A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

the Dialogue

2018 | VOLUME 14 | ISSUE 1

The Effects of Trauma on First Responders
The views, opinions, and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of SAMHSA 

or HHS. Nothing in this document constitutes a direct or indirect endorsement by SAMHSA or HHS of any non-federal entity’s products, services, or 

policies, and any reference to non-federal entity’s products, services, or policies should not be construed as such.

The Dialogue is a quarterly technical assistance journal on disaster behavioral health which 

is produced by the Substance Abuse and Mental Health Services Administration (SAMHSA)

Disaster Technical Assistance Center (DTAC). Through the pages of The Dialogue, disaster 

behavioral health professionals share information and resources while examining the 

disaster behavioral health preparedness and response issues that are important to the field. 

The Dialogue also provides a comprehensive look at the disaster training and technical 

assistance services SAMHSA DTAC provides to prepare states, territories, tribes, and local 

entities so they can deliver an effective behavioral health (mental health and substance 

misuse) response to disasters. To receive The Dialogue, please go to SAMHSA’s home 

page (http://www.samhsa.gov), click the “Sign Up for SAMHSA Email Updates” button, 

enter your email address, and mark the checkbox for “SAMHSA’s Disaster Technical 

Assistance newsletter, The Dialogue,” which is listed in the Newsletters section.

SAMHSA DTAC provides disaster technical assistance, training, consultation, resources, 

information exchange, and knowledge brokering to help disaster behavioral health 

professionals plan for and respond effectively to mental health and substance misuse needs 

following a disaster.

To learn more, please call 1-800-308-3515, email DTAC@samhsa.hhs.gov, or visit the 

SAMHSA DTAC website at https://www.samhsa.gov/dtac.

IN THIS ISSUE

1 In This Issue

2 Contributors

3 Recent Technical Assistance Requests

4 Technical Assistance Snapshot

5 Interview With an Officer in a Large Urban Police Department

9 Perception Is Reality for Disaster Survivors

12 Psychological Trauma in First Responders Following Disaster Response

15 How Do First Responders Experience and Cope With Trauma?

Cover image capture from Video by Robert Scott Button (http://robertscottbutton.com).
In This Issue

paramedic, firefighter, and emergency room physician 

discuss their field experiences and how they and their 

colleagues cope with job-related trauma and successfully 

recover from disasters. One common thread in these 

articles is the desire on the part of first responders to 

help their communities. By focusing on resilience 

building and taking care of their behavioral health, first 

responders may avoid secondary or vicarious trauma 

and be better able to do just that.

Are you a first responder? Please share your experiences 

with us. We encourage you to contact us with lessons 

learned from your field experiences or if you would 

like to learn more about any of the trainings that the 

SAMHSA Disaster Technical Assistance Center (DTAC) 

has available for first responders. ■

Captain Erik Hierholzer, B.S.N., Program 

Management Officer, Emergency Mental Health and 

Traumatic Stress Services Branch

erik.hierholzer@samhsa.hhs.gov

Nikki Bellamy, Ph.D., Public Health Advisor, 

Emergency Mental Health and Traumatic Stress 

Services Branch

nikki.bellamy@samhsa.hhs.gov

Shannon Loomis, M.A., Director, SAMHSA DTAC

dtac@samhsa.hhs.gov

Throughout this year, our country has experienced many 

record-breaking natural and human-caused disasters. 

During and after these events, the affected communities 

rely heavily on an effective and efficient response from 

first responders to be able to recover. But who can first 

responders rely on to ensure that they can recover too?

The situations first responders are generally faced with 

are inherently difficult and stressful. They are typically 

the first to arrive on the scene of events involving 

injuries and loss of life. They often provide emotional as 

well as physical support to traumatized survivors. These 

duties often put first responders at risk for secondary or 

vicarious traumatization.

Secondary or vicarious traumatization is 

“generally defined as experiencing similar symptoms 

to trauma victims as a result of indirect traumatic 

exposure via close contact with the survivors.”

Source: Brooks et al., 2015

First responders routinely are exposed to severe

trauma. Repeated exposures, coupled with the

immense stress of roles in emergency services, can

lead to an increased risk for adverse behavioral health

outcomes such as distress, worry, disturbed sleep or

concentration, alterations in work function, difficulties

with interpersonal relationships, increases in substance

use, somatization, and depression (Benedek, Fullerton,

& Ursano, 2007). However, it’s not all bad news.

According to studies, specialized training, elevated

levels of professional mastery, and assurance of personal

and team capabilities act as protective factors, enhance

resilience, and are associated with reduced stress

(Brooks et al., 2015; Brooks, Dunn, Amlot, Greenberg,

& Rubin, 2016).

This issue presents several articles reflecting the

experiences of first responders. We are leading this

issue off with an interview with a police officer about

his battle with posttraumatic stress disorder (PTSD) as

a result of a traumatic event. In subsequent articles, a 

Photograph by Loren Rodgers/Shutterstock

2018 | VOLUME 14 | ISSUE 1 | PAGE 1
Robert Cousins, NRP, FP-C 

works as a critical care 

paramedic and operational 

medicine instructor for the 

federal government. He is also 

active as an emergency medical services (EMS) provider 

and instructor in Montgomery County, Maryland. Robert 

was formerly a field training officer for University 

of Colorado Health EMS and has also worked as an 

emergency medical technician and paramedic in New 

York, New England, and Washington, DC. He has 

a bachelor’s degree from Dartmouth College and is 

pursuing his master’s in public health from The George 

Washington University. He has previously contributed to 

the Journal of Prehospital Emergency Care.

