Anna Kornetowska, Krzysztof Piórowski, Małgorzata A. Basińska Cognitive-behavioral therapy in the treatment of Post-Traumatic Stress Disorder (PTSD) in the group of professional firefighters – a review of studies

Artykuł jest dostępny na warunkach międzynarodowej licencji 4.0 (CC BY-NC-ND 4.0).

Introduction

The profession of firefighting involves high exposure to a permanent state of tension and stress. It is associated with responsibility for the life, health, and safety of others. The main factors associated with occupational stress which firefighters are exposed to include the aforementioned life-threatening situations, but also severe injuries, pain and suffering, and the death of those injured in incidents such as accidents, fires or drownings (Popiel, Pragłowska, 2009; Kliszcz, 2012; Zawadzki, Popiel, 2014; Ogińska-Bulik, 2015; Oskwarek, Tokarska-Rodak, 2018; Makara-Studzińska, Wajda, Lizińczyk, 2020; Popiel et al., 2020; Wagner et al., 2021). These situations fit into the definition of trauma (injury), which provides that it is: “a mental or physical state caused by the action of real life-threatening external factors (nature, people), often leading to profound and long-lasting changes in human functioning, which are expressed in somatic and mental disorders” (Zawadzki, Strelau, 2008, p. 47). Participation in a traumatic event, combined with the experience of severe helplessness or a threat to health or life, resulting in difficulties in recovery and functioning preceding the experience can cause the development of Post-Traumatic Stress Disorder (PTSD) (Ogińska-Bulik, 2015; Morrison, 2016; Popiel et al., 2020).

The purpose of this article is to present the current state of research on the effectiveness of Cognitive Behavioral Therapy (CBT) in the treatment of post-traumatic stress disorder. The review of the research focuses on a professional group – firefighters, due to the aforementioned factors related to the characteristics of their work. The effectiveness of cognitive-behavioral techniques in the treatment of PTSD has been confirmed in numerous domestic and foreign studies (Fisher, Etches, 2003; Meyer et al., 2012; Skogstad et al., 2013; Popiel, 2015; Popiel et al., 2020; Im, Kwak, 2021). Studies are also available on the effectiveness of pharmacotherapy, relaxation techniques or exposure in the treatment of PTSD (Popiel, 2015; Ash-Maheux et al., 2018).

I. Post-traumatic stress disorder (PTSD) F 43.1 – epidemiology and characteristics

The first descriptions of disorders caused by very difficult and frightening experiences can be found in ancient writers. In Homer’s Odyssey, for example, in the description of recurring intrusive scenes playing out in the mind of Odysseus. Shakespeare, on the other hand, in Henry IV, described that after returning from the war, the main character experienced a loss of former interests, a search for solitude, excessive agitation, and reliving images from battle in his dreams (Dudek, 2003; Makara-Studzińska, Partyka, Ziemecki, 2012).

A significant increase of interest in psychological disorders caused by traumatic experiences and the development of research in this field occurred during World War I. At the time, it was called “artillery shock.” The subsequent experience, World War II provided clear evidence that war stress was the cause of many psychological, somatic and behavioral disorders (Friedman, Terence, Resick, 2010; Makara-Studzińska, Partyka, Ziemecki, 2012; Jakubiak, 2021). In the 1960s and 1970s, there was a renewed interest in the issue. This was due to the Vietnam War and the huge number of veterans who began to reveal various pathologies upon their return home. These included aggressive behavior, suicide, depression, alcohol, or drug abuse, among others. It also happened that veterans engaged in criminal activity. They very often manifested psychosomatic disorders, suffered from persistent anxiety and nightmarish dreams, and isolated themselves. Moreover, they presented strong emotional inhibition and an inability to talk about their experiences (Dudek, 2003; Baird et al., 2018; Rubin et al., 2020; Livingston et al., 2021). Subsequent observations of people who have experienced traumatic accidents, acts of violence, or disasters have shown that they manifest very similar symptoms to those affected by war (Dudek, 2003; Makara-Studzińska, Partyka, Ziemecki, 2012; Baird et al., 2018; Fekadu et al., 2019; Jakubiak, 2021; Livingston et al., 2021).

