Clint A. Bowers*, Deborah C. Beidel†, Madeline R. Marks‡
ABSTRACT
First responders have been shown to be at risk for several negative mental health outcomes. However, it is not always clear how to intervene to prevent these outcomes. One approach has been to try to reduce the obstacles to care that might be imposed by the profession or the organization. In this paper, we investigate whether the nature of these obstacles varies as a function of the type of job. A group of 1,485 first responders were studied. The results indicate a number of important specialty-related differences. The results are discussed in terms of how to tailor prevention programs to confront obstacles to care.
Key Words: Obstacles to care, stigma
First responders (FRs) perform some of the most critical duties in our society. In performing these duties, they work under some of the most challenging conditions that exist in the civilian sector. Many of these employees routinely experience the risk of physical harm (Beaton et al., 1996). Furthermore, this occupation is often associated with challenging environmental conditions, such as heat, cramped spaces, and noise (Liberman et al., 2002). In addition, FRs are often required to work extended or irregular shifts, disrupting their sleep cycles (Liberman et al., 2002; Stergiopoulos et al., 2011). Finally, they often directly or vicariously experience traumatic events. Indeed, repeated exposure to these various stressors is common throughout the employee’s career.
Given the stressors described above, it is not surprising that FRs are at risk for a variety of negative mental health outcomes. Sadly, researchers have only recently turned their attention to this population, so the extent of these problems is not fully understood. However, existing data suggest that FRs are at risk for depression (Darensburg et al., 2006; Fullerton et al., 2006), substance abuse (Kimbrel et al., 2011; Murphy et al., 1999), post-traumatic stress disorder (Boffa et al., 2017; Marmar et al., 2006), suicide (Violanti, 1996; 2004), and family problems (Duarte et al., 2006). All of these risk factors highlight the need to ensure that effective treatment programs are developed and made available to this population.
It is important to note, however, that merely making services available may not be a sufficient approach to intervening with this group. Despite the apparent need for mental health services, it appears that FRs often do not use these resources even when they are available (Bell & Eski, 2015; Royle et al., 2009). Therefore, it is also important to understand the factors that influence the choice to seek care and create intervention strategies for the identified obstacles targeted at FRs.
Researchers studying under-utilization across a variety of populations and conditions have identified several factors that might influence the decision not to seek care. One of the most frequently mentioned factors is mental illness stigma. This type of stigma has been conceptualized as negative beliefs about persons who admit to having symptoms of mental illness, or towards the treatment itself (Corrigan & Penn, 1999). People who endorse these attitudes are less likely to seek treatment or to adhere to treatment when provided (Corrigan & Bink, 2005).
Mental illness stigma, thought to be common among first responders (Bell & Eski, 2015), is likely associated with an organizational culture that values strength and self-reliance. It is believed that admitting to experiencing symptoms of mental illness would lead to social isolation and distrust. Further, employees fear (sometimes correctly) that there will be negative career implications if such disclosures are made. There is often a belief that mental health professionals would not understand the unique circumstances confronted by these employees, or that conventional treatments would be not be effective for these unique experiences. Many believe that appropriate services are not available and/or affordable. Unfortunately, the consequence of these beliefs is that employees may not receive needed care.
Ben-Zeev and colleagues (2005) have described three subtypes of mental health stigma that are relevant to military personnel. The first type, public stigma, includes the extent to which the subject is aware of the general public’s negative attitudes towards those with mental illness. Self-stigma refers to negative attitudes about mental illness that the person attributes to themselves—leading to self-criticism and reduced self-worth. Finally, label avoidance refers to the process of denying or hiding symptoms to avoid the negative feelings associated with public and self-stigma. A review of the literature indicated that military members reported higher levels of all three types of stigma than did the general public (Clement et al., 2015).
While awareness of the potential stress disorders among FRs has been instrumental in creating resources for their identification and treatment, it is important to note that this area of research is in its relative infancy. There is still a need to identify the issues and interventions that are relevant to the diverse group of employees that make up the broad category of “first responders.” It may well be that there are reliable differences among groups that allow us to create optimal prevention and treatment approaches. For example, it has been hypothesized that the nature of workplace stress might be quite different between firefighters, police, and dispatchers (Krakauer, Stelnicki, & Carleton, 2020). Consequently, wellness programs designed for first responders might be differentially effective for the incumbent sub-groups. For example, Szeto, Dobson, and Knaak (2019) performed a review of outcomes resulting from the “Road to Mental Readiness” resilience training program (R2MR, Carleton et al., 2018). Their results indicated that the program was significantly more effective for police than for any other profession, including other first responder groups. Understanding the differences among first responder subgroups might allow us to create better interventions for each. Conversely, confirmation that groups are similar would allow us to pursue larger-scale cross-profession interventions with greater confidence.
