Introduction
Workers in the emergency services (such as law enforcement, firefighters, and EMS workers) have higher rates of posttraumatic stress symptoms and higher risk of PTSD than the general population. The high prevalence of posttraumatic stress among these occupational groups is caused by frequent exposure to traumatic incidents. EMS workers have higher levels of occupational stress and burnout compared with other emergency service workers and healthcare professionals (Boudreaux and Mandry 1996), and have higher rates of PTSD than firefighters and police officers (McFarlane, Williamson et al. 2009).
Studies that explored the association of PTSD with EMS profession found that EMS personnel had a greater risk of developing PTSD in comparison to rest of the first emergency responders. (Boudreaux and Mandry 1996; Newland, Barber et al. 2015) This was also found by a recent meta-analysis conducted by Petrie et al. (2018), who found a high prevalence of PTSD and other mental health conditions among EMTs and paramedics, estimating the prevalence of PTSD among them at approximately 11%. (Petrie, Milligan-Saville et al. 2018) EMS personnel had ten times higher rate of suicidal ideation (SI) and suicidal attempts as compared to general public (Newland, Barber et al. 2015).
The work context of EMS personnel is different to other emergency first responders, as their role involves spending more time dealing with, and treating injured patients (compared with other first responders), which increases the risk of PTSD (McFarlane, Williamson et al. 2009).
It is vital to develop specific interventions for EMS workers because the outcomes of evidence-informed interventions depend on the context. The replication of interventions developed for police officers and firefighters does not guarantee favorable results and requires adaptation for use in EMS populations (Moore et al., 2021). PTSD symptoms are manifested in 10% of all rescue workers (Boland et al., 2018). However, EMS workers are more vulnerable to occupational stress, PTSD, and turnover (Boland et al., 2018). Regular exposure to traumatic events, including pediatric incidents that paramedics classify as severe, contributes to the higher risk of posttraumatic stress in paramedics in comparison with other frontline workers.
The context of EMS is different from other frontline professions in several ways. Firstly, it involves occupational stress due to organizational or leadership stressors associated with the hierarchical culture of the EMS profession (Boland et al., 2018). The evidence reveals that unsatisfactory work environments, limited decision-making opportunities, and the lack of support from supervisors reported by 35% of paramedics contribute to the increased stress and PTSD risks (Drewitz-Chesney, 2012, p. 259). Secondly, cumulative exposure to critical incidents (CI) presents a unique combination of physical and psychological demands and causes EMS workers to become prone to PTSD (Boland et al., 2018). Thirdly, unlike firefighters or police officers responding to major accidents, EMS personnel also encounters small-scale events and experiencecumulative effects of CIs. Thus, effective interventions should acknowledge the specific challenges of the EMS profession and adapt existing methods of PTSD treatment and prevention for the target population.
There are many ways of classifying psychological interventions, one of the ways of classifying them is into two groups: Psychological interventions could be classified into two groups; (1) those that prevent the emergence of mental health conditions and (2) those that treat clinically diagnosed mental health conditions. The former interventions aim to lessen the chance of developing future illness (e.g., strategies aimed to induce resilience and stress management skills), and usually target individuals who are considered at risk. The latter group of interventions focus on improving psychological health by fostering the positive features of mental well-being such as enhancing coping and self-esteem (e.g. psychotherapy and pharmacological interventions) (Purgato et al., 2020).
Pharmacological or pharmaceutical interventions play a major role in the prevention and treatment of posttraumatic stress disorder (PTSD) in EMS workers. The large body of research evidence demonstrates the short-term and long-term efficacy of pharmacological treatment for PTSD prevention (Amos, Stein and Ipser, 2014). Preventive interventions may reduce the detrimental impact of traumatic events by regulating cortical secretion and blocking post-synaptic beta-adrenergic receptors. The medications proposed by PTSD researchers are glucocorticoids (hydrocortisone), selective serotonin reuptake inhibitors (SSRIs) (escitalopram), antipsychotics (risperidone), and antidepressants (imipramine, fluoxetine).
Several medications are being considered for PTSD treatment based on the changes in the brain caused by the disease. Fear and memories are processed by different regions of the brain, which determine the severity of the disorder and appropriate treatment strategies (Drewits-Chesney, 2012). For example, the amygdala region is responsible for the perception of fear, the medial prefrontal cortex reduces the response to fear-inducing stimuli, while the hippocampus processes and retrieves memories (Drewits-Chesney, 2012). PTSD is characterized by pathophysiological factors involving the abnormal activation of the amygdala by norepinephrine, the decreased response of the medial prefrontal cortex, and the reduced size of the hippocampus.