Years of research and accumulated material on post-traumatic stress resulted, in 1980, in the introduction of a new disease entity, post-traumatic stress disorder (PTSD), into the Diagnostic and Statistical Manual (DSM-3). The term was then used to describe an anxiety disorder caused by an unusual, extremely stressful event. It was thus recognized that a persistent disorder in healthy people could be caused by an external factor, such as an extremely unpleasant, difficult, and stressful experience (Rosen et al., 2010; Ogińska-Bulik, 2015; Morrison, 2016).

The definition of PTSD has evolved over the years. Among other things, an important criterion relating to the duration of symptoms has been added to it. A significant distinction was made, stating that a shock reaction occurring immediately after a traumatic event does not yet constitute post-traumatic stress disorder. It is treated as a natural reflex for human adaptation to the situation. By using the criterion of the time of onset and duration of the reaction to the experience, Acute Stress Reaction (ASR), Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) were distinguished. Symptoms of Acute Stress Reaction can appear “immediately” – up to an hour after exposure to a stressor. They can involve a mental or physical reaction of exceptional severity and usually fade gradually, up to 48hours after the event. When symptoms do not subside after this time, the period when acute stress disorder can be diagnosed begins. It lasts at least two days and can occur within four consecutive weeks of the traumatic event. ASD can be diagnosed in people who have been involved in a traumatic event and manifest PTSD symptoms that last less than a month. Symptoms lasting longer than a month, on the other hand, meet the time criterion for the diagnosis of post-traumatic stress disorder (Odachowska, 2013; Zawadzki, Popiel, 2014; Morrison, 2016; Pietkiewicz, Tomalski, 2018; Reisick, Monson, Chard, 2019; Popiel et al., 2020). The distribution of the above-described disorders with time dependence is shown in the figure below.

Figure 1. Occurrence of types of post-stress disorders over time

Source: own study.

The diagnostic criteria for making a diagnosis of PTSD (F 43.1), according to the ICD-10 (2000) classification, are as follows:

A. The patient has been exposed to a stressful event or situation (impacting for a short or long time) with extremely threatening or catastrophic characteristics that would cause penetrating suffering in almost anyone;

B. There is a persistent recollection or “re-living” of the stressor in the form of disruptive “flashes”, vivid memories, or recurring dreams, or in the form of feeling worse when confronted with circumstances reminiscent of or related to the stressor;

C. The patient currently avoids or prefers to avoid circumstances reminiscent of or related to the stressor, which was not present prior to exposure to the stressor;

D. Any of the following is present:

1)  Partial or complete inability to recall certain important circumstances of contact with the stressor,

(2)  Persistent symptoms of increased psychological sensitivity and a state of arousal (not present prior to contact with the stressor), in the form of any of the following:

(a)  difficulty falling asleep or sustaining sleep,
(b)  irritability or outbursts of anger,
(c)  difficulty concentrating,
(d)  excessive alertness,
(e)  increased surprise reaction;

E. All of criteria B, C and D were met either within 6 months of the stressful event or from the end of the period of exposure to the stressor (for some purposes, onset delayed by more than 6 months can also be included, but this should be made clear) (Pużyński, Wciórka, 2000, pp. 127–128).

This is an aspect that the CPTSD diagnosis has been expanded. In individuals who have experienced more than one traumatic event, additional symptoms can be observed, related to, among other things, disturbances in affect regulation, impulsivity, attention and awareness, as well as distorted self-perception, difficulties in relationships with others or somatization and even suicidal behavior (Wilson, Guliani, Boichev, 2016; Gerber et al., 2018; Hendriks et al., 2018; Lanza, Roysircar, Rodgers, 2018; Stanley et al., 2018; WHO, 2018; Krawczyk, Święcicki, 2020).