Laura Helfman, M.D., FACEP, 

WALS is a board-certified 

emergency physician with 

privileges at multiple hospitals 

in Tennessee and North 

Carolina. She attended Barnard College, Columbia

University for her B.A. and The Medical College

of Pennsylvania in Philadelphia for her M.D. She

is a member of the Tennessee-1 Disaster Medical

Assistance Team (TN-1 DMAT), as well as a lead

instructor for Wilderness Medical Associates, where she

teaches wilderness first response to outdoor education

professionals. She is also an avid whitewater enthusiast

and professional river guide. She believes that attention

to prevention, self-reliance, innovation, common sense,

and teamwork are the cornerstones of effective rescue.

In any trauma or mass casualty, these skills can help

bring order to chaos and clarity to indecision.

Contributors

Don McCullough, M.S., CMHC, 

EFO has spent over 35 years as 

a first responder, retiring at the 

rank of Captain in April 2016 

from the City of Rochester 

(New Hampshire) Fire Department. Since 2003 he has 

been a member of Federal Emergency Management 

Agency Urban Search and Rescue Massachusetts 

Task Force 1 (MATF-1), and he currently serves as a 

technical rescue specialist with the team.

He holds a master’s degree in clinical mental health 

counseling and has worked in several clinical settings. 

He is also a graduate of the National Fire Academy’s 

Executive Fire Officer Program in Emmitsburg, 

Maryland. Since 2005 he has been a member of the 

Granite State Critical Incident Stress Debriefing Team 

assisting police, fire, emergency medical services, 

and other emergency agencies that have experienced 

traumatic incidents, serving dual roles as both peer 

counselor and mental health professional. He is 

an approved International Critical Incident Stress 

Foundation Group Peer instructor and is a New 

Hampshire Disaster Behavioral Health Response Team 

regional co-leader. He is also a National Alliance on 

Mental Illness-trained Suicide Postvention facilitator.

He currently works as Program Coordinator for the 

Tri-City Co-Op in Rochester, New Hampshire. Tri-City 

Co-Op is a peer support agency that serves those who 

struggle with mental illness, substance use disorders, 

and homelessness. ■

2018 | VOLUME 14 | ISSUE 1 | PAGE 2
Recent Technical Assistance Requests

In this section, read about recent questions SAMHSA Disaster Technical Assistance Center (DTAC) staff have 

answered and technical assistance requests to which they have responded. Send your questions and comments to 

dtac@samhsa.hhs.gov.

Request: A state disaster behavioral health 

coordinator contacted SAMHSA DTAC to request 

a literature review on the psychological impacts of 

Hurricane Katrina, with emphasis on the incidence of 

depression and suicide following the disaster.

Response: SAMHSA DTAC provided an overview 

of several articles that examined mental illness 

incidence and prevalence after Hurricane Katrina. The 

articles covered a variety of different populations and 

demographic characteristics. Overall, the results of the 

literature review showed that Hurricane Katrina had 

lasting psychological effects on survivors. SAMHSA 

DTAC sent the state disaster behavioral health 

coordinator links to all the research from the review. 

Below are some selections:

■ Galea, S., Brewin, C. R., Gruber, M., Jones, R. T.,

King, D. W., King, L. A., & Kessler, R. C. (2007).

Exposure to hurricane-related stressors and mental

illness after Hurricane Katrina. Archives of General

Psychiatry, 64(12), 1427–1434.

■ Mills, M. A., Edmondson, D., & Park, C. L. (2007).

Trauma and stress response among Hurricane Katrina

evacuees. American Journal of Public Health,

97(Supplement_1), S116–S123.

■ Davis, T. E., Grills-Taquechel, A. E., & Ollendick, T.

H. (2010). The psychological impact from Hurricane

Katrina: Effects of displacement and trauma exposure

on university students. Behavior Therapy, 41(3),

340–349.

■ Hirschel, M. J., & Schulenberg, S. E. (2009).

Hurricane Katrina’s impact on the Mississippi Gulf

Coast: General self-efficacy’s relationship to PTSD

prevalence and severity. Psychological Services, 6(4),

293.

Request: A first responder who had taken the 

Creating Safe Scenes online training (https://www.

samhsa.gov/dtac/creating-safe-scenes-training) 

emailed SAMHSA DTAC to inquire about additional 

trainings available on mental illnesses, and specifically 

if there were any trainings applicable to attorneys. 

Response: SAMHSA DTAC provided a list of publicly 

available trainings that cover mental health topics, such 

as awareness and recognition of mental health issues and 

issues that may be encountered by those in the criminal 

justice field. The following resources were provided.

■ Psychological First Aid (https://learn.nctsn.org/

course/index.php?categoryid=11): This 6-hour

online course is provided free of charge. Content

includes an overview of mental illnesses and helps

users learn how to deal with those in a mental health

crisis after a disaster.

■ Mental Health Aspects of Emergencies and Disasters

for Non-mental Health Professionals (http://

ynhhs.emergencyeducation.org/flyers/EM230_

CourseFlyer.pdf): This course is offered online from

the Yale New Haven Health Center for Emergency

Preparedness and Disaster Response. The course

aims to raise awareness of mental illnesses and help

workers recognize the warning signs of mental health

issues in others.