Effective pharmacological interventions should address the pathological changes in the brain of PTSD-affected individuals. Beta-blockers, such as propranolol, are currently regarded for use in paramedics before or after traumatic events (Drewits-Chesney, 2012). The pharmaceutical aid proved to be more cost-effective than counseling services, and the risks of PTSD complications (anger, reduced physical function, suicide) outweigh the potential side effects. It is critical to be aware of ethical concerns regarding propranolol use, as the medication can cause memory loss and complicate recollection of details in criminal cases.
Many interventions are being employed to manage PTSD in EMS personnel, which include; Psychological interventions (e.g. cognitive behavioural therapy, critical incident stress management, eye movement desensitisation and reprocessing, etc.), Pharmacological interventions (e.g. selective serotonin reuptake inhibitors), and, Complementary and alternative therapies (Purgato, Uphoff et al. 2020).
Outcome of an intervention often depends on the context. (Davey, Hargreaves et al. 2018)
Effectiveness of the interventions can be improved by adapting these on the basis of existing evidence and making these contexts specific.(Moore, Campbell et al. 2021) There are few factors which may impact the effectiveness of interventions for adapting these to new settings, different nature of job and sociocultural groups of the participants. (Burrow-Sánchez, Minami et al. 2015; Sundell, Beelmann et al. 2016; Davey, Hargreaves et al. 2018)
One of the problems is that most interventions offered to EMS personnel with posttraumatic stress are generic and do not reflect their unique work environment. According to Maguen et al. (2009), other factors, besides experiencing trauma, contribute to the development of PTSD among paramedics. (Maguen, Metzler et al. 2009) As a consequence, approaches to general mental health support are habitually found to not be accepted in the emergency services culture and are often linked to stigma and weakness. (McGilloway and Gallagher 2008; Halpern, Gurevich et al. 2009; Reed 2016)
EMS organisations should realize that trauma-related interventions must be developed based on an understanding of the circumstances, the climate and culture of the organisation, employees’ experiences towards the traumatic event, level of organisational support, and level of distress experienced by employees at work on a daily basis. (Regehr and Bober 2005) Therefore, support provided to first responders should be adjusted to the needs of these individuals, their cultural values, and their distinctive personal and social characteristics. (Lanza, Roysircar et al. 2018)
To date only a few reviews have been published evaluating the effectiveness of interventions in ambulance personnel (Smith and Roberts 2003) and in first responders such as police officers, firefighters and military combatants (Haugen, Evces et al. 2012). The main intervention examined in the first review (Smith and Roberts 2003) was Critical Incident Stress Debriefing (CISD). However, none of the 17 studies reviewed in the second review (Haugen, Evces et al. 2012) included EMS workers but focused instead on police officers and veterans.
The primary goal of this review was to explore the effectiveness of worldwide interventions aimed at reducing or preventing posttraumatic stress (ASD and PTSD) in EMS workers. Secondly, whether intervention type, target group, timing and study settings is associated with the outcome.
Discussion
The purpose of this review was to synthesise the evidence related to worldwide interventions aimed at reducing or preventing posttraumatic stress among emergency medical responders. None of the studies included in this review was conducted in Asia, with most having carried out in the Western world. Of all the included studies, only four were RCTs and none involved pharmacological interventions. The dearth of research in this field is surprising, in particular when compared to the high volume of research related to the treatment of PTSD in other high-risk occupations, such as police officers and military personnel.
Critical Incident Stress Debriefing (CISD) was the main intervention used in half (n=5) of the studies included in this review. The findings indicated conflicting evidence relating to its usefulness in reduction of PTSD symptoms. Reduction in PTSD symptoms was reported in only one of the included studies. (Wee, Mills et al. 1999) According to Magyer & Theophilos (2010) benefits of debriefing included improvement in workers’ level of satisfaction, team morale and a decline in stress reactions in the short term (Magyar and Theophilos 2010). Interestingly, an RCT demonstrated the effectiveness of debriefing in reducing symptoms of PTSD, anxiety, and depression after encountering critical incidents, but only when adjusting it to fit the local cultural context by combining it with training to strengthen cohesion. This study established an intervention that fit the organizational context of military personnel, which incorporated cohesion training to CISD as a way of allowing individuals to experience feelings of belonging and enhance the sense of social support among them (Wu, Zhu et al. 2012). According to the authors, cohesion between employees in such an organisation has a critical role in their mental wellbeing, because the sense of belongingness among these rescue workers is considered to be vital (Wu, Zhu et al. 2012).
