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Tales From the Clinic: The Art of Psychiatry

, we visit the addiction clinic to discuss accidental overdose deaths. Although death by suicide is known to greatly impact psychiatrists, the impact of overdose deaths on physicians is not well studied. Despite the best efforts exerted in treatment, patients on medications for opioid use disorder may die of accidental overdoses on opioids, having misestimated their current opioid tolerance, or overdose on other substances such as sedatives/hypnotics and stimulants. This article is dedicated to 3 patients lost in this past year—AK, EG, and AW—with heartfelt wishes to their families.

“Ms Verona” was a 45-year-old female enrolled in an addictions treatment program and a mother of 7 children who struggled greatly with 

 and anxiety. She was motivated to stop her opioid use, as it was taking a toll on her health and her family. Ms Verona’s children would sense their mother’s lack of engagement with them, as she was constantly preoccupied with how to mitigate the inevitable opioid withdrawal symptoms. She was a good candidate for buprenorphine therapy, as she met criteria for severe opioid use disorder, and she preferred partial agonist therapy as opposed to naltrexone and methadone. Ms Verona was inducted onto buprenorphine, and her dose subsequently increased to 16 mg total daily in order to adequately address opioid cravings.

As treatment progressed, Ms Verona displayed a chronic tendency to arrive more than an hour late to appointments. Despite her tardiness, she would plead to still be seen, often citing traffic or lack of childcare arrangements. The psychiatrist, Dr Smith, would attempt to be flexible, given the understanding of treatment barriers stemming from social determinants of health, as well as recognizing the time-sensitive nature of 

 refills; however, these accommodations were placing Dr Smith and the treatment team under time constraints in a busy clinic. Such accommodation would either cause the psychiatrist to be late for other appointments, or it would lead to the appointment with Ms Verona feeling rushed. After the patient was accommodated for lateness over a few visits, Dr Smith became aware of his growing countertransference toward Ms Verona.

 (ADHD) may have been affecting her presentation. Ms Verona was noticeably circumstantial during sessions and required frequent redirection. She also described a childhood history with symptoms of difficulty concentrating. It was also explored whether her lateness was a manifestation of her inability to focus, organize, and prioritize. She often talked about having gotten Adderall “but not recently, doctor; I know you would not let me.” Dr Smith worked with Ms Verona in problem-solving therapy to help reduce treatment-interfering behaviors and promote punctuality. Ms Verona was also started on bupropion to target ongoing depressive symptoms and simultaneously provide a nonnarcotic option to treat attention-deficit symptoms. There was a concern for her using stimulants or other substances between appointments. Despite these treatment approaches, tardiness to her appointments continued and she appeared even sedated at times, despite negative urine drug screens.

One day, Ms Verona was more than an hour late. She was informed that she could not be seen and had to be rescheduled. She was visibly upset and opted, likely due to splitting defense mechanism, to reschedule to see a different provider in the clinic when this boundary was set. After this, Ms Verona ended up seeing a different psychiatrist for the next 6 months.

One day, Ms Verona’s former psychiatrist met with one of his active patients, Mr Kim, and the following dialog ensued:

Mr Kim: “One of my friends passed away, and I’m attending the funeral. I think you actually used to treat her before.”

Dr Smith: (Somewhat surprised) “I’m sorry to hear about the loss of your friend.”

Mr Kim: “Yea, it was sad… she (Ms Verona) said she used to see you. She was still on buprenorphine, but the suspicion was that she was taking alprazolam the whole time she was in treatment and did not tell anybody, and it is a suspected unintentional overdose. I used to see her all the time, and she would be nodding off. You didn’t hear about this?”

How Do Physicians Cope With Patient Suicide or Overdose?

Dealing with the loss of a patient due to suicide or 

 has a significant impact on the treating physician and is not often talked about. There are a variety of factors that determine how a psychiatrist will be impacted in such a situation. Younger clinicians and trainees are often affected more adversely, as they have not been exposed to the scenario and may feel more vulnerable in terms of their experience and knowledge base.

 According to literature, about 25% to 60% of psychiatrists will report having a patient who died by suicide during their career.

 The number of physicians who lose patients to overdose is not known. However, the rate of overdoses involving opioids jumped by 200% from 2000 to 2014, and between 2013 to 2019, the synthetic opioid-involved death rate increased 1040%.

 The sheer magnitude of these numbers suggest that most physicians dealing with addiction must have been exposed to patient death by overdose.

With these figures in mind, as well as the significant amount of perceived stigma and guilt surrounding disclosure of these outcomes, and with the fear of lawsuits that may occur in these situations, the overall emotional toll it can have on a clinician can be quite intense. The psychiatrist in this scenario was flooded with feelings of guilt related to potential responsibility for the outcome. In addition, there is a possibility of additional emotions of anger toward the patient who was already deceased. We hear team members often saying, “Oh, but they were doing so well,” or “So sad—they stayed off heroin but could not keep off meth.”