■ Trauma-informed Legal Advocacy Webinar (http://

www.nationalcenterdvtraumamh.org/trainingta/

trauma-informed-legal-advocacy-tila-project): This

webinar reviews how attorneys and legal counsel can

support those affected by domestic violence, sexual

assault, and mental health issues.

2018 | VOLUME 14 | ISSUE 1 | PAGE 3
Request: Following the civil unrest in Charlottesville, 

Virginia, a local organization reached out to SAMHSA 

DTAC to get technical assistance on leading the 

behavioral health response to the incident. 

Response: SAMHSA DTAC facilitated a conference 

call with the organization to determine their needs and 

help them coordinate their response efforts. Additionally, 

SAMHSA DTAC provided electronic and print 

resources on mass violence and related topics, as well as 

suggestions of trainers/consultants who are familiar with 

Psychological First Aid and Skills for Psychological 

Recovery training models, to aid in the community’s 

recovery. Below are selected resources sent.

■ Tips for Survivors: Coping With Grief After

Community Violence—This SAMHSA tip sheet

presents some of the common effects of an incident

of community violence, signs and symptoms of grief

and anger, and useful information about how to cope

with grief. Also provided are ways to support children

in coping, as well as helpful resources. https://store.

samhsa.gov/product/Coping-With-Grief-AfterCommunity-Violence/SMA14-4888

■ Effects of Traumatic Stress After Mass Violence,

Terror, or Disaster—This National Center for PTSD

webpage describes the emotional, cognitive, physical,

and interpersonal reactions that disaster survivors may

experience and discusses the potentially severe stress

symptoms that may lead to lasting PTSD, anxiety

disorders, or depression. Information on how survivors

can reduce their risk of psychological difficulties and

recover most effectively from disaster stress is also

provided. https://www.ptsd.va.gov/professional/

trauma/disaster-terrorism/stress-mv-t-dhtml.asp

■ Media Coverage of Traumatic Events: Research

on Effects—The National Center for PTSD presents

information on the effects of intense media exposure

following a disaster. The website describes the

association between watching media coverage of

traumatic events and stress symptoms. Guidance is

also offered for providers who work with children and

their parents to avoid retraumatization. https://www.

ptsd.va.gov/professional/trauma/basics/mediacoverage-traumatic-events.asp ■

SAMHSA DTAC continues to respond to training 

and technical assistance requests and is always 

improving our service to the field. This edition 

of The Dialogue is a direct response to needs 

identified by you—our customers and partners.

The results of the 2016–2017 SAMHSA DTAC 

Customer Feedback Survey demonstrated a 

need for more first responder information. 

Training disaster behavioral health workers 

and helping disaster responders manage 

stress were two of the top priorities for 

SAMHSA DTAC customers.

TECHNICAL ASSISTANCE SNAPSHOT

2018 | VOLUME 14 | ISSUE 1 | PAGE 4
To

Serve

and

Protect

Interview With an Officer in a Large Urban 

Police Department

Staying Fit To Protect and To Serve: A Police Officer Talks About PTSD

In 2004, in the middle of the night, the police officer interviewed for this 

article was shot in the line of duty. Following the incident, he had two 

surgeries, and, within 2 years, he developed PTSD. His PTSD continued 

for several more years before it was identified. His story illustrates some 

common responses to trauma, emphasizes the importance of talking with 

peers, and highlights key lessons he has learned from his experience.

What were the signs that you 

were having trouble coping with 

what had happened?

Two years or so after the incident, 

I started getting sick and fell into a 

really lousy state. The doctors could 

never figure out what was wrong. 

From 2006 to 2010, I went to work, 

came home, got into bed, and never 

left my bed until I went back to work 

the next day. But I was averaging 

3 or 4 hours of sleep a night. I 

had never sweated much before, 

and I would wake up in a pool of 

sweat. I was having migraines. I 

got admitted to the hospital with a 

24-hour migraine, and they gave me

the maximum dose of medication,

and it didn’t even put a dent in the

pain. They sent me to a neurologist,

but what I was going through was

because of the trauma.

It was about 3 to 4 years of extreme 

misery. One thing that made a lot of 

sense to me was a commercial I saw 

for an antidepressant where they say 

that depression hurts. That’s true—

it’s not just that you’re down in the 

dumps. You get physical pains too.

Instead of dealing with emotions 

and trying to get them back, it was 

easier to try to do something I could

feel. I got into some bad ways of 

coping. If I got angry, I would drink. 

It also seemed that sex was a big 

draw for me. If I was really stressed, 

that was what I went to. I couldn’t 

feel a lot of emotions. My family life 

suffered too—my relationship with 

my children dropped off.

On Halloween of last year, I tried 

to kill myself. That got me to a new 

therapist, who has been helping me 

a lot. It gets so bad, you sometimes 

feel even death has to be better than 

this. You don’t think, “If I die it will 

affect these people.” You’re focused 

on how much pain you’re in.

What changed so that you 

realized you had PTSD?

In 2009, I started talking to some 

officers. Two had just come 

back from overseas. I got in a 

conversation trying to find a decent 

doctor, and they said it sounded like 

I had PTSD. I did some research 

and took a couple of online tests and 

realized they were probably right.

Did you seek out professional 

behavioral health support?

Yes, twice—the first time in 2009. 

That first therapist helped a little, but 

I was the first person with PTSD she 

had worked with. I was out of work 

for a while, and then I went back, a 

little too soon, and things got bad 

again because I didn’t have really 

good coping skills.