In contrast to the findings of this systematic review, the authors of the articles discussing CISD did not consider teamwork, cohesion, and social support as critical factors determining debriefing effectiveness. Moreover, the reviewed studies did not adequately explain the importance of the factors for the prevention of PTSD, depression, and stress-related symptoms. The evidence provided by Wu et al. (2012) suggests that cohesion training improves the degree of social support by allowing the participants to experience team power and develop a sense of belonging (p. 1117). Cohesion is also important for preventing stress and reducing the feeling of isolation (Wu et al., 2012, p. 1113). CISD protocol established in the studies did not address the aspects related to teamwork, cohesion, and social support in the cultural context of hierarchal organizations. The findings of this systematic review demonstrate that psychological interventions should incorporate social and emotional support to minimize PTSD symptoms, depression, and anxiety (Drewitz-Chesney, 2012; Wu et al., 2012). Thus, adaptive CISD protocols promoting cohesion and social support might reduce the detrimental impact of traumatic events on EMS workers.
However two of the included studies reported that CISD had an insignificant effect on reduction of PTSD symptoms. (Warren 1995; Macnab, Russell et al. 1999) These findings are in line with a recent systematic review in which no association was found between debriefing and the level of psychological symptoms, as there was no significant difference between those who received debriefing and those who received no intervention. (Winders, Bustamante et al. 2021) A review conducted by Elhart, Dotson, and Smart (2019) indicated that some of the reasons for the ineffectiveness of psychological debriefing include lack of training and education of the person facilitating the debriefing session, lack of adherence to CISD standards or processes and conducting only a single debriefing session. (Elhart, Dotson et al. 2019)
Furthermore, according to Macnab et al., (1999), there was no correlation between the numbers of CISD sessions with the severity of PTSD symptoms. (Macnab, Russell et al. 1999) Debriefing in the study was conducted for those who had dealt with the crash of an air ambulance that resulted in the loss of medical and paramedical colleagues. All those who attended the debriefing sessions were still traumatised by this incident. The authors noted that debriefing was carried out by the hospital stress management personnel, who were unfamiliar with the working conditions of the ambulance staff. This could have affected the levels of confidence the clients had in the personnel delivering the debriefing session. This was affirmed by Lambert and Barley (2001), who outlined that the most important element when it comes to the effectiveness of interventions is the nature of the relationship rather than the model or approach used by the therapists. (Lambert and Barley 2001) This was also demonstrated by Kamena and Galvez (2020) in their study, which offered the WCPR retreat program to first responders in sessions that were delivered by professional psychologists and therapists, along with first responders who were previously clients at the retreat. (Kamena and Galvez 2020)
On the other hand, some studies (n=2) established that CISD is not effective in treating posttraumatic stress and actually may lead to a worsening of its symptoms. (Woods 2007; Wesemann, Mahnke et al. 2020) This assertion is in line with Bledsoe (2003), who noted that CISD is not only ineffective but also brings the risk of elevating the symptoms of PTSD. (Bledsoe 2003) Although debriefing models have been widely utilised among clinicians working in emergency departments, evidence has emphasised that there is lack of conclusive data related to the efficacy of this strategy. This has indicated the need for further detailed evaluation of the models of psychological debriefing in emergency care. (Magyar and Theophilos 2010) In addition, past research has indicated that the timing of delivering trauma-related interventions also matters. According to Campfield and Hills (2001), CISD must be conducted within 72 hours after the occurrence of the trauma. (Campfield and Hills 2001) Other parameters that should be considered in the application of CISD include the use of a small group (which was evident in the studies included in this review), the participants should not be distraught, and the group members must have similar exposure levels to those occurring during the critical incident. (Magyar and Theophilos 2010) The latter two conditions were not outlined in all the studies that were included here and could thus be considered reasons for inconclusive results.
