response times and getting cars out there and the next job and all that—performance and productivity. He talked about changing that to these reliability‑seeking organisations where we look at reliability, safety and resilience as the focus. They're not incompatible to me. If you look at reliability, safety and resilience and set that up in an organisation, you'll get the response and the performance, because you'll have happy people. That's where these experienced people have a role to play—in mentoring and coaching and bringing people along so that just gets embedded into a culture.
The committee notes that insufficient data exists on the prevalence of mental health conditions in retired first responders. However, anecdotal evidence suggests that this cohort may be at even higher risk of suffering from conditions such as PTSD than colleagues who are still working. This may be due to the combined effects of prolonged cumulative exposure to trauma and abrupt loss of any existing support from colleagues and possibly management. The committee is particularly concerned about this in light of the recent discussion about increases to the retirement age, which could add to the already considerable pressure cumulative exposure to trauma places on first responders. The committee is of the view that urgent attention should be given to funding the collection of national data on the prevalence of mental health conditions in retired first responders, and that strategies must be put in place to ensure that first responders are not simply forgotten when they do eventually retire.
The committee also received disturbing evidence relating to individual cases, where employers have allegedly attempted to force officers into early retirement through bullying and intimidation. The committee notes material contained in a supplementary submission from Justice 4 Workers Queensland relating to the Queensland Police Service. As was the case with allegations raised in a number of individual submissions the committee pursued with the employers in question, the service was offered an opportunity to address the allegations raised, however no response was received.
The committee recommends that the Commonwealth Government make funding available for research into the prevalence of mental health conditions in retired first responders.
The committee recommends that ongoing and adequate mental health support services be extended to all first responders who are no longer employees of first responder organisations around the country.
Senator Gavin MarshallSenator Anne Urquhart
Senator Deborah O'NeillSenator Rachel Siewert