Later, I ended up finding a therapist 

who specializes in trauma in first 

responders. He used Eye Movement 

Desensitization and Reprocessing 

2018 | VOLUME 14 | ISSUE 1 | PAGE 5
(EMDR) with me. It doesn’t work 

for everyone, but it was amazing for 

me. I also got my poor coping skills 

identified, and things are a lot better 

now. A few things have happened 

since then that I don’t know if I 

would have been able to handle 

before I saw him. I have better 

coping skills, and I never drink 

when I’m mad or upset. If I have a 

bad day I move around and don’t 

stay in my room.

Are there things you still need 

to do differently from day to day 

from someone who hasn’t had 

trauma?

I still don’t like fireworks. My wife 

loves the Fourth of July, but it’s 

tough for me to go downtown and 

watch fireworks—not because of 

the sound, but because of the smell. 

The smell of burnt gunpowder is a 

trigger for me.

How did you figure out about the 

smell as a trigger, or about any 

other triggers you have?

My first therapist wouldn’t give 

me approval to go back to work 

until I had fired my gun, so I went 

to a gun range. Our department 

range is open air, but I went to an 

indoor gun range with a friend of 

mine. I smelled the gunpowder, and 

suddenly it was 3 in the morning 

again, and the target was the suspect 

in the incident where I got shot. It 

was an awful experience, and the 

only flashback I’ve had. Part of the 

way in, I told my buddy I was done, 

and he made me continue on. I had 

to fight through it. I was thankful 

that he was there and recognized it 

and helped me fight through it.

Do you think there are any 

organizational or cultural 

changes that are needed to help 

first responders who are dealing 

with trauma?

If officers are involved in situations 

with shots fired and they don’t get 

injured, they usually have to go back 

to work pretty fast. Most places 

give you 3 days off, tests are done, 

evaluation, and then back to work. 

The mentality in first responders is 

you suck it up and you go on, and 

sometimes you just can’t.

Also, first responders should 

approach their peers when they 

The mentality in first responders is you suck it 

up and you go on, and sometimes you just can’t.

think they’re having problems. 

It’s not easy to approach someone 

you think is having issues, but 

sometimes that’s what you have 

to do. It doesn’t matter what rank 

you’re at. You can always pull 

someone aside and talk to them.

Do you have any self-care 

practices that work well for you 

or your colleagues? What keeps 

you grounded in this work, and 

where do you look to keep a 

positive outlook on life?

I talk to people more. One thing that 

really helps me is the work I do as 

a field training officer. When new 

officers graduate the academy they 

ride with me, and I show them how 

to use what they learned there and 

put it into practice on the streets. I 

talk about my incident a lot to my 

rookies. I’ve got a PowerPoint I use, 

and teaching about it makes me talk 

about it, and talking about it makes 

it better.

My faith has grown a little bit, and 

I tend to pray more. But for me, 

it’s not so much using good coping 

skills as not using bad ones—

learning, if I do this bad skill, it’s 

It is estimated that 30% of first 

responders develop behavioral 

health illnesses including, but not limited 

to, depression and PTSD as compared with 

20% in the general population.

Source: Abbott et al., 2015

30%

20%

10%

2018 | VOLUME 14 | ISSUE 1 | PAGE 6
going to lead to this bad outcome. 

It’s easier to do the poor coping skill 

than face the reality of the good 

coping skill.

Do you think there are key 

takeaway messages from your 

experience?

Had somebody seen my symptoms 

as PTSD sooner, before those two 

officers did, and had I actually 

gotten help and talked about my 

experiences sooner, it could have 

saved me 3 years of struggle without 

knowing what was wrong. It’s 

important to tell police and other first 

responders what can happen after 

an experience like a line-of-duty 

shooting. If someone had explained 

to me after the shooting the signs 

and symptoms that could come up—

not being able to sleep, and problems 

in your work and family life—and 

let me know that I needed to talk 

about it and work it out, I think that 

would have helped me.

Also, it’s really important to talk 

with others, and if you can find one, 

If someone had explained to me after the shooting the 

signs and symptoms that could come up—not being 

able to sleep, and problems in your work and family 

life—and let me know that I needed to talk about it and 

work it out, I think that would have helped me.

a peer group or support group of first 

responders who have similar issues 

is invaluable. It blew me away when 

I found out the number of officers 

that had been involved in shootings. 

I was feeling as though no one could 

feel as bad as I was feeling. But 

when I talked to others, they would 

let me know that yes, I was feeling 

really screwed up, but it was normal 

for the situation I’d been in.

Where I live, there are groups for 

people who developed PTSD after 

experiences in the military, and how 

they get PTSD is different from how 

first responders do. Police, fire, and 

emergency medical services are 

in the same settings, and we relate 

more.

I can say this—if I can help anybody 

to not go through what I went 

through, I’m more than willing 

to do what I need to do to make 

that happen. I don’t mind talking 

to anyone who’s been in a similar 

situation because I can relate. ■

Self-care tips 

for first responders:

Be aware of the stress you will be dealing with. For 

example, certain incidents may have specific effects on 

people with prior exposure to traumatic experiences.

Recognize good work during the disaster, empower staff, 

and assign responsibility to staff to have a protective effect.

Attempt to limit stress and keep in mind personal safety 

while looking after affected people.

Be aware of personal vulnerability and recognize signs of 

burnout and compassion fatigue.