Previous research has implicitly outlined the negative consequences resulting from CISD, manifesting as vicarious trauma (secondary trauma). (Regehr and Bober 2005) This occurs because individuals who have experienced trauma are more likely to be psychologically vulnerable; hence, it is difficult for them to derive the traumatic event’s meaning, resulting in the worsening of symptoms of posttraumatic stress. (Regehr and Bober 2005)
Effectiveness of CBT was examined in only one of the included study in this review. (Bryant, Kenny et al. 2019) In this RCT both forms of CBT (CBT-L and CBT-B) were positive in reducing the symptoms of PTSD among the emergency responders. (Bryant, Kenny et al. 2019) CBT is considered to be the first line of treatment for PTSD. (Paintain and Cassidy 2018) Similar findings were also reported in a single clinical case study that involved a one to one sessions of intensive CBT intervention with a firefighter-paramedic suffering from PTSD that was developed after death of an infant. (Gramlich and Neer 2018) In this case study substantial improvements in PTSD and depressive symptoms were observed following treatment. (Gramlich and Neer 2018)
CBT mainly focuses on the negative behaviours that a person develops following a traumatic event. The process of CBT, which can be tailored to the specific needs of the individual, targets the meaning that is attached to a traumatic event, which is said to be responsible for the development of PTSD. (Brown, Dewey et al. 2018)
Furthermore, research has shown that trauma-focused CBT techniques have been the most effective and commonly used treatment methods for individuals diagnosed with either ASD or PTSD. (Cukor, Spitalnick et al. 2009; Roberts, Kitchiner et al. 2019) In this review, studies that examined CBT depicted good sample sizes, employed sound methodologies with good follow-up schedules, and led to substantial decreases in the severity of PTSD symptoms. (Roberts, Kitchiner et al. 2019) Moreover, Bryant et al. (2018) found that there was no difference in the efficacies of the long- and short-exposure CBT. (Bryant, Kenny et al. 2019) This has implications for future practice, suggesting that short-exposure CBT for 10 minutes can also assist in reducing the severity of PTSD symptoms. Therefore, instead of mandatory sessions of CISD, which can do more harm than good – especially if incorrectly administered – short-exposure CBT can be used in one on one session for paramedics and other first responders in the event of experiencing a critical incident.
Eye Movement Desensitisation and Reprocessing (EMDR) therapy was found to be effective in reducing symptoms of PTSD in two RCTs included in this review. (Jarero, Amaya et al. 2013; Jarero, Schnaider et al. 2019) Both forms of EMDR (EMDR-PROPARA and EMDR-PRECI) were observed effective in reducing the severity of PTSD symptoms in emergency responders. EMDR-PROPARA was found to an effective early treatment that can be used by paraprofessionals to mitigate the symptoms of PTSD among first responders in the early stages after trauma. (Jarero, Amaya et al. 2013) Whereas, EMDR-PRECI, besides reducing the symptoms of PTSD among first responders, was also found effective for managing depression and anxiety.
Insignificant improvement in posttraumatic stress symptoms were observed with Self-help app called the SUPPORT Coach and Downtime interventions. (Halpern, Maunder et al. 2014; van der Meer, Bakker et al. 2020) However, this was inconsistent with Halpern et al. (2009), who demonstrated the benefit of having time to recover after trauma by allowing an individual to explore and identify his or her own feelings and thoughts about the traumatic event. (Halpern, Gurevich et al. 2009) In this study, the authors examined the effect of identifying, describing, and venting feelings as a way to cope with the effect of critical incidents on the mental wellbeing of a group of paramedics and supervisors. An interesting finding that was highlighted by Halpern et al. (2009) was that although expressing emotions had no effect on the level of PTSD symptoms, identifying emotions was correlated with a reduction of the symptoms. (Halpern, Gurevich et al. 2009)
However, Halpern et al. (2014) did not find a notable correlation between receiving downtime and exhibiting symptoms of PTSD. (Halpern, Maunder et al. 2014) This could be due to the fact that the effectiveness of downtime depends on how an individual uses this resource. In other words, some individuals might use avoidance strategies during downtime to cope with the trauma, whereas others may use downtime to process their traumatic reactions. The authors argued that the best length for downtime is less than a day, which helps individuals to process instead of avoiding their feelings and thoughts. (Halpern, Maunder et al. 2014) This research also revealed the importance of assisting and educating paramedics and EMTs in identifying emotions to reduce their risks of developing PTSD.
Since the reviewed studies required the participants to recall the critical incident, some bias could have resulted in relation to the feelings and memories that were related to that traumatic event. Notably, first responders encounter and deal with trauma as part of their occupation, which exposes them to the risk of cumulative trauma. Cumulative trauma occurs as a result of frequent traumatisation and it should be considered as one of the challenges in evaluating the effectiveness of an intervention on emergency first responders. (Marmar, McCaslin et al. 2006) In addition, this could bring into question the reliability of the studies that were based on a single traumatic experience. Moreover, many of the included studies in the review were cross-sectional and focused on relationship rather than on causality. The low response rate that was observed in survey-based studies was not surprising, as it could have resulted from privacy and confidentiality concerns, especially in measuring symptoms of trauma in EMS organisations. Beyond this, bias could arise in self-reporting surveys when severely distressed individuals avoid participating in these studies as a way to avoid thinking about the traumatic incident.
