When most people find themselves face-to-face with first responders—paramedics, EMTs, firefighters, and law enforcement officers—it’s on one of the worst days of their lives. Being first on the scene whenever something dangerous and potentially life-threatening happens is part of the job description. First responders race toward shootings, car accidents, house fires, medical emergencies, and other situations no one wishes to find themselves in, and it’s their job to save the day.

Professional heroism, however, often comes at a personal price. According to the U.S. Department of Health & Human Services, an estimated 30 percent of first responders experience mental health disorders, including depression and post-traumatic stress disorder (PTSD), compared to 20 percent of the general public—and this data predates the COVID-19 pandemic. Rates of suicide are stronger among first responders, too. According to the Centers for Disease Control and Prevention (CDC), law enforcement officers and firefighters are more likely to die by suicide than in the line of duty, and EMS providers are 1.39 times more likely to die by suicide than the general public.

COVID-19 has only exacerbated the problem. Though almost everyone on the planet has dealt with pandemic-related trauma and challenges in some form, first responders have been working overtime, constantly confronted with a deadly illness no one can stop. First responders, used to solving problems, encountered an invisible enemy they could not defeat. And it is one they continue to face.

A study published this February in the journal Cognitive Behavior Therapy found that COVID-19 first responders reported higher alcohol use during the pandemic. First responders who worried about COVID-19 also reported having more anxiety, depression, and greater rates of post-traumatic stress disorder (PTSD) than the general public. Another small study published last year in the journal Stigma and Health found that first responders experienced higher levels of isolation, depression, and reluctance to ask for help or receive mental health treatment during the pandemic.

As the pandemic raged and essential workers were treated to 7 pm salutes and encouraging posters, more people collectively began to realize that there’s nothing normal about relentless exposure to tragedy. “We are not humanistically wired to take in the amount of secondary trauma a first responder repeatedly is exposed to on an average 12-hour shift, during COVID-19 or otherwise,” says Colleen Hilton, LMFT, a therapist and the founder and CEO of Acuity Counseling, which offers mental health resources and therapy for first responders.

This collective realization—that first responders are exposed to trauma so regularly and consistently—is shepherding an era of change within first-responder culture that might reduce stigma and increase access to mental health resources so that those who are charged with helping people on their worst days can get the support they deserve.

Overcoming the martyrdom complex

While emergency nurses aren’t technically first responders, emotional distress and sacrifice are similarly a common part of the job. It’s something Christopher Monroe, RN, an emergency nurse in Indianapolis, Indiana, learned while he was still in nursing school. “My instructor paired me with a patient that was terminal,” he says. At that time, Monroe didn’t have much experience with death, but this is precisely why his instructor paired him with the patient. “He wanted to give me the experience of [a patient dying] in a controlled environment while I was still in school so that the first time I dealt with it I wasn’t on the job alone. That was really helpful to me,” Monroe says. “What I learned then—and put into practice still now—is that it’s important to be strong for your patients. You could lose a patient and immediately have to walk into the next room to care for another patient—you still have to show up for them.” Effective? Yes. But it’s also one factor of the job that contributes to high levels of burnout.

Historically, many first responders experience burnout as a point of pride—the mark of a job well done, says Rhonda Kelly, the executive director of the All Clear Foundation, a non-profit aimed at improving the mental well-being of first responders. “One of the worst parts of first-responder culture has been this martyrdom complex,” she says, adding that some wear their stress as a badge of honor. “Like, yeah you should be burned out. Maybe you do drink too much or have a divorce or two. Or maybe you do have a short fuse, but that’s a sign of accomplishment because it means you’re really doing the job.”

Shannon Sovndal, MD, a board-certified doctor in emergency medicine and emergency medical services (EMS) who worked as a firefighter before becoming a doctor, talks about coping with trauma in his memoir, Fragile. In his book, Dr. Sovndal reveals the personal impact that secondary trauma exposure in the emergency room has had on him and the pressure to not fall apart in front of his colleagues or patients. There are days when he’s seen children die, or people he knew were brought into the emergency room, their lives hanging in the balance. “I have a good lockbox around my heart,” he says. “I lock it up and shut the door so that I can function at my job. But at some point, that door is going to break down. You can’t hide [your heart] forever.”