Develop plans prior to the disaster and set limits, plan on 

taking breaks, sleeping adequately, and eating nutritious 

meals and exercising during the relief work.

Source: Quevillon et al., 2016

The following page is an

informational pullout 

poster that you can print

and post. It provides signs 

and symptoms of PTSD as 

well as resources for first 

responders to turn to 

for help.

2018 | VOLUME 14 | ISSUE 1 | PAGE 7
Know the signs and symptoms of posttraumatic 

stress disorder (PTSD):

Having Trouble 

 Forgetting That Call?

Feeling overly stressed or tense?

Find out where you can get help.

National Suicide Prevention Lifeline: 1-800-273-8255

Safe Call Now: 206-459-3020

Share the Load: Fire/EMS Helpline 1-888-731-FIRE (1-888-731-3473)

SAMHSA Behavioral Health Treatment Services Locator: 1-800-662-HELP (1-800-662-4357)

Distressing memories of traumatic events

Nightmares 

Irritability, angry outbursts, or aggressive behavior

Feeling “on guard”

Difficulty concentrating or sleeping

Feelings of overwhelming guilt or shame

Being easily startled or frightened

Self-destructive behavior

It is estimated that 1 in 10 

 first responders will develop PTSD.

You aren’t alone.
Perception Is Reality for Disaster Survivors

By Don McCullough, M.S., CMHC, EFO

I have described some scenes the 

search and rescue squads were 

operating in to set the stage to 

describe the psychological state of 

the storm victims. Imagine a scene 

of destruction, with normality turned 

on its head and an eerie quiet in the 

air, with no electricity and very few 

moving vehicles, which were mostly 

emergency vehicles. People stood in 

their yards, hands over their mouths 

and staring. Others wandered around 

in the streets, stopping to look at 

something damaged or destroyed 

that just 2 days before had looked 

completely normal. All these people 

were in that initial reaction state 

of numb shock and disbelief that 

we all experience in the immediate 

aftermath of widespread disaster.

First responders to such events, 

whether emergency personnel 

or disaster behavioral health 

responders, can expect many 

of the victims to be in a state of 

psychological upheaval. They 

will demonstrate a wide range of 

behavioral responses you must be 

prepared for. MATF-1 conducts 

an annual training that covers an 

overview of disaster behavioral 

health for victims and rescue 

personnel. This training enables 

Responding After Hurricane 

Sandy

On October 29, 2012, Hurricane 

Sandy slammed into central and 

northern New Jersey, as well as New 

York City and the southern Long 

Island shoreline, bringing with it a 

devastating storm surge.

FEMA’s Urban Search and Rescue MATF-1 Team responding to Superstorm Sandy. Image capture from 

Video by Robert Scott Button (http://robertscottbutton.com).

As a rescue specialist with the 

Massachusetts Task Force 1 (MATF1), 1 of 28 Federal Emergency 

Management Agency (FEMA) 

Urban Search & Rescue teams in 

place across the United States, I 

deployed with the team to New York 

City—specifically, the Rockaway 

section of Queens. The team 

arrived in the afternoon and was 

immediately tasked with search 

and rescue operations through the 

neighborhoods of the Rockaways, 

moving south toward the shoreline.

By nightfall, rescue squads reached 

the beaches of the Rockaways. It 

was a surreal landscape. By 10 p.m. 

safety concerns led command staff 

to terminate operations. I remember 

standing on the hard-packed beach 

sand and feeling a rock under 

my foot. I moved my boot and 

looked down. It wasn’t a rock I 

was standing on. It was the hex nut 

affixed to the top of the cap to a fire 

hydrant. The storm surge had moved 

the entire beach inland 200 yards. 

The following day we resumed 

operations on Staten Island.

2018 | VOLUME 14 | ISSUE 1 | PAGE 9
team members to anticipate a range 

of behavioral responses by victims 

and provide basic Psychological 

First Aid for them.

The MATF-1 training also covers 

self-care practices while in the field, 

such as hydration, nutrition, rest, 

and “hot wash” talks (squad-level 

discussions after a work period to 

discuss events and activities, as well 

as physical and mental well-being). 

Self-care is taken seriously by the 

team. If a deployed team member 

is unable to do his or her job for 

any reason, it diminishes team 

effectiveness to carry out its mission.

For example, we conducted search 

and rescue operations in one 

particular area of Staten Island 

devastated by the storm surge that 

traveled through a neighborhood 

inland for a quarter mile, swallowing 

every home. Every structure was 

heavily damaged or destroyed, 

and several had been washed out 

to sea. There were several deaths 

in this neighborhood, and there 

were reports of missing people. 

Many of the damaged homes 

had already been condemned by 

city officials, which left victims 

standing in their yards, unable to 

enter to retrieve belongings. Others 

wandered aimlessly in the streets. 

Still others sat on their front steps 

crying. Encountering this type of 

scenario is a defining and motivating 

moment for all first responders. It 

is the moment the gravity of the 

event becomes starkly evident 

and the moment when training, 

experience, and teamwork take over. 

Victims are engaged to assess needs; 

provide available comfort measures; 

and give any pertinent, factual 

information, such as the location of 

the nearest Red Cross field station, 

that may be of help.

FEMA’s Urban Search and Rescue MATF-1 Team responding to Superstorm Sandy. Image capture from Video by Robert Scott Button (http://robertscottbutton.com).