When one is processing the suicide of a patient, one should be mindful to not isolate oneself. Efforts should be conducted to reach out to colleagues, as it is likely they would have dealt with similar experiences in the past and can normalize and validate the experience. Discussion of experiences and coping mechanisms may have therapeutic effects for physicians going through such experiences. Clinicians, as part of an organization or group practice, can utilize case conferences—a pragmatic, systematic, and therapeutic approach to exploring the case outcome in more detail. Risk management reviews or meetings could help with apprehension about any impending or perceived lawsuits. This is especially important for clinicians in private practice, who may be more isolated given their work environment structure. The message we need to hear is that a patient loss does not undo or discard the multitude of meaningful life-changing and life-preserving work done with both living and deceased patients. Support and validation go a long way in reminding us why we do what we do.

How Can We Promote Honesty About Recurrence of Substance Use?

 (SUDs), it may be helpful to try to acknowledge and normalize the fear of disclosure of relapses, as well as to emphasize the importance of honesty in recovery from the very beginning of treatment. Although feelings of guilt and internal shame are common, they are not easy to talk about for patients. Whereas the patient may perceive recurrence of use as “starting from scratch,” the clinician can reframe a recurrence of use as a learning point and a way to troubleshoot the circumstances surrounding the use. Being too harsh or strict with the patient may backfire, lead to sustain-talk, erode the therapeutic alliance, and provoke even more feelings of guilt or shame. Relapses sometimes occur because being off substances uncovers a cooccurring mental illness, or because of stress in real life, to which patients with SUDs are more susceptible.

By definition, addiction is a relapsing and remitting illness. Similarly, depression is also a relapsing and remitting illness, but no one benefits from being kicked out of treatment for having a recurrent depressive episode. Thus, patients should not be terminated from treatment for recurrence of use as if often done—they should actually receive more intense care when in a greater time of need. Although recurrence of use might have clinical significance on modifying treatment plans, patients should be informed that using is only a setback if they do not seek further treatment to address it. Patients may be relieved if asked about any internalized and unfounded fear they may have about being terminated from treatment if they divulge recurrence of use.

If a patient states that they are feeling punished for having more frequent visits during recurrence of use, it may help to first empathize with concerns and then reframe the change in treatment plans as a goal toward well-being as opposed to punishment. Utilization of motivational interviewing may be helpful if the patient is still ambivalent about recovery. It is crucial for a provider to have a nonjudgmental approach toward relapses, both past and present. Subconscious criticism, even in the form of subtle body language, can promote denial or reliance on more primitive defense mechanisms in a patient and lead to poorer treatment outcomes, especially if the patient has a harsh superego or difficulty with trusting others.

Previous recurrence of use may lead some patients to think they are a lost cause and lack the willpower and discipline that might be needed for recovery. Internalizing this belief is characteristic of patients with complicated SUD histories. It is important to modify a patient's internal process and remind them that it is not solely willpower or motivation that determines the ability to improve, but also coping and relapse prevention skills, which can be taught through any type of therapy, but especially cognitive-behavioral therapy.

How Do You Find a Balance of Boundaries With the Patient?

Finding the right balance in setting boundaries can be a challenge in a busy schedule, and it requires being mindful of the patient’s perspective while simultaneously acknowledging a patient’s subconscious need for structure to meet treatment goals.

It was important in Ms Verona’s case to validate her struggle with circumstances in her life. After all, the social determinants of health (ie, social, behavioral, and environmental factors) are a predominant influence on treatment outcomes.

 In addition, it is important to acknowledge the role of untreated ADHD (like in Ms Verona’s case) in reducing recovery success.

 At the same time, the medical ethics concept of justice should also be considered. Although justice in this situation may apply to acknowledging Ms Verona’s barriers to care, it may also expose the caveats of this approach since other waiting patients were affected by the patient’s tardiness. A provider is tasked with collectively benefiting all of their patients, treating all with equity and making accommodations where necessary, and without putting 1 patient at risk at expense of another.

In this case, did the boundary-setting change the course of Ms Verona’s clinical treatment? Yes. Would it have been better without it? Not necessarily. Part of the treatment frame is for both physician and patient to be accessible, at a mutually convenient time. Reneging on appropriate boundaries may distort or enable certain expectations of the patient, which can undermine the patient’s perceived responsibility in treatment, reduce the patient’s ability to problem-solve, and lead to the approach that the physician drives the treatment, instead of the dyad making a shared and mutual responsibility. The physician can communicate these messages with empathy and genuine concern in the hopes that the patient will adopt that responsibility. In the case of mitigating overdoses—a poorly understood field—it is essential to know if the patient is using secondary substances outside the opioid being the target of treatment. Secondary substance use significantly increases risk of overdose.