While Dr. Sovndal may appear unaffected on the outside, inwardly, that is not the case. “You see all these negative things, and then you start having negative emotions. I talk about it as a black hole that sucks you in, and it’s really hard to get out of,” he says. For him—and many other first responders—this has led to insomnia. Lying in bed is often the first time someone has to be alone with their thoughts, and for first responders, those thoughts are often troubling.

Ashley McGirt, a therapist who often works with first responders, has seen in her clients what burnout looks like. “For some, it’s anxiety or depression. For others, it manifests in physical ways, like migraines,” she says, and while some first responders work with her to prevent burnout, the martyrdom complex persists. “There was this mentality of ‘suck it up, buttercup,’ or ‘maybe you’re just not cut out for this,'” she says, adding that this mentality has long been a massive obstacle when it comes to first responder mental health care.

This “tough guy” mentality is something Paul Grattan, a sergeant and 20-year veteran of the New York City Police Department, says he’s seen his whole career. Grattan is part of what he says is known as the “9/11 class” because he graduated from the police academy days before the attack on the World Trade Center and worked at Ground Zero. He says even after that devastating tragedy, discussions about mental health resources for first responders were minimal. “The conversations at that time focused on the impact of the World Trade Center attacks on first responders, but there were not general screenings [for depression or anxiety] put in place or conversations about what we go through as just part of the job,” he says.

“People are drawn to this profession to help; they’re not used to asking for it.” — Paul Grattan, Sergeant, NYPD

For decades, Grattan says the way mental health was addressed in law enforcement came down to checking off a few boxes. “It was like, ‘Okay, are we putting a poster on the wall about getting help if you’re drinking too much? Great,'” he says. Grattan says people in law enforcement are viewed as “strong.” “People are drawn to this profession to help; they’re not used to asking for it,” he says.

The pressure (including self-imposed expectations) to appear strong for others and the stigma surrounding that often means that first responders aren’t getting the help they need before it’s too late. This is what inspired Jeff McGill, PhD, to found Blue H.E.L.P., a nonprofit that tracks the number of officers who died by suicide and also aims to reduce the stigma of asking for mental health resources. “My partner and I were involved in a shooting where he was shot multiple times, once in the face. Ultimately, he survived the physical wounds, but then he had to face the psychological side of it, too,” Dr. McGill says. He adds that it affected him personally as well. “I had my first anxiety attack after that shooting,” he says. “The aftermath of the shooting really opened our eyes to the way your brain function literally changes after experiencing extreme stress.” But these after-effects weren’t commonly talked about in his profession. Again, he says it was viewed as part of the job.

Dr. McGill says another big reason why Blue H.E.L.P. was created was to address the way suicide was viewed in the law enforcement community. He cites the 1997 North Hollywood bank shootout as a specific example. “This was a horrendous gun battle and [Sgt. Israel ‘Sonny’] Medina, was seen as a hero for his courage during this shootout and received the Medal of Valor. He is credited with changing the way law enforcement operates during shootouts,” Dr. McGill says. He says that Sgt. Medina ultimately died by suicide and, because of this, is not considered to have died in the line of duty or honored as such.

When police officers’ mental health is neglected, its ramifications can affect entire communities. According to the U.S. Department of Justice, experiencing post-traumatic stress can manifest as aggression and can cloud decision-making, including decisions directly related to public safety, the site reads, adding that the U.S. Department of Justice is currently researching the effect of symptoms of PTSD on decision-making brain functions among police officers. What’s clear is that untreated trauma doesn’t just affect the person experiencing it; it affects everyone who interacts with that person as well, a fact that’s particularly relevant as police brutality continues to plague communities and police departments across the country.

