By Erica Olson, Katrina Scaife, Dr. John Streukens
“On getting help, cultural competence, and common questions
about mental health support answered by EMS Psychologists.”
Lying awake in bed, you seek sleep which comes in unreliable and unpredictable spurts. Disrupted by dreams, thoughts, memories, and an ongoing pervasive tension incompatible with rest. You know how much sleep hygiene matters and keep a dark, quiet, cool room, reserving the bedroom for only sex and sleep. Despite that knowledge, you’ve noticed you’re using the bedroom more and more for screen time: TV, social media, YouTube, etc. Sometimes pills, and even alcohol, induce sleep but nothing has resulted in deep, sustained, restorative rest for a maddening length of time.
It’s 18:00. Call center shift starts at 19:00. You did love this job once, but it’s hard to feel any of that enthusiasm now. Some days you might pack a lunch, but that type of shift preparation doesn’t really matter these days. It feels like you are moving through a muted version of someone else’s life. It’s not so bad, because there isn’t anything really wrong. There’s just no joy. It’s not bad. It’s not good. It’s just surviving.
You are proud to work on ambulance, enjoying the challenges and your ability to respond to whatever comes next. You’re not sure why you are irritable with your work partner, or the ER nurse. You have been more impatient when driving in traffic for several months and almost confronted a driver in traffic last week. That was unusual, you even surprised yourself at how angry you felt. Thankfully sleep comes easily, but it would be nice to feel rested in the morning. You think, “this must be how everyone feels,” so you ‘pull up your socks’ and push through the day.
What if the old adage, ‘pull up your socks’ isn’t wise or helpful? Therapy may be an uncomfortable option, especially if you haven’t gone before. Or worse, you heard of someone who accessed their assistance provider for help and the mental health professional (MHP) apparently started sobbing in the first five minutes. In this popularized worst case scenario, the EMS provider didn’t get help and had to look after the very person they went to for help. Perhaps you have even had your own previous experience with therapy that wasn’t beneficial.
There are misconceptions and early obstacles to overcome when considering professional help, sometimes made more challenging by the stressed state of mind which may be driving the decision to reach out. This article is for those still curious, despite the barriers. After walking this path myself, hearing from staff members in a peer support setting, and learning from the EMS Psychologists at AHS EMS, there is no doubt that professional mental health help is one powerful way to move forward towards a healthy career, improved relationships, and overall an improved quality of life.
Once the decision to get help is made, there are important questions. Who do you go to? What criteria matters most? Do they need to understand the challenges of life in EMS? From the world of acronyms and para-military structure to the unpredictable environments and critical decisions, you can only really understand it if you do the job. Do they need to be culturally competent to provide competent help?
Spoiler: Therapy with a properly trained MHP can provide meaningful support to an EMS provider in a powerful, specific-to-you way, even if they do not have an in-depth understanding of EMS. If they have training to work with psychological trauma, they may be able to help. Like a physiotherapist guides recovery from physical trauma, MHPs support recovery from psychological trauma, and can even help prevent it. You can be stronger and more resilient than you were before the stress injury or trauma.
Dr. John Streukens and Katrina Scaife are psychologists providing clinical oversite to the AHS EMS Health Wellness & Culture (HWC) division in Alberta. They have offered their key thoughts on what matters most when considering EMS provider health and support. In short, be prepared to shop around, don’t hesitate to ask questions, and the clinical relationship matters the most.
Katrina on Cultural Competence, The Worst Case MHP Scenario, and Therapy Tips
Cultural Competence Defined
Cultural competency is the working understanding, familiarity, and knowledge of core features of a population or group who may, by way of organization and history, have several elements of distinctness. This includes features of social functioning, hierarchical structures, norms, language, and communication. Moreover, it is the ability to engage with members of a group in a way that is sensitive to their distinctness while still acknowledging that familiarity with a group does not constitute absolute understanding. Interactions are respectful.