From a larger perspective, a physician’s taking of the alternate approach can contribute to burnout and distress, and potentially adversely affecting outcomes for the other patients. Thus, boundaries can be a mechanism of protection for both the patient and the physician.

Triple Threat of Death: Suicide, Unintentional Overdoses, and COVID-19

Although there is growing literature about how patient 

 can impact physicians, there is a lack of data particularly on how substance overdose may impact a physician’s mental well-being. The lack of data on overdoses and how to cope with them is further compounded by the problem that busy schedules or shift work may inadvertently reduce the physician’s ability to access resources for support while the physician also thinks that “I must carry on.”

In addition, it would be important to differentiate how suicide and overdose are not necessarily the same. Overdoses are not always done with the intention of taking one’s life. In fact, most overdoses are accidental, but ultimately occur due to overestimated tolerance, unknown ingestion, or increasing amounts taken during stressful/inciting events. In 2014, only 12% of drug overdoses were intentional according to the Centers for Disease Control and Prevention (CDC).

 Although the percentage of intentional overdoses is the minority, another thing to consider is whether clinician perception of guilt is more intense if the overdose is intentional. A physician can be vulnerable to guilt for not effectively being able to treat a patient’s addiction or form a close enough relationship to know of their usage—even if the patient knowingly did not disclose use. Then there is the question of whether some severe addictive disorders could be considered like a “terminal illness,” where a clinician may feel that no matter how many treatment approaches have been tried, it is a matter of “not if, but when” in regards to either overdose or a chronic decompensation toward death.

Although we have seen that doctors who hear about their patients overdosing may actually reduce the amount of their opioid prescribing,

 mental health clinicians may be affected in a somewhat different capacity, as their role is also tied inevitably into also treating comorbid depression, anxiety, and suicidal ideation. The COVID-19 pandemic has further exacerbated this problem, as the estimated prevalence of suicidal ideation today is higher in comparison to the prevalence prepandemic.

If a clinician’s natural tendency to do more and become more hypervigilant following the loss of a patient, it is noteworthy to mention that most physicians suffer from burnout at one point in their life. A cross-sectional study was able to demonstrate that increases in suicidal ideation endorsement were significantly correlated with physician burnout rates.

 Considering that overdoses can be as lethal as suicides, it would be a fair but unproven assumption that it would also similarly contribute to physician burnout.

We believe further research is necessary to understand the many ways in which patient overdoses are affecting physicians, as well as developing more efficient strategies and support for dealing with the aftermath. 

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He is Director of Harris Health Substance Addiction Treatment Program and Associate Program Director for Baylor College of Medicine Addiction Fellowship Program. 

is currently a resident in psychiatry at Baylor College of Medicine. 

 is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the 

1. Ruskin R, Sakinofsky I, Bagby RM, et al. 

Impact of patient suicide on psychiatrists and psychiatric trainees.

2. Plakun EM, Tillman JG. The impact of patient suicide on clinicians. 

https://www.psychiatrictimes.com/view/impact-patient-suicide-clinicians

3. Rudd RA, Aleshire N, Zibbell JE, Gladden M. Increases in drug and opioid overdose deaths - United States, 2000–2014. Centers for Disease Control and Prevention. Accessed September 12, 2022. 

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm

Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths - United States, 2013-2019.

Relapse prevention and the five rules of recovery.

6. Williams N, Bossert N, Chen Y, et al. 

Influence of social determinants of health and substance use characteristics on persons who use drugs pursuit of care for hepatitis C virus infection.

Adult attention-deficit hyperactivity disorders and its correlates in patients with opioid dependence: an exploratory study.

8. Austin AE, Proescholdbell SK, Creppage KE, Asbun A. 

Characteristics of self-inflicted drug overdose deaths in North Carolina.

Opioid prescribing decreases after learning of a patient's fatal overdose.

Suicide, self-harm and suicidal ideation during COVID-19: a systematic review.

11. Menon NK, Shanafelt TD, Sinsky CA, et al. 

Association of physician burnout with suicidal ideation and medical errors.

My Patient Overdosed and Now I Feel Guilty… 

As September is National Suicide Prevention Awareness Month, this article focuses on the exposure and affect regarding those who have been charged with protecting the population’s health and preserving a community’s population—namely, first responders.

In 2022, the world has been challenged by several unprecedented large-scale crisis events such as increases in 

, increases in violence, and pernicious natural disasters. Although first responders have been trained to engage in extreme conditions amid rapid onset of change circumstances, such trainings do not comprehensively address or provide resources for the post-response mental health needs of these professionals. In fact, because of the pandemic, alongside a host of other various social ingressions like public insurrections and aggressive social discord over the past 2 years, the mental health needs of first responders have gained more attention. In this, a larger scope of questions predominates, such as: What happens to those same professionals who continuously endure the gross impact of such phenomena beyond their psychological and physical capabilities? Additionally, what is being done to assist first responders regarding assessment and remediation of mental health issues? Finally, how prevalent are things like posttraumatic stress disorder (PTSD) and other pathologies that may result from being a first responder?