Ultimately, Dr. McGill wonders why wounds of the mind aren’t given the same attention as wounds of the body—both while officers are currently in need of mental health services and in cases where help didn’t come in time. “We’ve heard horrendous cases of families where their medical insurance was discontinued the same day their spouse died by suicide,” he says, adding that this would not happen if the officer died in the line of duty. Blue H.E.L.P. is one of the first organizations to track law enforcement suicides—which they are now doing with firefighters—and they honor those who died by suicide through their honor wall. “Some are anonymous, but some include the photo and story of the person sent by the family,” Dr. McGill says. “They want people to know what happened and to put a face with a story.”

How COVID-19 is bringing awareness to first responders’ mental health

Even if a first responder doesn’t develop full-blown PTSD, the regular exposure to trauma still can have deep effects. “They can be long-lasting and become a disorder, like PTSD, but what happens more commonly is what we call an ‘operational stress injury,'” says Jaime Brower, PsyD, a licensed clinical psychotherapist who has dedicated the past 17 years of her career to working with first responders.

An operational stress injury is any persistent psychological difficulty resulting from operational duties. It’s also often referred to as critical incident stress (CIS). Symptoms can be physical (like dizziness, fatigue, or headaches), cognitive (confusion, nightmares, and trouble concentrating), or emotional (fear, guilt, anger, and chronic anxiety).

Dr. Sovndal, Hilton, and Dr. Brower all say the pandemic has intensified the mental and emotional toll first responders were already experiencing. “COVID-19 presented what we call a ‘moral injury,'” Hilton says. “Not only were first responders experiencing the type of burnout that comes from working long hours and feeling exhausted, but on top of that they’re seeing all these horrible things happen and the ways they’ve been trained to help no longer work. When you’re a first responder and you show up to save someone’s life, but no one understands the virus well enough for you to be able to do that, it wears on you.”

Dr. Sovndal says on top of moral injury, first responders also worried about their own health and what contracting the virus would mean for them and their families if they brought it home. “I was very worried about the rise of depression, anxiety, and PTSD among first responders since the start of the pandemic because it adds so much extra stress,” he says. “It’s something we talk about among ourselves. What’s the call that’s going to put me over the edge?”

“Burnout was something we talked about inside the first responder community, but now there are more people outside just this community talking about it.” — Shannon Sovndal, MD 

McGirt adds that the social unrest of last summer also confounded the stress many first responders already faced. While many first responders were happy to volunteer their services, looking out for the safety of protestors even though they were off the clock, for many, it still took an emotional toll, she says. “It’s a heavy load to carry. Many were seeing things they had never witnessed before. I have some [other] clients who are ex-military who experienced flashbacks or post-traumatic stress disorder because of the flash bombs,” McGirt says. “Even a year later, I’m still working with some clients to help them work through what they experienced during the protests.”

All the experts say that what COVID-19 did for first-responders was get people talking about their mental health. “Burnout was something we talked about inside the first responder community, but now there are more people outside just this community talking about it,” Dr. Sovndal says. “The conversation surrounding anxiety, depression, and suicide among first responders really gained momentum during the pandemic.” Hilton and Kelly both echo this sentiment. “People are paying attention in a new way,” Kelly says. “There was this collective moment of, ‘Wow, this pandemic is really tough for me. I wonder what it’s like for them,'” Hilton says.

The greater understanding that first responders were and have been working in such a psychologically challenging field started happening as virtual mental health services became more widely available, leading providers in this space to think specifically about how to help the community. One example of this is the launch of the Heroes Health app, created by developers at the University of North Carolina School of Medicine and UNC Health, that allows healthcare workers and first responders to track their mental health and access relevant resources. Another example is First Responder Toolkit, a free app that helps first responders manage emotional and physical exhaustion. These are resources that did not exist before COVID-19 forced more people to think more about how first responders were coping emotionally.