Handling Survivor Reactions

In an adjacent neighborhood, just 

a 10-minute walk away, it was 

a totally different scene. This 

particular neighborhood suffered 

relatively little damage other than 

a few downed trees and loss of 

power. A distraught older woman 

approached us in front of her home. 

Seeing our FEMA uniforms, she 

said that some of her patio furniture 

had been damaged and asked for 

assistance in the form of a check to 

replace the patio furniture. We spent 

some time with her, just listening. 

We then politely explained we 

were a search and rescue team and 

she would need to apply for funds 

through another FEMA department. 

2018 | VOLUME 14 | ISSUE 1 | PAGE 10
After a little while she was able to 

collect herself, and we continued on 

our way.

Her reactions mirrored those from 

the destroyed neighborhood we 

had just left. Later, some team 

members expressed difficulty 

having any empathy for her. They 

were frustrated by her behavior 

after witnessing the level of 

tragedy experienced in the previous 

neighborhood.

During our “hot wash” discussions 

we are encouraged to talk about 

frustrations or difficulties with a 

“better out than in” philosophy 

to “get things off our chests.” 

Principles of disaster psychology 

from our annual training are then 

discussed. As disaster responders, 

we must remember to set aside 

judgmental thoughts that have no 

productive value while we are at 

work. In fact, this kind of thinking 

is debilitating at a time when our 

resilience is being taxed to the 

maximum.

Encouraging Responder 

Resilience

Professionals in the behavioral 

health community need to recognize 

the unique culture of the first 

responder community and work 

toward competency in assisting 

them. The first responder is not 

going to ask you for help. The 

behavioral health professional has 

to go to them and overcome a strong 

resistance and stigma attached 

to seeking psychological help. 

Strength and the ability to endure 

physical and mental extremes are 

highly valued, and anything less is 

viewed as weakness. Behavioral 

health professionals with particular 

training in the peer counseling 

model of providing stress awareness 

and resiliency-building practices 

would be of great value to the first 

responder community.

MATF-1 has been proactive in this 

area and has included a member for 

10 years who is a behavioral health 

professional. Over that time, through 

use of the peer counseling model, 

an attitudinal shift has occurred. 

The resistance to seeking help with 

mental and emotional stress is 

greatly diminished, and resilience 

among the members has been 

enhanced.

As previously mentioned, there are 

28 FEMA Urban Search & Rescue 

teams positioned across the country. 

Opportunities exist for behavioral 

health professionals to become 

attached to these teams in a variety 

of ways and even become members. 

This creates a unique opportunity to 

become familiar with a unique world 

inhabited by remarkable men and 

women. ■

FEMA’s Urban Search and Rescue MATF-1 Team. Image provided by Don McCullough.

2018 | VOLUME 14 | ISSUE 1 | PAGE 11
Psychological Trauma in First Responders 

Following Disaster Response

By Robert Cousins, NRP, FP-C

The burden of these psychological 

stressors, including the 

disproportionately high incidence 

of suicide attempts among 

first responders, has been well 

documented. In many cases this 

trauma is long overlooked due to 

many providers’ not realizing the 

effects of their exposure until years 

after the fact.

The Effects of Disaster 

Response

Disaster response is different. 

During a disaster, existing 

infrastructure and procedures are 

overwhelmed, and normal rules 

cease to apply. And while disaster 

response training has improved, no 

amount of tabletop exercises can 

prepare you for the real thing. First 

responders are used to operating 

on the edge, so to speak, but during 

disasters they are forced far beyond 

even their own flexible comfort 

zones. And that’s just in the first 15 

minutes.

Part of what makes disaster response 

so psychologically challenging for 

first responders is the compressed, 

intensified nature of operations. 

The First Responder Role

The first responder community—

police, fire, and emergency medical 

services personnel—encounters the 

full spectrum of human emotion. 

There are periods of banality 

and moments of terror. We get 

heartwarming glimpses into the best 

humanity has to offer, and we run 

calls so horrifying they are never 

discussed, lest others have our 

nightmares too. This comes part and 

parcel with the work. No one has 

“seen it all,” but sooner or later most 

first responders start wondering if 

they’re getting close.

Photograph by Michael Jung/Shutterstock

2018 | VOLUME 14 | ISSUE 1 | PAGE 12
All disasters, whether natural or 

human-caused, are chaotic. Events 

unfold quickly, and information is 

alternatingly difficult to come by or 

arriving in an overwhelming torrent. 

What’s more, communications are 

compromised, resources are limited, 

logistics are impeded, and patient 

volume is high. And in the case of 

human-caused disasters, such as 

active shooter incidents or bomb 

detonations, patients are often much 

more seriously injured than during 

weather-related disasters.

This operating environment is 

extremely challenging. It can also be 

energizing at first, but the adrenaline 

always wears off, and there is still 

work to do. For this reason, it is 

critical that first responder care 

be incorporated into any disaster 

plan. Food, water, shelter, and rest 

must all be incorporated into the 

disaster pre-planning and must also 

be executed along with the rest of 

the disaster mitigation and recovery 

efforts.

The Role of Behavioral Health

Behavioral health, in the form of 

first responder care, must play a role 

here. Disasters, particularly humancaused ones, expose responders to 

situations they have not previously 

experienced or even imagined. 

The scale, scope, and duration 

of disasters exceed anything first 

responders encounter in the regular 

scope of their duties. And if their 

regular duties invariably bring 

exposure to psychological stressors, 

hyper-intense disaster events will 

exponentially increase the mental 

burden on responders.