Definitive trends also underscore these kinds of questions regarding first responders and the pathos-defined issues that have emerged from studies that depict PTSD, suicide, depression, alcoholism, and drug abuse as most predominant among this group of professionals.

 Although this observation was made nearly a decade ago, current research shows these same trends have negatively increased in 2022.

As well, more sobering statistics from the Centers for Disease Control and Prevention (CDC) have found that occupational stress in first responders can be associated with increased risk of serious mental health issues including hopelessness, anxiety, depression, posttraumatic stress, and 

 such as suicidal ideation and actualized attempts.

The following article presents a purview and inquiry into how society, policy makers, and government agencies can begin to synthesize the current trends regarding the mental health issues of first responders, as well as their compromised and vulnerable realities, and emotional valance

 Additionally, this article examines a few of the current promising psychological preventatives being tested with first-responder populations and the future prospects to be considered for building mental health resources for this group.

To more clearly define “first responders,” one must consider the cross-segment of industry categorized as helping professionals, where the primary role is first-line contact in any emergency situation. For the purposes of this article, the author will refer to such a role primarily as “first responder”; however, this reference can be somewhat arbitrary, and first responders may also be characterized as “emergency response providers” or “public health workers.” Either way, first responders are those who must meet the challenging demands of their front-line status within roles that represent a collection of various helping professions.

Under the umbrella of those considered first responders are police officers, firefighters, and emergency medical technicians (EMTs). Given their occupational demands, these helping professionals are the ones who are also the most chronically exposed to stress and traumatic scenes in the line of duty on a daily basis. To expand on this, according to 

, the term “emergency response providers” might also include federal, state, and local governmental and nongovernmental emergency public safety, fire, law enforcement, emergency response, emergency medical (including hospital emergency facilities), and related personnel, agencies, and authorities.

The next section provides a look at some of the emergent literature that has been documented concerning the mental health sequelae of first responders and the psychopathology that may perseverate. This may include the artifacts of depression, anxiety, suicidal ideation, and a host of other variants.

Some statistics provided on first responders and their mental health have been documented by the US Department of Healthin a supplement from the Substance Abuse and Mental Health Administration Help for Heroes Program.

 The statistics reveal the following associated with firefighters, police officers, and EMS professionals

“It is estimated that 30 percent of first responders develop behavioral health conditions including, but not limited to, depression and [PTSD], as compared with 20% in the general population. In a study about suicidality, firefighters were reported to have higher attempt and ideation rates than the general population. In law enforcement, the estimates suggest between 125 and 300 police officers commit suicide every year.”

These are staggering results compared to those in other professions. If one reflects on the nature of each of these roles and what they are called to do to preserve life and community, the possibility of such tremendous role strain will always have some psychological implications. In looking at the work of firefighters, for example, these professionals are often the first on the scene in an emergency response call. “The nature of their work, including repeated exposure to painful and provocative experiences, and erratic sleep schedules, can impose significant risks to their mental health.”

 Thus, repeated exposure to hard circumstances that arise from crises are, by nature, psychically scarring and elevate the risk for future traumatic sequelae. To this end, one may add yet another insidious element of risk to be considered: intrinsic barriers that bar them from seeking help because of stigma, diminished capacity on the job, informal codes of silence, and treatment costs.

As with most exposure to extreme stressors, the elevated risk of things like anxiety, suicidal ideation, 

, and other issues may become more acute. Using the following example, according to research by Stanley et al, “over 50% of firefighter deaths are due to stress and extreme exhaustion.”

 In addition, “the suicidality of firefighters in yet another study revealed markedly greater elevated levels of posttraumatic stress from the profession, while career firefighters reported higher levels of PTSD.”

In turn, according to Bentley et al, an estimated 69% of EMS providers report not having enough recovery time between traumatic incidents.

 As most EMS providers are expected to be on duty for strenuous amounts of time—up to and beyond 24 hours—the duration and intensity of being on-call, engaging in extremely stressful situations, and having little opportunity for rest in between incidents becomes an unbalanced centrifuge of extraordinary circumstances to contend with that can lead to negative outcomes for the individual. Also, EMS workers typically experience greater noted degrees of problematic alcohol and drug use—more so than the general population.

 Like firefighters and police officers, most EMS personnel are reluctant to seek care due to fears of 

, irrational codes of silence, and fear of possible disciplinary action such as being put on leave or desk duty indefinitely.