Similarly, it is important to understand any differences in the obstacles to mental health treatment that these subgroups might experience. Because first responders are often grouped together as a homogeneous group, it may be that we are overlooking obstacles that are particularly relevant (or including irrelevant ones) for specific sub-groups. Again, understanding these differences might allow us to create policies and interventions to maximize the outcomes of these programs.
Unfortunately, little work has been done to identify the specific barriers that are relevant to sub-groups of FRs. Haugen et al. (2017) conducted a meta-analysis of stigma and other barriers among FRs. Their literature review yielded 12 studies with some empirical data on the topic. The very large majority of these studies were conducted with police officers. The results showed a high prevalence (~30%) of stigma beliefs among respondents. Only 5 of the 12 studies assessed other barriers to care. These studies indicated that about 10% of respondents experienced some significant barrier. Unfortunately, there were an insufficient number of studies to draw conclusions about other first responder sub-groups.
More recently, Krakauer and her colleagues (2020) studied differences between Canadian Public Service Employees in issues such as “Stigma” and “Intent to use mental health services.” They found that there were, indeed, significant differences in stigma (with firefighters being higher than all other groups). However, the data were only reported as means so one cannot identify specific differences among the groups. It may be that a more granular analysis of sub-group differences would allow us to identify strategies to best serve each of the distinct sub-groups that make up the larger group of FRs. To that end, the current study sought to analyze differences in barriers to care and stigma among sub-groups of American first responders. The goal of the study is to identify differences (if they exist) among the groups and to suggest how these differences might inform intervention strategies going forward.
Participants for this study were 1,485 first responders who attended a mandatory Mental Health Awareness training session in central Florida. The training included information on stress and stress responses, typical responses to the aftermath of traumatic events, psychological disorders that may result from exposure to trauma, and information on how and where to seek help for psychological distress. Participants completed a pre-test online prior to attending the session. The pre-test data were used as the basis for the following results: 134 participants were police officers, 1,301 were firefighters/EMT, and 50 were dispatchers. Most (1,436 respondents) were male, 14 were female, and 16 were non-binary. The mean age of the sample was 37.98 years. A majority (1,337) identified as White, 67 as Black, 216 as Hispanic, 19 as Asian, 20 as Native American, and 11 as Middle Eastern. All data were collected following the ethical guidelines of the American Psychological Association. The protocol was reviewed and approved by the Institutional Review Board at the University of Central Florida.
Barriers to care were assessed using the Barriers to Care subscale of the Perceived Stigma and Barriers to Care assessment (Britt et al., 2008). This subscale includes 5 items designed to assess barriers to care that may prevent an individual from seeking mental health treatment. Past research has demonstrated that this scale has good internal consistency (α = .70–.82; Britt et al., 2008). This scale has been used to assess barriers to care in a variety of populations including, veterans, first responders, and medical professionals.
Stigma was assessed using the Police Officer Stigma Scale (POSS; Stuart, 2017). The POSS is an 11-item scale designed to measure stigma among police officers. The POSS is based on the widely used Perceived Devaluation and Discrimination Scale (PDSS; Link,). The stem was changed in the POSS to clarify that the questions targeted police environments. Like the PDSS, the POSS reports a high Cronbach’s alpha (a = .82), implying good reliability (Stuart, 2017). For the current study, we altered the questions slightly to facilitate the assessment of self-stigma across professions. An earlier study demonstrated that this alteration did not change the internal reliability of the scale (Burzee et al., 2022).
Items from the Barriers to Care measure were evaluated for group differences using a chi-square test. The results indicated no significant difference in participants’ concerns about where to seek help (X2 (8) = 13.33, p > .05). Participants were generally well informed about where to seek help. These data are illustrated in Table S1.
There were no significant differences in reported difficulty finding transportation to appointments (X2 (8) = 7.67, p > .05). Participants generally reported little concern about transportation. These results are provided in Table S2.
There was no difference among groups in perceived difficulty scheduling appointments (X2 (8) = 8.18, p > .05). Across groups, about 10% of respondents reported such concerns. The complete data are presented in Table S3.
