Mental health considerations

The incidence of mental illness continues to increase in the general population. Current public and private resources are inadequate to deal with both chronic and acute clinical manifestations of these disorders. Recent surveys and publications support the notion that mental health issues for EMS professionals are endemic at an even greater magnitude. The efficacy of the interventions of mental health professionals (MHP) in assisting prehospital personnel may be diminished by a lack of familiarity with the reality of EMS or by the failure of the EMS provider to perceive the commonality of their experiences with pathologies extant in non-EMS individuals. Given the dearth of resources and the erraticism of their distribution, it is unlikely that EMS specific mental health resources will be widely or readily available. Consequently, it is not practical to create mandates for organizations to provide services for which there are no local or fiscally reasonable resources.

The NAEMT provides resources on their web-site. Recently the IAFF has opened the IAFF Center of Excellence for Behavioral Health Treatment and Recovery. The Center opened March 5, 2017 with collaboration of Advanced Recovery Systems and will provide “evidence-based care” for addiction and mental health disorders. It is a 58 bed facility housed on 15 acres. Staff took the IAFF’s FireOps 101 training to gain familiarity. Further information may be found at and There are 303,000 members of the IAFF.  Although these activities may provide models, what is the likelihood that such services will be available for EMS?

Some respondents to the NAEMT Mental Health survey engaged in self-diagnosis. Others describe the lack of resources. Unfortunately, there are still organizations whose cultures abuse and malign those who need help. The risks involved with those who are not MHPs diagnosing mental disorders coupled with overt hostility are self-evident. Perhaps perception of mental health as a dual responsibility of EMS providers and the organizations for which they serve is reasonable.

We, as individuals, clearly have a responsibility to maintain a level of physical readiness to perform our jobs. Proper diet, exercise and adequate sleep are the tools we use. When our physical limits have been exceeded, fatigue and pain do a pretty good job of letting us know. There are mechanisms in place, such as rest, physical therapy, and other therapeutic interventions (many covered by workers’ compensation) that specifically target these physical issues. Don’t we have a responsibility to maintain mental readiness to perform our jobs? Don’t our organizations have a responsibility to have resources in place when our mental limits have been exceeded?

The NAEMT Safety Course Student Manual describes the First Response Resiliency course developed by Drs. Michael Marks and Philip Callahan. Resiliency training has been used to successfully treat and prevent PTSD in military personnel. There are 12 Resiliency skills categorized as physical and behavioral skills, cognitive skills, and social skills.  Using these skills creates the habits of thinking about how we are progressing, or not progressing, mentally. This is crucial. The warning signs that our physical limits are exceeded are much easier to perceive than the mental ones. If we wait to consider our mental health until we are exposed to major stressor, we are performing the equivalent of starting an exercise program after a career-ending back injury. When commonly practiced, resiliency skills will be evidenced by common behaviors which will evolve the culture of safety to the point that peer-pressure will not allow negativity towards those who are suffering.

If the only resources made available by an employer are designed to deal with major stressors after the fact. It’s too little too late. There are baseline organizational activities pertinent to mental health. Stress occurs when our expectations and experiences don’t match. People must be given a understanding of the reality of their job. A service that does 90% of their transports non-emergently should not create the expectation that lights and sirens are commonplace. Some organizations employ psychological testing to measure risk taking. Burnout is caused by exhaustion, inefficacy, and cynicism. The physical detriments of long work hours, exposure to the elements, limitation of nutrition, hydration, and rest must be taken into consideration in determining shift schedules, distribution of workload, and policies and procedures. Inefficacy is the feeling that what you do doesn’t make any difference. Mechanisms should be in place, which create positive feedback to employees for both clinically significant and mundane events. Is transporting 500 dialysis patients safely any less important than performing one dramatic resuscitation?  Cynicism is assumed to be an inherent characteristic of EMS providers. A supportive work environment might mitigate what can be considered a defense mechanism. Bullying must never be tolerated.

In order to deal with both emergent and non-emergent mental health issues, employers must be aware of all mental health resources that could be available to personnel. They must also be compliant with all federal, state and local regulatory requirements. When health insurance is provided, the provision of mental health services must be addressed contractually. The same consideration is applicable to workers’ compensation coverage. Independent of the availability of insurance coverage the employer needs to be aware of available mental health services.

The employer, with the aid of the medical director and appropriate agencies in the community, should identify service providers and make them aware of the reality of the local EMS environment. Employers should be creative in searching for resources and consider community mental health assets, psychiatric institutions, hospitals, academic medical centers, and items available to other public service providers such as, police and fire. Relationships should be established that facilitate access, privacy, and effectiveness. Naturally, when available formal interventions specific to EMS are appropriate and given by certified or licensed personnel. Ideally, multiple resources will be available. What works for one EMS provider might not work for another. While Critical Incident Stress Management may be successful for some. Others might require a different type of intervention.


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