In a number of studies, first responders showed disturbingly clear outcomes in reference to suicidal ideation. According to the studies, there was a 28% lifetime prevalence rate of feeling as though life was not worth living, 10.4% had more extreme instances of suicidal ideation, and 3.1% revealed past suicide attempts. As well, 37% of the first responders surveyed for 2 primary studies had contemplated suicide nearly 10 times more than the typical American adult. The lifetime prevalence of suicidal ideation among police officers was revealed to be 25% in female officers and 23% for male officers. Suicide attempt rates among police officers ranged from 0.7% to 55% in studies based on extensive literature reviews.

 As well, international analysis concerning suicides among law enforcement and their proportionate mortality ratios (PMRs)—or more so, the ratio of death count for this occupation compared to the expected number of deaths in all occupations combined—appeared significantly higher for all races and sexes combined (all law enforcement PMR equals 169%).

In the wake of the pandemic, the volatility and precarious nature of widescale crises only added to the extreme pressures of first responders. As we begin to uncover more data and evidence from the impact of the pandemic, much more will be learned about just how devastating and long-lasting those impacts have become. In the following section we look at some of the current resources being developed and implemented to address the needs of these professionals.

Part of the issue concerns the gap in research concerning a more comprehensive understanding of first-responder suicides. However, there have been several initiatives underway to help close this gap so that more enhanced resourcing is prevalent. One of the first steps was the construction of an interagency team of researchers composed from the National Highway Traffic Safety Administration (NHTSA) and the CDC’s National Center for Injury Prevention and Control (NCIPC), alongside the National Institute for Occupational Safety and Health (NIOSH).

This aggregated team of researchers is now analyzing and gathering more data around suicides of first responders using data from the most recent 3 years abstracted from the National Violent Death Reporting System (NVDRS). It is the only state-based surveillance system that aggregates data on the various types of violent deaths that include suicides. But why would suicides among first responders be an important data point to explore? Such specific data will actually help provide clarity around the circumstances of suicides among first responders. Although it can only provide a basic understanding of first-responder suicides, the information will be a significant start in the right direction for helping understand how first responders are dealing with extreme stress issues.

However, there are still inherent missing data elements that will need to be addressed to fill the voids in information and data collected. As a result, in 2020 the United States House and Senate had approved funding for this very need known as the Helping Emergency Responders Overcome (HERO) Act.

 This has led to legislation that directly incorporates the CDC to initiate a “public safety officer suicide reporting system” that will help increase and gather important and sometimes nuanced details around such events.

 Such legislation actually opens the door to promote research that will be targeted and directed toward helping first responders understand and hopefully circumvent negative outcomes in the future. These are the first in a series of promising steps.

With the number of mass shootings that have taken place over the years and the experience of first responders arriving at such scenes of mass destruction (which often are compared to war zones), investigators are starting to explore those effects most recently in regard to police, EMTs, and firefighters who attempt to control and manage real-time atrocities. Some studies have revealed distinct derivative similarities regarding military soldiers engaged in war and those who are repeatedly exposed to “warlike” environments, such as those in which first responders must work.

. As part of progressive steps to help first responders navigate the negative effects of the role, more and more clinics are using intensive outpatient programs (IOPs) as an avenue of hope. IOPs provide a more aggressive intervention path for first responders to be treated, which is being proposed and implemented as a possible conduit to regulating trauma symptomology. IOPs are designed to deliver treatment in a more rapid fashion, establishing rigorous psychosocial supports for participants and addressing relapse anchors while enhancing an individual’s coping skills.

 The IOP outpatient setting also provides clinicians the opportunity to work intensively with patients daily for an extended amount of time.

Deborah Beidel, a professor of psychology and medical education at the University of Central Florida, and her colleague, Amie Newins, an assistant professor of psychology at the same institution, are using IOPs as a way to help first responders. Both have been studying the effects of an empirically tested PTSD treatment program utilizing the IOP protocols that were originally developed for treating 

 in trauma management therapy. They have begun modifying this particular treatment over time to adjust for first responders. This program relies on some aspects of exposure therapy that offer a homeopathic opportunity that does not abruptly attempt to challenge fears, but rather, allows the individual the opportunity to gradually explore and diminish feelings in tandem with measured exposure to simulations that might create anxious states.

 As a result, when those first responders treated begin to understand that their reactions and feelings are not applicable to all situations, their fears—for instance, of large-scale benign events like concerts or meetings that may feel similar to a former mass crisis they may have worked in—may begin to lessen. In the results of their intensive outpatient program, Beidel and Newins found that about 70% of first responders who participated and demonstrated signs of PTSD no longer met the criteria after completing the program.

 Such experimental therapies like this one are beginning to show great promise, but more resources like this are still needed.