There was a significant difference in the perceived difficulty in getting time off for treatment (X2 (8) = 18.09, p < .05). Dispatchers reported significantly more concern about this issue than the other groups. These data are provided in Table S4.
There were significant differences among the groups regarding concerns about cost of care. There was a significant difference in this concern between the three groups. Specifically, dispatchers voiced a greater level of concern than the other groups. These data are displayed in Table S5.
A one-way Analysis of Variance was used to compare the groups on total stigma. The results show that all three groups were similar in terms of their overall stigma ratings (F(2,1414) = 2.61, p > .05). Additional analyses were conducted using the subscales identified by Burzee et al. (2022). On the “Stigma towards others” factor, there was no significant difference (F(2,1414) = 1.50, p > .05). However, the “self-stigma” factor did yield a significant difference (F(2,1414) = 4.55, p < .05). Firefighters reported lower levels of self-stigma (M = 19.9) than police (M = 18.7) and dispatchers (M = 15.8) (higher scores indicate lower stigma).
To further explore this finding, chi-square analyses were conducted on the individual items that comprise this factor. There was a significant difference among the groups on will-ingness to disclose mental illness to supervisors. Firefighters were significantly more likely to make such a disclosure than were police officers (X2 (8) = 19.01, p < .05). This result is illustrated in Table S6.
There was also a significant difference in willingness to disclose to a co-worker (X2 (8) = 21.32, p < .05). Once again, firefighters were more willing than the other groups to make such a disclosure. The data are presented in Table S7.
There was a significant difference in the degree to which the groups expected to be discriminated against if they did disclose a mental illness (X2 (8) = 21.22, p < .05). Firefighters were less likely to endorse this concern than other groups (see Table S8).
There was no difference between the groups in their opinions about supervisors with a history of mental illness (X2 (8) = 10.42, p <. 05). Nor was there any difference about whether mental health treatment represented a personal failure (X2 (8) = 4.39, p > .05).
The goal of this study was to identify differences in obstacles to care between police, firefighters, and dispatchers. The results of the study indicate that dispatchers were more likely than the other two groups to report two distinct obstacles to care: difficulty getting time off and cost of care. This may be due to the belief that dispatchers are at less risk for mental illness than the other groups. Seeking time off for mental health care may be perceived as these employees “playing the system” (Riciardelli et al., 2020). This concern might be especially salient given the fact that many call centres are understaffed (Perez et al., 2021). This, in turn, might lead to resentment from co-workers. However, previous research has demonstrated that dispatchers experience formidable levels of potentially traumatic exposures (Trachik et al., 2015). There may be a need to educate decision-makers about the stresses of this job, with the goal of changing policies to allow better access to care. It may be that the shiftwork nature of dispatching makes it difficult to schedule appointments. This might be resolved by contracting after-hours care agencies or even through use of innovative approaches, such as phone-based appointments (cf. Willis et al., 2020). Finally, this might be a result of the increased public attention to mental health directed towards police and firefighting professions. This level of attention (and associated resources) has not yet been directed towards emergency call takers.
Interestingly, a second finding of this study was that fire-fighters reported lower levels of self-stigma than the other two groups. This may be a result of the very aggressive prevention programs that have been conducted by professional societies such as the International Association of Fire Fighters. This includes mental health education (cf. Moffitt et al., 2014) and peer support programs (Marks et al., 2017). It might be that the other first responder professions should adopt a similar approach to reduce stigma among their peers. Because these services are often free, they might also address the cost concerns voiced by dispatchers.
Barriers to care are clearly a subject worthy of further study. Even when effective mental health interventions exist, they are not useful if those who need them are reluctant to seek care. While the data presented in this paper are based on a rather large sample, it is noted that the respondents were generally from one state and were predominantly firefighters. It is important to note that there may be regional differences in the observed pattern of results. It is also important to identify which particular barriers are associated with the decision to seek care. Overcoming those barriers may be a prerequisite to the delivery of other mental health interventions.
This project was funded by the State of Florida.
The authors declare that there are no conflicts of interest.
Supplemental information linked to the online version of the paper at journalcswb.ca:
■ Table S1
■ Table S2
■ Table S3
■ Table S4
■ Table S5
■ Table S6
■ Table S7
■ Table S8
*Dept. Of Psychology, University of Central Florida, Orlando, FL, USA,
†UCF RESTORES, University of Central Florida, Orlando, FL, USA,
‡University of Maryland School of Medicine, Baltimore, MD, USA.