One of the main factors contributing to the development of post-traumatic stress reactions in firefighters is at least the aforementioned exposure to potentially traumatic events. This is an aspect inherent, so to speak, in the characteristics of this profession. Most survivors of a traumatic event can expect not to be exposed to a similar trauma again during their recovery. Firefighters, on the other hand, cannot count on this natural period of calm that promotes recovery. While doing their job, they are aware that another traumatic event is only a matter of time (Ogińska-Bulik, Kaflik-Pieróg, 2006; Ogińska-Bulik, 2015; Boyd et al., 2018; Juczyński, Ogińska-Bulik, 2018; Straud et al., 2018; Popiel et al., 2020; Langtry et al., 2021). The higher the level of traumatic stress symptoms, the lower the satisfaction with service, the greater the readiness to leave service, the greater the physical and mental fatigue, and the worse the functioning in private life (Lee et al., 2014; McCanlies et al., 2014; Katsavouni et al., 2015; Onyedire et al., 2017; Theleritis et al., 2020; Mohamad, Ali, Makhbul, 2021).

There are few studies focusing on the relationship between traumatic experience and functioning in professional roles among Polish firefighters. The Institute of Occupational Medicine in Lodz, Poland, conducted a study in 2000 in a group of 974 firefighters to investigate the prevalence of PTSD in this group. It turned out that participation in service-related traumatic events was common. The vast majority, 86%, of the firefighters surveyed said they had participated in such an event, and 79% of them estimated that they had more than once. Half of the incidents described by the respondents were related to fires, 23% were related to accidents in action, while the rest of the situations involved, for example, accidents, the extraction of victims after a gas explosion, people who sank or died many days ago. The dominant emotion they experienced was compassion, but helplessness and fear were also disturbingly common. Emotions most associated with the presence of PTSD symptoms. A group representing 4.9% of surveyed firefighters who manifested symptoms from the PTSD spectrum that lasted or have lasted at least a month was also revealed (Koniarek, Dudek, 2007).

In 2018, another large study was conducted in the population of Polish fire-fighters, which resulted in the construction of a prevention program for this professional group. Tailored to the needs and expectations of this professional group, the program has proven to be a very valuable tool in preventing the negative effects of the occupational stress experienced. It is especially important for firefighters with the shortest length of service, as it shows how to deal constructively with occupational stresses (Popiel et al., 2020).

II. Therapeutic recommendations

The National Institute for Health and Care Excellence (NICE) guidelines, dated December 2018, include recommendations for the treatment of patients diagnosed with PTSD in sections 1.6.16–23. The results of the studies cited by the organization showed the effectiveness of individual therapy with a cognitivebe-havioral approach. These included trauma-focused therapy, cognitive processing therapy, cognitive therapy and prolonged exposure therapy implemented by a CBT psychotherapist. All the methods mentioned are widely described in the literature and based on approved protocols. In addition to this, the effectiveness of the Eye Movement Desensitization and Reprocessing (EMDR) method of reprocessing and desensitization has also been pointed out – but with limitations that mainly apply to patients with war experiences (Gulcz, Polak, 2002; Popiel, 2015; Ash-Maheux et al., 2018; NICE, 2018, 2020; Mavranezouli et al., 2020). The NICE recommendations also include indications that CBT therapy should last about 12sessions (with the possibility of extension for patients experiencing multiple trauma). A very important aspect of it is psychoeducation, which has been given special emphasis. Within the framework of the meetings, issues related to the trauma symptoms experienced and coping mechanisms (arousal, recurring memories, protective mechanisms) are addressed. In the therapy process, it is important to work through and process the traumatic memories and the emotions associated with it, especially shame, guilt or loss, and anger. Another important part of the therapeutic process is the restructuring of cognitive distortions related to the trauma and working on avoidance and regaining a sense of control over one’s own life (in spheres such as work, relationships with others). As part of the closure of the therapeutic process, support sessions are planned that also take into account moments related to anniversaries of trauma (NICE, 2018, 2020; Mavranezouli et al., 2020; Allen et al., 2021).

