Psychiatr Q (2015) 86:261–267

DOI 10.1007/s11126-014-9329-z

ORIGINAL PAPER

Treating Psychological Trauma in First Responders:

A Multi-Modal Paradigm

Raymond B. Flannery Jr.

Published online: 18 November 2014

Ó Springer Science+Business Media New York 2014

Abstract Responding to critical incidents may result in 5.9–22 % of first responders

developing psychological trauma and posttraumatic stress disorder. These impacts may be
physical, mental, and/or behavioral. This population remains at risk, given the daily
occurrence of critical incidents. Current treatments, primarily focused on combat and rape
victims, have included single and double interventions, which have proven helpful to some
but not all victims and one standard of care has remained elusive. However, even though
the need is established, research on the treatment interventions of first responders has been
limited. Given the multiplicity of impacts from psychological trauma and the inadequacies
of responder treatment intervention research thus far, this paper proposes a paradigmatic
shift from single/double treatment interventions to a multi-modal approach to first
responder victim needs. A conceptual framework based on psychological trauma is pre-
sented and possible multi-modal interventions selected from the limited, extant first
responder research are utilized to illustrate how the approach would work and to encourage
clinical and experimental research into first responder treatment needs.

Keywords First responders
Multi-modal approach
Paradigm shift
Psychological

trauma
Treatment interventions

R. B. Flannery Jr. (&)

Department of Psychiatry, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge,
MA 02139, USA
e-mail: raymond_flannery@hms.harvard.edu

R. B. Flannery Jr.
Harvard Medical School, Boston, USA

R. B. Flannery Jr.
The University of Massachusetts Medical School, Worcester, USA

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Introduction

Psychological trauma has been a present but little understood entity in American history. It
was most frequently recorded in war, where it was known as Soldier’s Heart in the Civil
War and as Shell Shock in the World Wars. In the last quarter of the twentieth century, the
National Vietnam Readjustment Survey of returning soldiers [1] and the women’s
movement with its emphasis on women victims [2] provided a special impetus for the
thorough study the nature of psychological trauma and posttraumatic stress disorder
(PTSD).
This concentrated national emphasis resulted in a wide array of empirical studies on the
nature of trauma and the search for a basic treatment intervention, such as cognitive
behavior therapy (CBT) [3] or eye movement desensitization and reprocessing (EMDR)
[4]. These interventions proved helpful to some victims but not all and the search for a
basic treatment intervention has remained elusive with no single standard of care emerging
[5].
However, clinicians treating trauma victims with multiple needs created integrated
treatments with various pragmatic rationales, not necessarily related to trauma [6].
Research followed suit with some outcome studies assessing the efficacy of double
treatment interventions. As with single interventions, the combined intervention studies
were again efficacious for some but not all victims [5, 7]. Although 5.9–22 % of first
responders may develop psychological trauma when responding to critical incidents [8]
and remain an at risk population because of recurring, daily critical incidents, much of the
research effort thus far has focused on combat and rape victims with less attention directed
to the treatment needs of first responder victim [5]. This is an important neglected area in
the trauma research literature.
There are several possible reasons why first responder victims may have received less
attention.
(1) In general, less media attention has been directed toward the needs of first
responders. Unlike the needs of combat and rape victims, there is little public awareness of
first responders developing psychological trauma/PTSD during critical incidents. An
important exception to general media coverage was that of the needs of first responders
during 9/11, which did result in empirical research [8]. (2) First responders as a group are
action-oriented, self-contained, deferential men and women where ‘‘complaining’’ is not
acceptable behavior and seeking mental health counseling for impairments arising from
doing one’s job is not likely to be thought about. If anything, responders might focus on
symptoms rather than developing a support group or seeking to process the critical
incident(s).
(3) Even if counseling were sought, the reality of the work would leave limited time for
processing one critical incident before a second call for assistance at the next critical
incident is received. (4) Much of the experienced distress is often self-medicated through
substance abuse and the basic trauma issues remain unaddressed. (5) Unlike those
researchers who study combat and rape victims, first responders have fewer links to aca-
deme and a faculty that might be interested in addressing first responder treatment needs.
Given these factors, while the general findings from combat and rape are in some ways
similar to the more limited research on treating first responders [9, 10], more inquiry is
needed, especially on targeted symptom treatments as a first step in engaging responders in
overall care.