When It Matters (When It Doesn’t)
Operational debriefs are a place where an understanding of the system and influences on providers in the work environment can be integral to a successful and productive debriefing. In personal therapy with a professional, the operational details and day to day context is not as important. Don’t be too worried about having to share all the details to explain the job. A good MHP will be able to help process the emotional underbelly regardless of the scenario. A therapist who is genuine, has a desire to understand, and is comfortable asking questions can engage with anyone from a different culture, group, or background effectively. If you feel it is needed, you can provide context by sharing how out of the norm a scenario is. Was it very exceptional or was it a pretty average day to day interaction? Was it a day to day thing gone wrong or a very unusual event that is standing out?
On Therapy and Choosing a MHP
Essentially therapy is two humans sitting in a room. That idea can help diffuse some of the pressure. There are always expectations in a relationship, and it ultimately comes down to two humans talking who have more similar than different. A therapist is someone to help you feel the feelings without judging them so you can hear the message they bring.
If it feels positive to be sitting with someone, they are probably the person for you regardless of if they have dealt with a first responder before. Feel empowered to ask questions and get your needs met. Some providers want an office far from a hospital or a certain professional designation in their therapist. Google people and look at their website, it can give you a really good sense of what perspective they bring to their practice, who they are, what modalities they use, and what they believe in. Most therapists have an online presence detailing their approach which is an advantage that wasn’t available 10-20 years ago. Clients can also learn a lot about their therapist in the informed consent process which usually happens in the early days of the therapeutic relationship.
Can I Just Go Hiking Instead?
Hiking is awesome, but it’s not the same as therapy. To reflect on having lived through something horrible, seeing how you learned from it and integrated it, is empowering. The space a MHP can hold is unique because of the safety, confidentiality, and freedom from judgement. It’s a gift people can give themselves. It’s a lot of work, but it’s a time that’s just for you, and that can be really important for people in helping professions.
On The “Worst Case MHP Scenario”
I have strong feelings about this story, I don’t know if there is any truth in it. Regardless, it’s worth noting that at any point when it becomes about the MHP as opposed to the client the session is off the rails. It is an expectation of the MHP to have emotional stability. The MHP needs to be vulnerable and open and when they are unable to maintain that balance, they need to step back. Therapists know they are going to hear horrible stuff – human distress and strife and pain. Competent professionals are successful at weeding through distracting micro-information to recognize the horribleness for what it is, but not to get wrapped up in it themselves.
MHPs are not mind readers. Be empowered to speak up if you have questions about their approach, and when you have thoughts you would like to explore, tell them. Therapy has a stigma, and therapists can be really good at their jobs and still be off base with exactly where you’re at. It is okay to correct a therapist – they are taught to take a stab at what they think is going on with the idea they will be corrected if they are off track. Creating a genuine relationship is key to effective therapy.
Connect with a therapist in a way that aligns with your values. E-counselling has come a long way, even more so with social distancing, and most therapists provide a secure platform. Check-in with your values regarding what you need from the help you want. For example if saving time and not traveling are the utmost important thing, prioritize that. Any approach can work if it aligns with what you think you need. Some support is better than nothing – support doesn’t have to be perfect. Text and email may not help one person but may get another person through. Information can be shared more easily live – through voice or in person – but the information shared over text/email may still be very valuable. Take advantage of the initial free consult that many therapists offer to ask questions and see if you find them to be a good fit.
John on Selecting a MHP, Cultural Competency, and the Key to EMS Provider Health
Do your homework on their training and background, very few clients ask, “What are your qualifications?” It is a buyer beware marketplace. A few terms like ‘Psychologist’ and ‘Psychiatrist’ are protected terms and must meet certain criteria, but there are numerous unprotected terms like therapist, clinician, psychotherapist, or counsellor that range significantly in both education and experience. There may be potential value in therapists that don’t meet the criteria or choose not to register with a college, however, it is essential that you go prepared with questions related to their training and credentials. Do your homework.
