Treating First Responders with Addiction

First responders are a fascinating population to treat. As a rule, they are interesting, funny, deeply compassionate, and loyal to colleagues, friends, and family, but the work they do takes a toll. Most patients that therapists see may have one traumatic incident in their past, but these are people who may be traumatized several times a month. They see, and often experience, the worst of what humans go through. So it’s not surprising that they find going to therapy difficult and will avoid it. They aren’t going to readily tell you about their experiences. Unfortunately many first responders with addiction hide it well.

In the general population, addiction can show up in all parts of a person’s life, including work, where colleagues may notice they are drinking during work or hung over from earlier drinking or drug use. First responders, however, generally stay actively engaged in their work and rarely use alcohol or drugs on the job. By the time they need to seek help, their personal and family lives may be in trouble, but their work performance and work relationships may remain on an even keel. The nature of the shift work that first responders have decreases the possibility that anyone will notice the symptoms of substance use disorder since they are often alone in their homes on their days off with spouses off to work and kids off to school.

Ask the Right Questions

As a clinician, I have learned to look at the first responder’s personal life for clues about substance use disorder and other mental health issues. Are they engaging in recreational activities? Going on vacation? Are they still enjoying hobbies and other enjoyable activities, fishing or golfing or working on their cars or motorcycles? What are they telling me about their relationships with their spouses? Children? Friends outside of work? What are their family members and friends telling me? Where are the danger signs, the differences between what they say and what others say about their life outside of work? This often paints an understand of how first responders with addiction can be treated.

Understand Their Coping Mechanisms

Don’t judge the first responder as you would someone from the general population. Be attentive to what they are telling you. Ask questions. Don’t assume that what sounds like a traumatic experience for them was traumatic. It may have just been another Tuesday at work. It may take time, careful questioning, and building trust to understand what was traumatizing for them, what triggers them and why.

You may also find yourself struggling with what they tell you and how they tell you. Humor is often a coping strategy, and that humor can be dark. It can be shocking to hear the jokes the first time but understand that humor can help this group of professionals tolerate the work they do. If they are willing to share that humor with the therapist, it’s a first step in processing the trauma and treating the substance use disorder. Joking with them can build trust and acceptance, and can let them know that they can trust you with experiences they wouldn’t presume to burden others with hearing.

It’s also necessary not to show how shocked and disturbed you may be by what they have witnessed. They are protectors, if not by nature, then by experience, and they will button up quickly if they see how their stories are affecting you. First Responders with addiction have often witnessed devastation that deeply hurts them.

Treatment Modalities

The treatment modalities I often use with first responders include:

Motivational interviewing: This modality is based on asking the patient questions and talking with them about their need for change and what would motivate them to make changes. One of the most critical questions I ask first responders in treatment is, “Do you like your life outside of work? What does that life look like?” Often the response I get is that they are just existing from one shift to the next. If there is PTSD or other co-occurring disorders like depression and anxiety, they may tell me they try to drink enough to put themselves into dreamless sleep. Some are hypervigilant, which causes a lot of tension in their significant relationships and may even have destroyed those relationships.

So what will happen when they retire, which could be while they are in their 40s or early 50s?

What are they going to do without the job? Do they have social connections outside of the job they can count on? Are their kids still at home or are they young adults? What kind of relationship do they have with their spouse? Have they talked about retirement plans with them?

With the information they provide, I paint a picture of what their quality of life will be like with only drinking or drugs versus a life in recovery with golfing, fishing, vacations with their spouse and kids, etc.

We also take stock of their work performance and evaluate their level of satisfaction at work. Is it still a source of pride? Or a significant source of trauma and stress? Many of them have a high endurance for pain, stress, and trauma and will just keep doing what they expect of themselves way past the point most people would, and they will suffer in silence. There’s a high rate of suicide among first responders and that culture of endurance can be a significant contributing factor.

If we can talk through what work is like for them and how they deal with stress and trauma, we can get to the unhealthy coping methods they have developed.

Cognitive behavioral therapy: This mode of treatment has been proven effective in treating not only addiction but also PTSD and anxiety, which makes it a good treatment for first responders. By figuring out why someone behaves the way they do — the thoughts that lead to the behaviors — the therapist can work with the patient to change those thoughts and thus the maladaptive behaviors.

Because first responders will often try to deflect a therapist from how an incident impacted them by telling a good story, it’s important to stay focused on the impact. “What did it mean to you when X happened? Was it because it involved a family? A child? Did it affect how you look at yourself or your family?” For example, a police officer may keep his kids from playing in the street, even though it’s a dead-end and very few cars come into the street, because he was on the scene of a fatal hit-and-run involving children. Unpacking what is behind a behavior gives the patient the ability to change it.

Dialectical behavior therapy: This therapy focuses on acceptance and change at the same time: helping patients to accept themselves as they are and to change what is not working in their lives. Because a large part of the therapy is teaching patients skills to manage their emotions, it’s a good fit for many first responders who appreciate its practicality.

Psychoeducation: Like DBT, psychoeducation is a learning-based treatment method. Rather than asking patients to focus inward and delve into their histories and emotions, psychoeducation teaches them how they can deal with substance use disorder, anxiety, depression, and PTSD by using tools. For a group that is action oriented, this can be quite effective.

Group therapy: First responders live in a specialized culture and, for most, other first responders are not only colleagues they are best friends and often, family members. For that reason, group therapy is a helpful way to provide treatment for addiction and mental health disorders. In a group setting with other first responders, they can eventually feel safe and understood. They are less likely to be challenged about something that is accepted within that culture but not understood outside of it. They see others with similar work experiences and histories opening up about addiction and mental health and learn that it’s okay for them to speak up too.

Family therapy: Because first responders learn to protect their spouses, kids, and other family members from the difficult and traumatic realities of their work, it’s hard for them to turn off their protective instincts and inclination to hide the mental, emotional, and physical effects of their work. Family therapy can be an important tool in helping them to understand why vulnerability and honesty are critical to healthy personal relationships and how they can negotiate the very different environments in which they operate — work and home — in ways that are healthy for them and healthier for the family unit as a whole.

Helping First Responders with Addiction find Recovery

Working with first responders has been some of the most rewarding work I have done as a therapist. I come from a family of first responders and worked for three years with first responders who experienced PTSD. For every challenge they bring to treatment, there is a corresponding reward. Once they realize that they need treatment and have built a trust in their therapist, they will put themselves fully into the work. Contact us today to learn more about helping first responders with addiction.