Several important observations were noted while going through the aforementioned studies. For instance, it is not advisable to generalize the amount of stress caused by critical incidents, since each individual’s perceptions can differ. (Kamena and Galvez 2020) Moreover, men and women seem to handle stress differently, as was evidenced in the study conducted by Woods (2007), which revealed that female ambulance workers reported more PTSD symptoms than their male colleagues. (Woods 2007) Thus, this study showed that gender had an effect on the extent of PTSD symptom reporting. Therefore, it may be useful to focus on making therapy sessions more individualized and educating therapists regarding this phenomenon. As noted in the narrative review (previous chapter), several pre-existing elements affect how an individual reacts to trauma, including individuals’ coping strategies, personalities and cultural factors. Therefore, EMS organisations should take these factors into account when implementing interventions for their frontline staff.
Conclusion
This review began with the aim of identifying which interventions would be effective for the treatment of PTSD and/or ASD among EMS personnel. Using an extensive literature search strategy, a total of ten studies were included in the review. Several interventions were applied in these selected studies. CISD was the most commonly applied intervention, along with CBT, which was often coupled with some form of exposure therapy. Of these interventions, CISD provided the most inconsistent results, which was in line with past evidence, with some EMS personnel reporting a worsening of symptoms. The risk of applying CISD is that if a strict protocol is not followed, the intervention may cause more harm than good, which means CISD should not be used in psychological care as a mandatory intervention. In contrast, the technique that provided the most consistent results was CBT. Even a 10-minute session of TF-CBT was shown to produce comparable benefits. This revealed the potential for using short CBT sessions to treat posttraumatic stress. CBT also generated overall positive psychological health outcomes for individuals.
Moreover, results of these studies might not be generalised to other EMS personnel with different cultural backgrounds and education levels. Cultural context is an essential component of effective PTSD treatment and trauma-informed care (Bryant-Davis, 2019). The main reason why the findings of the studies cannot be generalized is the fact that culture impacts individual vulnerability to a traumatic experience and regulates the recovery process. The cultural backgrounds of EMS workers from diverse settings influence the definition of trauma, its evaluation, and appropriate treatment recommendations (Bryant-Davis, 2019). Moreover, the presence of multiple and intersecting identities in trauma survivors defines their understanding of trauma, therapy, and recovery, which complicates the selection of suitable treatment options.
It is important to adapt interventions to the unique characteristics of each cultural setting and the needs of diverse EMS workers. Culturally responsive interventions should consider cultural context, socio-political realities, and resources available to PTSD-affected individuals. Culturally modified evidence-based interventions require therapists to be aware of survivors’ intersecting identities, spirituality, and cultural differences between the therapist and the client. Additionally, therapists should express cultural humility and acknowledge sociocultural factors (access to mental health care, comprehension of proposed interventions) specific to each trauma survivor to increase client satisfaction and treatment response. Notably, members of marginalized communities and minority groups are especially vulnerable to trauma, PTSD, and the lack of resources for treatment (Bryant-Davis, 2019). Intervention models emerging from Western culture cannot address the peculiarities of settings and trauma survivors from non-Western cultures with distinct beliefs and approaches to spirituality. Hence, future studies should focus on non-western countries, where there is a comparative lack of research in this field.
In addition, further studies that include prospective designs are needed. The rapid overview conducted by Antony et al. (2020) demonstrates a considerable lack of research dedicated to the problem of PTSD prevention and treatment in paramedics and ambulance staff. The majority of existing studies investigate primary interventions applied to police and firefighter populations and disregard the impact of PTSD and occupational stress injury on EMS personnel (Antony et al., 2020). Several recent studies propose that stress injury patterns in EMS workers are similar to those in military veterans (Antony et al., 2020). However, additional research might be needed to provide evidence for the hypothesis. Culturally rooted and indigenous methods of trauma treatment have not been adequately researched and discussed in the psychology literature (Bryant-Davis, 2019). Further research can focus on the decolonization of psychology and the development of culturally emergent models that recognize the value of group- and family-based treatment for frontline workers. Thus, future studies may investigate intergenerational and racial trauma for efficient PTSD diagnosis, treatment, and suicide prevention in diverse populations of EMS workers.
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