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Given that psychological trauma and PTSD may have multiple impacts on victims, and
given that single/double interventions have thus far proven inadequate for the needs of
several.
Victims, some examples from other branches of medicine may provide a useful
perspective on the need for multi-modal interventions. Two examples: If a person was
in a car accident and suffered a concussion, a dislocated finger, and a laceration that
became infected, one would not expect the antibiotic to resolve all three issues. Sim-
ilarly, for many years, there was a single treatment for cancer, yet with advances in the
field there are now many interventions designed specifically to differing patient bio-
logical and psychological needs. Similarly, since trauma may impact the human
organism in many ways, expecting one or two interventions to resolve all issues may
not be the best approach. These medical examples suggest that it may be more effi-
cacious to shift or extend the current trauma treatment paradigm from single/double
interventions to one of a multi-modal approach for the varied treatment needs of
responder victims. Such a multi-modal approach needs to be based on a clear rationale
derived from the major impacts of psychological trauma on first responder victims.
The purpose of this paper is present one such multi-modal treatment paradigm with the
current extant research data on first responders to illustrate its possible implementation and
to interest the clinical and academic research communities to consider empirical inquiry of
first responder treatment needs.

Psychological Trauma/PTSD

Psychological trauma is a person’s physical and psychological response to experiencing,

witnessing, or being confronted with events(s) that involve actual or threatened death,
serious injury, or threats to the physical integrity of the self or others that result in intense
fear of helplessness [11]. As noted earlier, the published literature documents the onset of
psychological trauma anywhere from 5.9 to 22 % of first responders responding to a
critical incident [8].
Psychological trauma may involve disruptions in the three domains of good
physical and mental health: reasonable mastery of one’s environment, caring attach-
ments to others, and meaningful purpose in life that motivates one to invest energy in
the world each day to pursue some socially acceptable goal [12]. Psychological
trauma also includes three sets of symptoms: physical symptoms due to physiological
arousal, such as hypervigilance and exaggerated startle response; intrusive symptoms
that are comprised of memories of the event; and avoidant symptoms where the
victim actively avoids the site of the critical incident, avoids discussing it, and in time
has a reduced interest in significant life activities [12]. If these disruptions are not
treated, PTSD emerges after 30 days. Without treatment, the PTSD symptoms may
last until death.
First responder victims may experience disruptions in any of the three domains of good
health and/or any of the three sets of symptoms. The multi-modal intervention approach
would encourage specific treatments for any of these six disrupted areas. Below is what the
published first responder literature has documented to date as being possible efficacious
interventions for these varied disruptions. The selected studies are empirically-based or
literature reviews of empirical-based research.

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Potential First Responder Interventions

Disrupted Health Domains

Mastery

Since traumatic events disrupt a sense of mastery, three reviews of the empirical literature
have documented a variety of strategies that have proven helpful in restoring mastery in
first responders [6, 13, 14]. In studies of disaster workers Gibbs and colleagues [6] noted
the importance of addressing role conflict between providing care onsite and caring for
one’s own family and the problem of repeated exposure to critical incidents, especially
in situations involving dead or mutilated bodies. Limiting exposure time onsite, providing
local responders with updated information about their families, and fielding workers from
outside the local area were interventions that reduced stress and restored mastery [6].
Klein and Westphalia [13] and Waters [14] reviewed the literature that has primarily
focused on police. Several studies found that self-care, education about traumatic events,
limited onsite workloads, and clearly defined organizational cultures maintained mastery or
quickly restored it. Neira and his co-workers [8] reviewed the 9/11 studies of both
responders and civilians and noted that resilient individuals with good self-enhancement
and social support coped more adaptively in both the short and longer terms. More recent
research on firefighters [15] found that focused coping which included appraising situations
as challenging resulted in better port-incident outcomes than did negative self-blame.
Caring Attachments: The research on caring attachments or social support with disaster
workers and police is extensive and has generally found social support to ameliorate
possible negative impacts associated with traumatic events [6, 16–19]. Two reviews noted
some studies where social support was not helpful in all circumstances [6, 17] but the
preponderance of the data emphasizes the importance of caring attachments from col-
leagues and supervisors in managing trauma/PTSD.
Meaning: Thus far, the primary intervention for restoring a meaningful purpose in life
has been CBT. As with caring attachments, the published literature [9, 20–22] found this
intervention to be effective with some of various types of disaster workers assessed. There
is no appreciable finding for other forms of treatment, such as EMDR. Chapko [23] notes
that personal and spiritual growth may also emerge from traumatic events and create a
positive meaning in the responder’s world view.

Symptoms

Given that research has clearly identified the symptoms common in psychological trauma
and PTSD, given that some first responders routinely manifest these symptoms, given that
the major treatments such as CBT do not always resolve these symptoms, and given that
practicing clinicians continue to try to treat these symptoms in their own right, research on
treating symptoms is needed. This is especially important in first responders who will
likely feel more at ease discussing symptoms first in any recovery program. Two papers
have reported on the success of pharmacological agents [20, 24] and mindfulness [25] in
addressing the physical symptoms and pharmacological agents and CBT has at times
reduced intrusive symptoms [20–22]. Although CBT discussions might at times lead to
reduced avoidance, there appears to be no study addressing avoidance symptoms in their
own right, such as with in vivo desensitization procedures. Research in all three symptom
clusters continues unaddressed, even though factor analytic research has suggested that

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targeted treatment of symptoms may provide the best benefits [26]. This is especially true
for first responders, who, if they speak of any negative impact, will focus on symptoms.