In the 2017 recommendations of the American Psychological Association (APA), one can find convergent indications for PTSD therapy. Among the therapeutic approaches listed are cognitive-behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT) and prolonged exposure (PE) therapy. In addition, short-term eclectic psychotherapy (BEP), eye movement desensitization therapy (EMDR) and narrative exposure therapy (NET) have also been described (APA, 2017; Watkins, Sprang, Rothbaum, 2018; Bufka, Wright, Halfond, 2020).

III. Cognitive-behavioral approach in the treatment of PTSD

The most commonly described treatment programs for PSTD that can be found in the cognitive-behavioral therapy literature are Cognitive Therapy (CT) by Ehlers and Clark (2000), Prolonged Exposure (PE) Therapy by Foa and colleagues (1998, 2020), and Cognitive Processing Therapy (CPT) by Resick (2021) and colleagues (2019).

Eye Movement Desensitization with Reprocessing (EMDR), according to Shapiro (1995, 2002) also has a growing number of proponents. The aforementioned techniques are also found in the aforementioned guidelines of international organizations setting standards for the treatment of PTSD (APA, 2017; NICE, 2018). They are also recommended by the International Society of Traumatic Stress Studies, International Society of Traumatic Stress Studies (ISTSS, 2019).

Cognitive Therapy (CT) for PTSD Ehlers and Clark (2000)

The PTSD therapy model presented by Ehlers and Clark (2000) addresses specifically the deficits in memory of the traumatic event. The authors emphasize that processing is based on sensory stimuli rather than the meaning of the situation in these situations, and the patient lacks his own perspective. The aforementioned deficits and the dissociation experienced prevent the integration of the event as a sequence of one’s own life story, which is the goal of therapy.

The cognitive model of PTSD (Figure 2) highlights the specificity of cognitive processing of information related to the traumatic event. Ehlers and Clark (2000) underline that the mere recall of the memory of a traumatic event is only a pretext for modifying the dysfunctional beliefs, attitudes revealed during the exposure. The primary factor responsible for the persistence of PTSD is a sense of constant threat.

Figure 2.Cognitive model of PTSD development

Source: own elaboration based on: Ehlers, Clark (2000, s. 321)

It is formed as a result of dysfunctional evaluations – beliefs about the traumatic event and its impact on the individual’s subsequent life, evaluations of oneself, one’s attitude during the trauma and its impact on subsequent life, and evaluations of the PTSD symptoms themselves. Feeling threatened, experiencing anxiety, and increasing symptoms of vegetative arousal leads to the use of a series of strategies having the qualities of cognitive avoidance (thought avoidance) and/or behavioral avoidance (avoidance of places, situations associated with the trauma).

The main methods used during therapy according to this model include modification of beliefs using classical cognitive restructuring and imaginal techniques. Exposure-related behavioral techniques are also incorporated during the therapeutic process. In working with the client in the initial phase, the most important thing is to safely establish a relationship and build trust in the therapist-patient relationship. Subsequent stages deal with reducing fragmentation of trauma memories, modifying misjudgments and PTSD symptoms, and reducing dysfunctional coping symptoms (Ehlers, Clark, 2000; Ehlers et al., 2005; Kleim et al., 2013; Juczyński, Ogińska-Bulik, 2018; Köhler, Goebel, Pedersen, 2019; Wild et al., 2020; Ehlers, Wild, 2021).

Figure 3. A model of the processes leading to the development of PTSD

Source: own elaboration based on: Foa, Rothbaum (1998).