Even though many people in the U.S. feel we’re approaching “the other side of the pandemic,” Dr. Brower says the need for resources like these remains important. In fact, she believes there will be a delay in when many first responders are hit the hardest mentally and emotionally because of what they’ve experienced during the pandemic. For almost two years, she says first responders have been busy solving crisis after crisis. But as the pandemic begins to ease up, first responders might find that they have more time to breathe and process what has happened, Dr. Brower says. “Because of that, the mental health crisis isn’t close to over,” she says. “The worst is yet to come.”

What’s being done for first responder mental health

The conversation COVID-19 sparked about first responder mental health is encouraging a cultural shift. Dr. Brower says she’s been having many conversations with first responder unit leaders about what stress management resources are available for free, including peer support, therapists, and chaplaincy. She also helps set them up with free online access to the National Emergency Responder & Public Safety Center, which offers mental health and stress management courses that people can do anonymously at home. “There are courses on how to reduce alcohol consumption or how to get better sleep, for example,” Dr. Brower says.

The All Clear Foundation created a library with a wide range of free resources that can be accessed online or through an app, Kelly says. It includes advice on stress management, maintaining healthy relationships, developing resilience, understanding PTSD, and virtual 12-step recovery meetings, to name just a few. She also says the organization recently launched an anonymous peer-to-peer chat app so first responders can talk about their experiences in chat rooms or one-on-one. She says there is integrated AI technology that recognizes phrases indicating when someone should speak with a professional mental health provider and prompts them with a way to do so when necessary.

Another major shift involves integrating mental health curriculum into first responder training so that they can start their careers knowing how to protect their mental health, Kelly says. Hilton also says she is seeing more emphasis on giving first responders tools during training. “An ounce of prevention is worth a pound of cure,” she says. “Many first responders are being taught in training how to develop resiliency and build it into a lifestyle that supports health and wellness holistically. You are not destined to get PTSD if you are a first responder, and you don’t have to wait until you’re burned out to seek out ways to manage your mental health,” she says.

Giving first responders tools to care for themselves during training, all the experts say, is key to changing the culture from one that thrives on martyrdom to one where it’s okay—even encouraged—to ask for help. “We’re starting to see that shift,” Kelly says. “Millennial first responders in training are starting to ask questions about work-life balance—and that’s important. People are recognizing it’s not a dishonor to look after yourself.”

Grattan says he’s noticed a shift with younger generations entering law enforcement. “A [new] generation of first responders is being raised in an environment that’s a bit more helpful when it comes to mental health and well-being,” he says. Instead of just a poster on the wall, Grattan says stations are making more serious investments partnering with organizations that offer therapy and other resources; he named Blue H.E.L.P. as one in particular. But he adds that there is still a long way to go.

*Cailey, who has been a full-time firefighter in Orlando, Florida, for eight years and an EMT for four, says since the beginning of COVID-19 she’s started to see a change among her colleagues. “The walls are coming down and more people are opening up and saying, ‘Hey, I’m not okay,'” she says. This isn’t the first time she has seen something positive stem from immense tragedy. “We had a chief who committed suicide, and that was what led to the peer support team being formed,” she says. “Then, the Pulse nightclub shooting happened, which made it even more pressing,” she says. Now, fire stations in her city have a peer support team who show up with coffee and cookies anytime a station responds to a particularly distressing call, she says.

Cailey is hopeful but says there’s a long way to go for the culture to truly change. “It’s going to be a while until [first responders] feel more comfortable talking about [mental health] and being able to say, ‘Hey, I need a break. I need to tap out because I can’t do this anymore.'” She adds that while more conversations surrounding mental health seem to be happening, she still wouldn’t feel comfortable asking for a day off after an emotionally difficult call or shift.

Change is slow, but it is happening and it’s a shift Dr. Brower says society as a whole will benefit from. “If you want healthy communities, you need healthy first responders,” she says. “Healthy first responders interact with their community in a healthy way. If we don’t prioritize their mental health, it will only lead to more problems—for all of us.”

*Last name has been withheld. 

If you or someone you know is struggling with suicidal thoughts, call the National Suicide Prevention Lifeline at 1-800-273-8255 or chat with a counselor online.