EMS providers should look for someone well trained in the area of trauma and trauma management, substance use disorders, and/or depression and anxiety management. Unfortunately, many people list an extensive range of skill sets that may not fully reflect their training competencies. After finding a potential therapist, even if it’s on their profile, ask questions like: “If you’re doing work with me in the area of trauma, where did you get your training?” “What qualifies you to do this work?” If an MHP deflects a question with something like, “we’re here to talk about you, not me,” you would be well advised to end the conversation, and the relationship, there.
Cultural Competence and “Knowing EMS”
If cultural competency is important to you, then it might be important to the clinical relationship; this feature is unique to every individual. Over the last 10 years or so, psychologists have received more instruction in this area to ensure that the counseling relationship and technique meet the complex demands during interventions. When it is important to the patient, it is critical to have a comprehensive understanding of their environment and milieu; their work, culture, and the importance of these factors to the process. The clinical relationship is the most important factor for positive outcomes, as such, ensure that there is a good fit and understanding between yourself and your clinician across multiple areas of importance.
I Feel Great, Why Should I Care?
Be Proactive: Anyone working in a high stress or high trauma environment would benefit from going for an assessment every 2 or 3 years.
If you are even questioning your current functioning, go for an assessment, it can reveal if you are doing what you need to be doing, or if a small shift may make a big difference.
If there aren’t any issues – a qualified person will say, “Hey, you’re doing alright.”
Someone that is not qualified might make recommendations anyway (from a business oriented motivation). You can differentiate between the two based on the content of the sessions and if you feel the work is helping you.
The Key to EMS Provider Health
The number one thing for health is a person’s support system, and regular use of it. Research has shown that people with a healthy support system are least likely to develop mental health issues. The two questions to test the health of your support system are:
- Do you have someone you can talk to about anything and everything that goes on in your life? Yes? Great.
- Do you call/connect with them? If not, you do not have a healthy support system. Humans thrive when we have someone we can share our full and complete selves with.
Final Thoughts from John and Katrina
You can look for a therapist with a really specific skill set, a specific approach in trauma, but even that is somewhat negotiable. It’s really the rapport that ultimately matters. If you work with someone you can trust, who you feel ‘gets’ you, that is the most powerful predictor of positive therapeutic outcomes. In saying that, it is also important to note that this is more than just a casual conversation; therapy has a direction, goals, and techniques that advance and alter mental health status. Beyond the qualitative features to the relationship, therapy is also measurable.
No one has to wait until they are in crisis, seeking out proactive psychological support can reduce the risk of ever developing a serious psychological injury and will improve recovery for those working in careers, like EMS, that have a known increased risk of injury.
After seeing a skilled MHP, sleep is becoming more regular and sustained and there is a return of enjoyment to life that you never expected. On shift you appreciate your crew and again feel honoured to be there for patients in the difficult moments of their lives. You know that enjoying work requires prioritizing psychological health, so you maintain a supportive social environment outside of work and use stress management tools as a part of your daily routine. Not every day is easy, but you’re focused on having a psychologically healthy career. You know your signs and symptoms of stress, and they change, just like you do. A sense of dread associated with going to work is now a big flag, being irritated in traffic might be another. Other flags might include not paying attention during conversations, not answering the phone when a friend calls, and multi-tasking when it’s time to play with the kids. Because you talk about these signs at work, your colleagues are empowered to notice theirs too, and when they see them, accessing help is a natural step because you started to break down the barriers. You know the truth behind ‘pulling up your socks,’ and you stomp out stigma by talking about it. You know it’s not about the socks.
A note from the authors
The examples used in this narrative are not intended to be diagnostic, the stories depicted involve common stress-related symptoms which may be experienced by anyone, first responder or not. There are common signs and symptoms consistently associated with issues of acute or cumulative stress and psychological injury. Knowing the signs and symptoms can help an EMS provider identify when they may need support. Which symptoms arise, and in what order, are to some degree individual, but an understanding of the whole spectrum will facilitate early awareness and intervention. Practitioners are encouraged to reach out to their local services and resources.