Beaton, R., Murphy, S., Pike, K. (1996). Work and nonwork stressors, negative affective states, and pain complaints among firefighters and paramedics. International Journal of Stress Management, 3(4), 223–237. https://doi.org/10.1007/BF01857685
Crossref
Bell, S., Eski, Y. (2015). “Break a leg—it’s all in the mind”: Police officers’ attitudes towards colleagues with mental health issues. Policing: A Journal of Policy and Practice, 10 (2), 95–101. https://doi.org/10.1093/police/pav041
Crossref
Ben-Zeev, T., Fein, S., Inzlicht, M. (2005). Arousal and stereotype threat. Journal of Experimental Social Psychology, 41(2), 174–181.
Crossref
Boffa, J. W., Stanley, I. H., Hom, M. A., Norr, A. M., Joiner, T. E., Schmidt, N. B. (2017). PTSD symptoms and suicidal thoughts and behaviors among firefighters. Journal of Psychiatric Research, 84, 277–283. https://doi.org/10.1016/j.jpsychires.2016.10.014
Crossref
Britt, T. W., Greene–Shortridge, T. M., Brink, S., Nguyen, Q. B., Rath, J., Cox, A. L., Hoge, C. W., Castro, C. A. (2008). Perceived stigma and barriers to care for psychological treatment: Implications for reactions to stressors in different contexts. Journal of Social and Clinical Psychology 27, 317–335. https://doi.org/10.1521/jscp.2008.27.4.317
Crossref
Burzee, Z., Bowers, C., Beidel, D. (2022). Psychometric evaluation of the Police Officer’s Stigma Scale. Manuscript submitted for publication.
Carleton, R. N., Korol, S., Mason, J. E., Hozempa, K., Anderson, G. S., Jones, N. A., Dobson, K. S., Szeto, A., Bailey, S. A longitudinal assessment of the road to mental readiness training among municipal police. Cognitive Behavior Therapy, 47(6), 508–528. https://doi.org/10.1080/16506073.2018.1475504
Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., Morgan, C., Rüsche, N., Brown, J. S. L., Thornicroft, G. (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(01), 11e27. https://doi.org.10.1017/S0033291714000129
Crossref
Corrigan, P., Bink, A. B. (2005). On the stigma of mental illness (pp. 11–44). American Psychological Association.
Corrigan, P. W., Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54 (9), 765. https://doi.org/10.1037/0003-066X.54.9.765
Crossref
Darensburg, T., Andrew, M. E., Hartley, T. A., Burchfiel, C. M., Fekedulegn, D., Violanti, J. M. (2006). Gender and age differences in posttraumatic stress disorder and depression among Buffalo police officers. Traumatology, 12(3), 220–228. https://doi.org/10.1177/1534765606296271
Crossref
Duarte, C. S., Hoven, C. W., Wu, P., Bin, F., Cotel, S., Mandell, D. J., Nagasawa, M., Balaban, V., Wernikoff, L. Markenson, D. (2006). Posttraumatic stress in children with first responders in their families. Journal of Traumatic Stress, 19, 301–306. https://doi.org/10.1002/jts.20120
Crossref
Fullerton, C. S., Ursano, R., Reeves, J., Shigemura, J., Grieger, T. (2006). Perceived safety in disaster workers following 9/11. Journal of Nervous and Mental Disease, 194(1), 61–63. https://doi.org/10.1097/01.nmd.0000195307.28743.b2
Crossref
Haugen, P. T., McCrillis, A. M., Smid, G. E., Nijdam, M. J. (2017). Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis. Journal of psychiatric research, 94, 218–229.
Crossref
Kimbrel, N. A., Steffen, L. E., Meyer, E. C., Kruse, M. I., Knight, J. A., Zimering, R. T., Gulliver, S. B. (2011). A revised measure of occupational stress for firefighters: Psychometric properties and relationship to posttraumatic stress disorder, depression, and substance abuse. Psychological Services, 8(4), 294–306. https://doi.org/10.1037/a0025845
Crossref
Krakauer, R. L., Stelnicki, A. M., Carleton, R. N. (2020). Examining mental health knowledge, stigma, and service use intentions among public safety personnel. Frontiers in psychology, 11, 949.