 Utilizing peer-to-peer sessions as a way to become more dialogic in communicating and processing various traumata is also finding its way into resourcing for first responders. Jeffrey Brown, PsyD, a private practitioner and assistant clinical professor in the Department of Psychiatry at Harvard Medical School, and Beth Meister, EdD, a private practitioner and also a clinical instructor at Harvard Medical School, were at the forefront of the very traumatic Boston Marathon bombing. At the time, both were working on the ground in a makeshift tent to help victims. As first responders at such a crisis-level event, both professionals were asked in interviews following the incident about their own self-care. Here is what they said

Brown: “I’ve been practicing what I preach: focusing on healthy eating, regular exercise, and a routine that includes ample sleep. While I’ve processed the event many times with patients who've brought their own experiences into therapy, I’ve also participated in a team support session and other meetings focused on shared experiences and support for medical team members directly exposed.”

Meister: “I attended a support session for race volunteers 2 weeks after the event, which was helpful. Although I felt no prominent after-effects, I tried to talk to family and friends about the experience when they asked and when I felt it would be helpful for me to talk. My initial anger at the loss of life, injury, destruction, and disruption of a sense of security has been replaced by a feeling of sadness when my mind goes to that day. I have found cognitive strategies helpful in dealing with the memories, just as I teach them to my patients.”

Peer support programs are being implemented both in the United States, Canada, and other countries across the world. They are steadily becoming part of frontline responder programs, such as police officer peer-support programs. One of the main goals of such programs is to help, for instance, police officers handle the exposure of daily stressors and traumatic material by being able to process it with a peer. The emergence of such programs evidenced greater proliferation during the 9/11 terrorist attacks in New York, where “a peer-based assistant program was found to be extremely beneficial in screening for stress-related symptoms amongst police officers, as well as helping them to process the aftermath of exposure to the 9/11 terrorist attacks in New York.”

. The rise of more “state-based programs similar to the program sponsored by the University of Texas Health Science Center at Houston have worked toward designing and implementing short continuing education (CE) virtual training programs specifically for first responders, describing how to recognize mental health and substance use issues in oneself or one’s peers. They have also established a statewide, completely confidential toll-free helpline (1-833-EMS-IN-TX) to provide screening, brief interventions, motivational interviewing, and other resources for first responders. Other states have formed similar programs.

 The hope is that more state agencies begin addressing the mental health needs of first responders as programs like this begin seeing results.

. Finally, another idea comes from the prospect of how such resources are marketed to both first responders and their agencies. Those working as mental health professionals need to find more creative ways to market the potential of counseling and therapy to first responders who might be hesitant to engage otherwise. Therapists can conduct agency trainings for first responders, volunteer for ride-alongs, or participate in community events with police officers, firefighters, and EMTs as first steps to initiating a mental health dialogue. A psychotherapeutic approach where first responders engage in counseling shows promise, with group therapy leading the way forward from the work of researcher Vallejo.17 In this particular study, first responders participated in psychoanalytically oriented group psychotherapy practice twice per week over a 3-month period. Utilizing a group of police officers (

 = 8) from Colombia who had been previously diagnosed with PTSD symptomology, the results of the study showed that posttraumatic stress symptomatology had improved in the trial sample after group psychotherapy was completed.

In a similar study, a randomized clinical trial (

 = 42) of Dutch police officers were sampled and divided into 2 distinct groups: an experimental group and a control group.

 In this study, the experimental group was given a combination of cognitive-behavioral and psychodynamic treatments for 16 weekly sessions. The findings of this study indicate that officers who attended psychotherapy for PTSD produced more significant improvements in altering their PTSD symptomatology compared with officers in the control group.

 Such results are again promising for the future of treatment possibilities for first responders.

The potential challenges faced by first responders have grown exponentially. As the nation counts on the heroic efforts displayed by these individuals daily in their line of work, policies and supplemental resourcing need to be modified to address the ever-burgeoning needs of this group. Some strategies, however, are beginning to take shape and show efficacious promise in fighting the deleterious effects that first responders might internally battle. More data is needed, though, to help understand the areas of opportunity available for continued research. As natural environmental impacts and socioeconomic issues continue to grow, so too must the efforts of research and policy to help sustain and treat the mental health needs of those we count on daily to arrive at and treat the victims of torrential situations. It is no longer a hope but an imperative that we address and help fortify one of the most valued and critical areas of professional avocation—namely, first responders.

is senior director of research strategy, innovation, and development in the College of Doctoral Studies at the 

, in addition to running his own private practice called Inspirethought Counseling.

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https://onlinedegrees.bradley.edu/blog/counseling-for-first-responders/

2. Tiesman HM, Elkins KL, Brown M, et al. Suicides among first responders: a call to action. Centers for Disease Control and Prevention. 

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A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and paramedics.

7. Badge of Life. A study of police suicide 2008-2016. Facebook. 2016. Accessed September 6, 2022. 

https://www.facebook.com/law.enforcement.today/photos/a-study-of-police-suicide-2008-20152015-suicidesa-six-month-sampling-july-throug/10156954081320244/?_rdr

Differences in psychiatric symptoms and barriers to mental health care between volunteer and career firefighters.