Discussion

Although single [3, 4] and double [5–7] interventions have been helpful to some combat
and rape victims, these interventions have not been helpful for many first responder victims
[20]. This paper presented a multi-modal paradigm for first responder treatment inter-
ventions to begin to address this need. The model is based on a conceptual understanding
of psychological trauma that emphasizes the three domains of mastery, caring attachments
(social support) and a meaningful purpose in life and the three sets of symptoms [12]. Since
trauma may have differing negative impacts, the multi-modal approach proposes specific
treatment interventions for each impairment in any and/or all six of these areas. The early
first responder empirical literature [6, 8, 13–26] provided examples of treatment inter-
ventions in these six areas that have already proven effective singly. The next step is to
encourage researchers to consider first responder victims and their treatment needs in
providing a comprehensive multi-modal approach for all types of responder impairments.
There are two issues that need to be addressed in such research. Researchers and
clinicians will the need to shift first responder mind sets so that treatment interventions will
prove helpful. The first responder mindset during the critical incident is one of detachment,
quick assessment, and self-directed immediate decisions. This mindset of vigilance needs
to be relaxed post-incident to obtain treatment benefits. The needed post-incident mindset
would encourage empathy, experiencing of affects, and relying on others for assistance.
The second issue is that of substance abuse [14]. While substance abuse is a medical
problem in its own right, many first responders use substances to self-medicate the
symptoms of untreated trauma and PTSD. Substance abuse is frequently mentioned as a
risk factor in first responders [12, 14]. It is reasonable to assume some clinicians in
individual practice my refer first responder victims to substance abuse treatment programs
but the empirical first responder treatment literature is silent on this matter. When first
responder self-medication is related to symptom management, it is important that both be
addressed in any multi-modal approach, as sobriety will result in increased intensity of
trauma/PTSD symptoms and increase the risk of relapse. Both issues need to be addressed
conjointly.

Methodological Issues

First responder treatment research is in its early stages and several basic issues need to be
addressed in future research. First is the need for operational definitions of the health
domains of mastery, attachment, and meaningful purpose. Any particular study would need
to indicate what aspect(s) of particular health domain is under study. The three sets of
symptoms are more operationally defined but studies will need to be clear about which
symptom cluster or specific symptom(s) is being assessed. Clear operational definitions
need to be accompanied by clear, reliable, validated measures of the domains or symptoms
being investigated.
Control groups in some format will also need to be assessed. Randomized controlled
studies may be difficult to field initially given the nature of the critical incident work.
However, pre-/post-designs of experimental and control groups are a first step that is now
possible in the field. Subjects as their own controls is another initial approach, as data

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begins to accumulate for research consideration. Symptom targeted research, such as the
recent psychopharmacology study of industrial workers in an industrial accident in France
[27], is a needed first step in assessing the treatment needs of first responders. Longitudinal
prospective studies will emerge as basic research findings provide direction. At present,
each multi-modal intervention will need to be assessed in its own right. Over time, science
data and technological advances may allow for each specific multi-modal intervention to
be assessed as part of some overall assessment protocol.
In addition to these basic research design variables, there are specific first responder
variables that require specific consideration and control. First is the type of responder being
evaluated. Police, firefighters, paramedics, and health care personnel have differing skill
sets, differing organization cultures, and differing critical incident policies and procedures
that will need to be controlled for. Responders in all groups have differing years of
experience, differing histories of critical incident exposure, and differing past histories of
debriefings and/or onsite counseling that will be to be addressed to assure the validity of
research conclusions drawn. Consideration will also need to be paid to possible gender
differences, physical strength and endurances, empathic understanding, decision-making
processes, and the like, so that in time results may be generalized across studies.
Finally, there are some factors inherent in the work itself that will need to be addressed.
Responding to critical incidents requires flexible and sequential responder decision mak-
ing. However, there are often uncontrollable logistic limitations that may emerge onsite
and disrupt the best of basic research designs. A second work-related factor in found in
determining the subject sample. To date, first responders have volunteered to participate
and attendance has not been mandated. Such an approach may skew findings. A third
work-related factor is the issue of underreporting. First responders often deny any negative
impacts from their work. This is often an avoidance response that precludes the responder
from addressing these issues in a more efficacious format.
The first responder needs are complex and challenging. The current research funda-
mentals to be addressed are many but the first responder population is at daily risk. Sound
research on responder treatments will reduce suffering and enhance the quality of crisis
services that will benefit the communities that first responders serve.

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Raymond B. Flannery, Jr. Ph.D. is Director of The Assaulted Staff Action Program (ASAP), Boston MA.
Dr. Flannery is Associate Clinical Professor of Psychology, Harvard Medical School, Boston, and Adjunct
Assistant Professor of Psychiatry, The University of Massachusetts Medical School, Worcester, MA.

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