Many behavioral health providers 

who have disaster response 

training already work alongside 

first responders and have been 

exposed to the first response culture. 

During a disaster, however, demand 

will exceed supply. Additional 

behavioral health resources may 

need to be deployed, some of whom 

may be entering the public safety 

environment for the first time. It is 

critical, however, that whoever is 

called upon understands the culture. 

Whatever operational briefing the 

behavioral health staff receive must 

include an introduction to working 

with first responders. Otherwise their 

efforts will be at best fruitless, if not 

actively counterproductive.

Barriers to Care Among First 

Responders

First responders often take on a 

“whatever it takes” mentality, which 

is a positive trait; in this line of work, 

giving up is not an option. But this 

can be taken too far. All too often, 

behavioral health needs are seen as 

a sign of weakness, and those who 

admit such needs are stigmatized. 

Very few first responders will take 

initiative to seek out behavioral 

health care on a normal day. Throw 

in an ongoing disaster, and that 

number drops to zero.

Depending on the nature of the 

disaster, it may not be practical 

Higher levels of resilience and lower levels

of burnout were associated with first responders who 

had disaster behavioral health training.

Source: Atkins & Burnett, 2016

Very few first responders will

take initiative to seek out behavioral

health care on a normal day. Throw in 

an ongoing disaster, and that number 

drops to zero.

2018 | VOLUME 14 | ISSUE 1 | PAGE 13
to provide behavioral health 

support to responders during 

disaster operations. For example, 

a weeks-long hurricane recovery 

effort is fairly well suited to onsite 

behavioral health care. An active 

shooter response, on the other hand, 

will be over in a matter of hours, 

and it may not be practical to divert 

responders during active operations. 

And as mentioned above, responders 

may be unwilling to access resources 

onsite for fear of appearing weak 

before their peers.

Effectively reaching first responders 

begins by understanding that for 

them, the unusual is all in a day’s 

work. First responders tend to have 

well-developed coping mechanisms, 

and they will process what they 

see differently than the rest of the 

public. It would be wise in the 

planning stage to dedicate certain 

behavioral health resources to 

the responders and task separate 

resources to assist victims. This 

would save the behavioral health 

providers from constantly changing 

gears as they switch back and forth 

between populations.

First responders absolutely benefit 

from having onsite behavioral health 

resources available to them, and 

this practice should be maintained 

or instituted where needed. But 

it is essential that every single 

responder to a disaster be followed 

up with privately after the event 

is concluded, be checked in on 

periodically, and have ongoing 

access to behavioral health care. ■

Steps for leaders to 

minimize stress before, 

during, and after deployment:

Plan in advance of disaster mobilization, and 

develop clear, written protocols and strategic 

plans.

Include all the team members in the 

development of the protocol, and ensure they 

are all adequately trained.

Gather as much information as possible 

about the disaster to reduce the dangers 

from the disaster exposure.

Develop a clearly defined leadership cadre, 

establish sub-teams, and determine factors 

that would prevent some of the team 

members from participating.

Model the structure of the team on the 

Incident Command System.

Develop clear lines of communication.

Assess the welfare of their team, resolve any 

conflicts between team members, and rotate 

assignments.

Provide team group sessions upon return 

to their home base, as well as staff support 

services.

Thank the team following conclusion of the 

assignment.

Source: Mitchell, 2011

2018 | VOLUME 14 | ISSUE 1 | PAGE 14
How Do First Responders Experience 

and Cope With Trauma?

By Laura Helfman, M.D., FACEP, WALS

“You see things; and you say 

‘Why?’But I dream things that 

never were; and I say ‘Why 

not?’”—George Bernard Shaw

First responders are motivated by a

strong desire to alleviate suffering

and save lives during times of crisis.

Whether due to natural phenomena

or human action, trauma leading to

injury or death requires prompt and

steady hands and minds. Often when

a disaster occurs, there is little time

to prepare and limited information

about the nature of the mission. First

responders hit the ground running in

many cases in harsh environments

with limited resources and backup,

despite the risk of personal peril.

What matters most is that someone

somewhere needs assistance, and to

a first responder that means it is time

to “answer the call.”

A traumatic event is defined as a

situation that causes perceived or

actual threat of death or serious

injury to self or others, which

evokes feelings of fear or horror.

In my experience as an emergency

physician and as a first responder, I

have seen survivors having multiple

physiologic and psychological

responses during a traumatic

event that are both expected and

normal. A healthy recognition of

these responses is essential for the

responder and mission success.

Source: Berger, 2012

PTSDprevalence per 

occupational group:

Police officers 

exposed to 

major disasters 4.7%

Firefighters 7.3%

Other 

rescue 

teams

13.5%

Ambulance 

personnel

4.6%

2018 | VOLUME 14 | ISSUE 1 | PAGE 15
In times of crisis, fight-or-flight 

(adrenergic) responses may 

cause elevated heart rate and 

blood pressure. This can lead to 

hypervigilance or a feeling of being 

on overdrive. If the mission is 

extended in the case of large-scale 

disasters, there may be problems 

with sleeping, changes in appetite, 

irritability, and impatience. Often, 

there is profound fatigue caused 

by long shifts with limited down 

time and limited space for sleep and 

relaxation. The longer the mission, 

the greater the risk of shifting from 

normal to maladaptive responses.

when there is significant injury which in turn lead to a stronger

Inherent in any response to trauma or a fatality. Over a lifetime of ability to respond.

is a degree of anxiety regarding service, many first responders can In my experience, there is a spark one’s own personal safety and the recount times when it was difficult 

that ignites and unites those who safety of the team as well as those to separate the personal and the 

choose to respond to disasters. who are in need. It is also common professional.