Crossref
Liberman, A. M., Best, S. R., Metzler, T. J., Fagan, J. A., Weiss, D. S., Marmar, C. R. (2002). Routine occupational stress and psychological distress in police. Policing: An International Journal of Police Strategies Management, 25(2), 421–441. https://doi.org/10.1108/13639510210429446
Crossref
Link, B. G. (1987). Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review, 52, 96–112. https://doi.org/10.2307/2095395
Crossref
Marks, M. R., Bowers, C., DePesa, N. S., Trachik, B., Deavers, F. E., James, N. T. (2017). REACT: A paraprofessional training program for first responders—A pilot study. Bulletin of the Menninger Clinic, 81(2), 150–166. https://doi.org/10.1521/bumc.2017.81.2.150
Crossref
Marmar, C. R., McCaslin, S. E., Metzler, T. J., Best, S., Weiss, D. S., Fagan, J., Liberman, A., Pole, N., Otte, C., Yehuda, R., Mohr, D., Neylan, T. (2006). Predictors of posttraumatic stress in police and other first responders. Annals of the New York Academy of Sciences, 1071(1), 1–18. https://doi.org/10.1196/annals.1364.001
Crossref
Moffitt, J., Bostock, J. and Cave, A. (2014). Promoting well-being and reducing stigma about mental health in the fire service. Journal of Public Mental Health, 13 (2), 103–113. https://doi.org/10.1108/JPMH-02-2013-0004.
Crossref
Murphy, S. A., Beaton, R. D., Pike, K. C., Johnson, L. C. (1999). Occupational stressors, stress responses, and alcohol consumption among professional firefighters: A prospective, longitudinal analysis. International Journal of Stress Management, 6, 179–196. https://doi.org/10.1023/A:1021934725246
Crossref
Perez, R. A., Jetelina, K. K., Gonzalez, J. M. R. (2021). The chronic health effects of work-related stressors experienced by police communications workers. Safety and health at work, 12(3), 365–369. https://doi.org/10.1016/j.shaw.2021.05.005
Crossref
Ricciardelli, R., Carleton, R. N., Mooney, T., Cramm, H. (2020). “Playing the system”: Structural factors potentiating mental health stigma, challenging awareness, and creating barriers to care for Canadian public safety personnel. Health, 24(3), 259–278. https://doi.org/10.1177/1363459318800167
Crossref
Royle, L., Keenan, P., Farrell, D. (2009). Issues of stigma for first responders accessing support for post-traumatic stress. International journal of emergency mental health, 11(2), 79–85. Retrieved from: https://www.researchgate.net/profile/Derek-Farrell-3/publication/40020978_Issues_of_stigma_for_first_responders_accessing_support_for_post_traumatic_stress/links/55c87da308aea2d9bdc8da75/Issues-of-stigma-for-first-responders-accessing-support-for-post-traumaticstress.pdf
Stergiopoulos, E., Cimo, A., Cheng, C., Bonato, S., Dewa, C. S. (2011). Interventions to improve work outcomes in work-related PTSD: A systematic review. BMC public health, 11(1), 838. https://doi.org/10.1186/1471-2458-11-838
Crossref
Stuart, H. (2017). Mental illness stigma expressed by police to police. The Israel journal of psychiatry and related sciences, 54 (1), 18–23.
Szeto, A., Dobson, K. S., Knaak, S. The road to mental readiness for first responders: A meta-analysis of program outcomes. The Canadian Journal of Psychiatry, 64(1 suppl), 18S–29S. https://doi.org/10.1177/0706743719842562
Trachik, B., Marks, M., Bowers, C., Scott, G., Olala, C., Gardett, I. (2015). Is dispatching to a traffic accident as stressful as being in one? Acute stress disorder, secondary traumatic stress, and occupational burnout in 911 Emergency dispatchers. Annals of Emergency Dispatch, 3(1), 27–38.
Violanti, J. M. (1996). Police suicide: Epidemic in blue. Springfiled, Ill: Charles C. Thomas.
Violanti, J. M. (2004). Predictors of police suicide ideation. Suicide and Life-Threatening Behavior, 4, 277–283. Retrieved from: https://guilfordjournals.com/doi/abs/10.1521/suli.34.3.277.42775#
Crossref
Willis, E., Beidel, D., Bowers, C., Neer, S. (2020). Using a mobile application to address stress-related symptoms in emergency dispatchers. Annals of Emergency Dispatch Response, 8 (1), 9–15. Retrieved from: https://ucfrestores.com/wp-content/uploads/2021/12/Willis_Using-Mobile-Application15945.pdf
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Journal of CSWB, VOLUME 7, NUMBER 2, June 2022