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An assessment of depression, anxiety, and stress among nationally certified EMS professionals.

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. October 9, 2020. Accessed September 6, 2022. 

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11. First responders: behavioral health concerns, emergency response, and trauma. SAMHSA. May 2018. Accessed September 6, 2022. 

https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf

12. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. The National Occupational Mortality Surveillance (NOMS): Resource and related links. 2016. Accessed September 6, 2022. 

https://www.cdc.gov/niosh/topics/noms/link.html

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The efficacy of trauma management therapy: a controlled pilot investigation of a three-week intensive outpatient program for combat-related PTSD.

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Randomized clinical trial of brief eclectic psychotherapy for police officers with posttraumatic stress disorder.

As Suicide Prevention Month continues, we take a look at the mental health of a group constantly caring for others: first responders.  

First Responders and Mental Health: When Heroes Need Rescuing

Contingency management (CM) is an effective behavior change technique commonly used to treat substance use disorders (SUDs). CM is one of the most effective behavioral interventions for initiating and maintaining abstinence from most types of commonly used drugs and alcohol.

CM-based treatments for SUD originate in basic behavioral science, namely the operant conditioning literature. Operant conditioning is a type of learning in which behavior is modified or maintained through the consequences it produces. In the context of SUD treatment, CM typically modifies substance use by delivering tangible, positive reinforcers (eg, prizes, vouchers, or monetary reinforcement) in exchange for evidence of the performance of the targeted behavior, such as the submission of a drug-negative urine sample.

Several meta-analyses have found CM to be among the most effective interventions for SUDs, in addition to being effective at promoting treatment retention and medication adherence.

 Moreover, clinical trials have consistently shown that CM is also a cost-effective technique.

 Indeed, studies conducted over the past 30 years have found that CM can be used to promote abstinence from substances including cocaine,

 Further, the aforementioned meta-analyses have also found CM to be effective among highly diverse populations, including pregnant women, adolescents, veterans of war, individuals with serious mental illness, unhoused individuals, those from racial and ethnic minority backgrounds, LGBTQ+ community members, and individuals with HIV and hepatitis. Notably, CM’s consistent effects during treatment across diverse trials may be indicative of CM’s ability to improve long-term treatment outcomes, in light of evidence indicating that longer abstinence during treatment is associated with better long-term treatment outcomes.

Research results suggest that CM must have 3 key ingredients to optimize utility (

). The first is the frequency with which the reinforcer is delivered. Studies suggest that reinforcers should be provided at least twice weekly to enhance the efficacy of CM for SUD management.

 The second ingredient is the immediacy of the reinforcer, or the exchange delay (ie, the shorter the period between the performance of the targeted behavior and delivery of the reinforcer, the greater likelihood of behavioral change).

 The third ingredient is the magnitude of the reinforcer. Although higher-magnitude reinforcers increase the chances of behavior change, they also increase the cost of the CM intervention.

 In at least 1 study, however, it is notable that the average reinforcer actually costs around 40% of the maximum amount.

Although more than 30 years of research evidence collected throughout the world supports the effectiveness of CM, widescale implementation of CM in clinical care has been limited, particularly due to funding and regulatory issues. While reinforcers are commonly used in health care to increase a targeted behavior (eg, gift cards for completing a health assessment), the recommended frequency (twice weekly) and magnitude of CM reinforcers is unique. Historically, funding for CM programs has relied on grants, donations, and funding from federal sources. Currently, the Substance Use and Mental Health Services Administration (SAMHSA) allows grantees to spend up to $75 per patient for CM incentives, although there is limited evidence for the efficacy of this amount.

In addition to funding, the prohibition against the use of reinforcers with Medicaid and Medicare patients through antikickback regulations, has produced a regulatory roadblock. Until recently, it was unclear if CM violated these prohibitions; however, in 2019, the Office of the Inspector General published a document providing guidance on how CM can be used within specific parameters. This has led to increased interest in CM, with state-level implementation underway in Montana, Washington, and California. California received a Medicaid demonstration waiver for the state’s CM pilot, planned to cost more than $50 million, that will include as many as 200 sites. Importantly, these implementations of CM include models that are based on research evidence with funding for reinforcers varying from $325 to $599. These policy changes represent a pivotal modification that may provide a path for nationwide dissemination and implementation of one of the most effective, yet underutilized, interventions for SUDs.

One important challenge for CM implementation includes philosophical and/or moral concerns about “paying substance users” to stop using drugs; another is the belief that the effect may not persist after CM is concluded.

 Implementation research has shown that provider resistance can be allayed with education and training and, more importantly, from observing increased patient engagement and other positive treatment outcomes.