Though the danger is often great, the to feel overwhelmed and frustrated. 

To cope with the effects of trauma, cries of the wounded and needy take These feelings can be magnified 

many emergency personnel will rely precedence over personal comforts when resources and personnel seem 

on defense mechanisms that aim and security. This willingness to insufficient or are slow to arrive.

to minimize psychological trauma. serve is one of the greatest gifts that

Additionally, there are often Stoicism, depersonalization, and any of us can give to our neighbors,

bureaucratic obstacles that either derealization are the three most our country, and humanity.

get in the way of providing care common ways that responders will “All you need are these: certainty or mandate adherence to outdated separate themselves from what they of judgement in the present protocols. Depending on the setting, are experiencing. Over time these moment; action for the common 

there may be confusion as to the coping skills are detrimental and can good in the present moment; and 

chain of command when many lead to delayed PTSD. an attitude of gratitude in the 

different agencies are involved. This present moment for anything that One of the best ways to avoid can lead to a sense of loss of control. comes your way.”—Marcus burnout and PTSD is for first Aurelius

Maintaining objectivity, which responders to bond with their fellow 

is necessary and required, can rescuers as a team, or “family.” This I would like to thank the members

be difficult. Many rescuers are extended family then becomes a of TN-1 DMAT (the Tennessee-1

particularly affected when they are source of strength both during and Disaster Medical Assistance Team)

involved with the care of someone after an event. Team loyalty takes on for giving me the friendship and

that reminds them of their own a life of its own. With loyalty comes guidance to become who I am and

child or family member, especially accountability and responsibility, the opportunity to serve. ■

Source: Bentley et al., 2013

According to a study,69%of

EMS professionals have never had 

enough time to recover between 

traumatic 

events. 

2018 | VOLUME 14 | ISSUE 1 | PAGE 16
RECOMMENDED RESOURCES

Creating Safe Scenes Training Course

This SAMHSA DTAC training course aims to help

first responders better comprehend mental illness and

substance use (behavioral health) disorders so they

can serve individuals in behavioral health crisis more

effectively and safely. Through a series of first-hand

video accounts, informational slides, and quizzes,

first responders will learn methods for taking care of

others in behavioral health crisis. They will gain a

better understanding of why a behavioral health crisis

may occur, the best way to make a connection with an

individual in crisis, and more.

Read more and find a link to the training at

http://bit.ly/2zlfDuV.

Shield of Resilience Training Course

This SAMHSA DTAC training course is designed for

law enforcement officers. It is a useful tool to help

recognize signs and symptoms of various mental health

issues. In addition to videos and quizzes, the training

also provides resources to help law enforcement officers

understand how to build resiliency and when and where

to seek help if necessary.

Read more and find a link to the training at

http://bit.ly/2yifUM4.

Tips for Disaster Responders: Identifying Substance

Misuse in the Responder Community

This tip sheet identifies factors that may create a higher

risk of substance misuse in disaster responders. It lists

signs of possible substance misuse to look out for in

yourself and in others that may display themselves

physically, emotionally, and socially. Along with when

to seek help, the tip sheet also provides a list of helpful

resources that are available for your benefit.

Read and download the tip sheet at 

http://bit.ly/2zH9NVZ.

Access the tip sheet in Spanish at 

http://bit.ly/2yjZZwJ.

Disaster Rescue and Response Workers

The U.S. Department of Veterans Affairs discusses the 

risk of psychological issues rescue workers have after 

directly experiencing or witnessing disasters. They offer 

tips on how to manage stress after the disaster and upon 

returning home.

Access these tips at http://bit.ly/2m8dMVF.

Coping With a Disaster or Traumatic Event

The Centers for Disease Control and Prevention 

provides emergency responders with tips on recognizing 

signs of burnout and secondary traumatic stress, which 

can both arise after a stressful and traumatic event. It 

shares techniques on working with other emergency 

responders to manage stress and methods for doing so 

on your own. The page also shares several additional 

resources.

Access this page at http://bit.ly/2AwJ1N4.

2018 | VOLUME 14 | ISSUE 1 | PAGE 17
2018 | VOLUME 14 | ISSUE 1 | PAGE 18

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Rose, M., & Young, A. (2015). 

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pt5lehsknczsaofld89leijbmehz3c

Atkins, C. D., & Burnett, H. J., 

Jr. (2016). Specialized disaster 

behavioral health training: Its 

connection with response, practice, 

trauma health, and resilience. 

Disaster Health, 3(2), 57–65. 

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& Ursano, R. J. (2007). First 

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Bentley, M. A., Crawford, J. M., 

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Berger, W., Coutinho, E. S. F., 

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Brooks, S. K., Dunn, R., 

Amlot, R., Greenberg, N., & 

Rubin, G. J. (2016). Social and 

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Brooks, S. K., Dunn, R., Sage, 

C. A. M., Amlot, R., Greenberg,

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necessarily reflect the views, opinions, 

or policies of the Center for Mental 

Health Services (CMHS), the Substance 

Abuse and Mental Health Services 

Administration (SAMHSA), or the U.S. 

Department of Health and Human 

Services (HHS).
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