 In fact, after being exposed to CM in the workplace, previously skeptical clinicians noticed that CM had not only improved response to treatment, but also helped improve therapeutic alliances with patients and increased practitioners’ job satisfaction.

 In other words, training and exposing practitioners to CM in the workplace is effective in overturning philosophical and moral concerns.

A burgeoning science is focused on CM implementation, and lessons learned from the Veterans Administration CM program and other state-level implementations can provide guidance to clinicians hoping to implement CM.

 Clinicians must secure funding for an adequate dose (eg, reinforcer monetary value) of CM. Programs must identify the clinical staff members who will implement the program. We have found that nurses, care managers, substance use disorder counselors, and peer support specialists are well positioned to conduct CM, depending on the clinical setting required to effectively deliver CM.

 CM can be integrated into other treatment modalities or delivered separately by nonlicensed staff, as long as the CM provider has been adequately trained in the use of CM, with emphasis on administering urine tests, tracking reinforcer distribution, and maintaining a positive, nonjudgmental tone with patients. Coaching sessions and fidelity monitoring are also important elements to ensure the success of a CM program.

Although evidence indicates that CM is associated with increased attendance, use of reinforcers to increase revenue from billable encounters is prohibited and should be avoided.

Another tip includes using an electronic CM platform system to calculate and monitor reinforcer magnitude and distribution. CM often incorporates a reinforcement schedule that includes escalating reinforcement magnitude as increased durations of abstinence are achieved, as well as loss and recovery of the escalation bonus if and when a return to use and a return to sustained abstinence occur (known as “reset” and “recovery”).

 Although adding these features to a CM program increases the complexity, the therapeutic benefit is well documented and can be executed consistently by using an electronic CM platform. Notably, in various stages of development are a number of phone apps (with accompanying web-based management portals) that could help clinicians, staff, and patients deliver and receive reinforcers more readily; such a system would reduce staff burden for tracking and calculating reinforcer values.

Lastly, CM can represent a paradigm shift for many systems and clinicians who have been required to deliver punitive consequences when substance use occurs. When objective evidence of use is recorded, clinicians focus on strength-based feedback, such as praise for attendance, and encouragement that the next opportunity for reinforcement will occur again in just a few days. They can further engage the patient by discussing what reinforcer they are excited to work toward, orienting the patient toward the reinforcement inherent in CM.

Obtaining initial training and ongoing technical support from CM experts is key to successful implementation and compliance with Office of Inspector General regulations. Several teams have developed extensive training materials that provide best-practice guidance on CM implementation, including didactic trainings, ongoing coaching, and technical support. Driven by the escalating prevalence of methamphetamine use and recent changes in federal policy, the rapid dissemination of CM can bring this feasible, strength-based approach to millions of people affected by stimulant use disorders throughout the United States—if the unique challenges that the method presents can be overcome.

One of the biggest barriers to effectively utilizing CM in real-world treatment situations has been the lack of adequate public policies to finance CM interventions. Convincing policy makers why CM should be more broadly integrated into drug and alcohol use disorder treatment has proven difficult. Nonetheless, CM interventions are being applied in a variety of clinical practices throughout the United States and the United Kingdom.

 For example, CM is being increasingly used as the SUD treatment of choice within the Veterans Administration system in the United States.

 Since 2011, the Veterans Administration has successfully integrated CM into 70 of its intensive outpatient substance abuse treatment clinics for veterans.

 At the same time, the National Health Service in the United Kingdom has also implemented CM into its SUD treatment guidelines, and CM is currently being offered at several treatment facilities.

Investigations of CM dissemination are currently underway, including studies designed to better understand systemic and clinician variables that impede or facilitate CM implementation.

 One of the most important pieces of evidence that has emerged in the CM literature, especially in light of the political challenges, is that CM is a cost-effective treatment option.

 This should lead to greater adoption across the US health care system, which is in desperate search of economically viable alternatives in the face of scarce and diminishing resources.

A final crucial aspect of CM that makes it amenable to several different adaptations and optimizations is that CM produces virtually no adverse events and can be combined with virtually any other form of treatment.

 This makes CM both effective and amenable to ongoing experimentation and optimization efforts across a diverse array of settings and populations that will only be leveraged further by ongoing technological, psychosocial, and pharmacological developments.

is director of the Program of Excellence in Addictions Research; assistant dean, research; and a professor at the Washington State University (WSU) Elson S. Floyd College of Medicine. He is also associate director of research for analytics and discovery at the Providence Medical Research Center and head and principal investigator of the Analytics and Psychopharmacology Laboratory.

is an assistant research professor at WSU Elson S. Floyd College of Medicine.

 is a professor in the Department of Community and Behavioral Health at WSU Elson S. Floyd College of Medicine.

is a professor and vice dean for research at WSU Elson S. Floyd College of Medicine.

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Contingency management is an effective behavior change technique commonly used to treat substance use disorders. 

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