The protocol created by Foa and colleagues (2018, 2020), describes the next steps in working with a patient, which begin with more data from an interview about the event and psychoeducation about PTSD itself and its treatment. Another element of therapeutic work is learning breathing techniques (diaphragmatic, square and others) and introducing tools for monitoring well-being. The primary tool is the Subjective Units of Discomfort Scale (SUDS), created for this protocol. However, other scales monitoring PTSD or depression, for example, are also recommended, depending on other symptoms. Another important moment of working with the patient refers to the establishment a hierarchy of in vivo exposures, which the patient carries out as part of their own work between sessions. During session with the therapist, these are discussed, and the proper work refers to the application of the imaginal exposure technique with trauma processing. Therapy ends when the patient scores low on the SUSD scale, their functioning improves, and therapy goals are achieved. Then there comes a moment of summarizing of the progress made by the patient and a discussion of the new competencies he has learned during therapy. Finally, the patient is given instructions for post-therapy exercises as part of relapse prevention. Sessions according to this protocol last 90minutes and are recorded. Listening to them is one of the main tasks in the patient’s own work between sessions (Foa, Hembree, Rothbaum, 2020).

Cognitive Processing Therapy (CPT) for PTSD Resick (2021) and colleagues (2019)

Resick (2021) and colleagues (2019) based their concept of PTSD therapy primarily on direct therapeutic exposure, referring to the information processing model. CPT therapy focuses on the cognitive processing of information, explaining the reaction to the traumatic event and describing the meaning the patient gave to the experience. An important step in working with the patient here, as in earlier protocols, is psychoeducation about emotions. Issues related to the role of emotions, their impact on our functioning and perception of ourselves, the world and other people are discussed. In the therapeutic process, the patient works on his beliefs regarding, among other things, guilt, and responsibility for the traumatic event. These emotions are analyzed in the context of other dysfunctional beliefs that have been reinforced by the traumatic experience (Popiel, 2014; Resick, Monson, Chard, 2019).

The author, along with colleagues (2019), created a protocol for therapeutic management that includes 12 steps to follow with the patient, during 12 sessions. At the first session, the patient is introduced to the method, a history of the traumatic event is collected, and the role of thoughts, emotions in human functioning is discussed. The next two meetings deal with learning about the blind spots of the event. The impact of the trauma is discussed with the patient and the work related to the analysis of thoughts, behavior, and emotions (ABC model) is expanded. This is followed by therapeutic work related to processing the initial event (session 4and 5) to then move on to work on changing the patient’s cognitive patterns (session 6 and 7). The topic of safety, trust and a sense of control is the leading issue in sessions 9 and 10 and it is continued with issues related to respect, closeness and future perspective in sessions 11 and 12. At the end of the therapeutic process, issues related to sustaining the effects achieved in therapy are also discussed and follow-up meetings are scheduled, at a monthly interval. Patients can also benefit from group meetings. There are two variants of conducting therapy in this trend, which refer to the inclusion, or not, in the therapy process of written accounts of the traumatic event. This therapy can be conducted in both individual and group formats. For the protocol outlined above, patient work sheets were also created, which are discussed in detail in the book by the authors of this method (Resick, Monson, Chard, 2019). It is worth noting that this method has been found useful and effective in the context of online pandemic work with patients who experience PTSD (Moring et al., 2020).

Eye movement desensitization with reprocessing (EMDR) according to Shapiro (1995, 2002)

This is a therapy based on the adaptive information processing (AIP) model and experiential-exposure techniques (Shapiro, 1995, 2001; Shapiro, Maxfield, 2002). This method is still controversial in the therapeutic world, having both its supporters and opponents (Pasternak, 2006). The fact is that it is not based on a specific psychological, neurological, or other theory (Pasternak, 2006; Jeśka, 2012). The assumption of the author of this technique is based on the thesis that the information processing system is stopped by the symptoms of experienced PTSD. In this method, eye movement is an element that unlocks this process, which is most controversial among therapists due to insufficient scientific evidence supporting the effectiveness of this movement (Shapiro, Maxfield, 2002; Natcha, Daiches, 2016).

During an EMDR therapy session, techniques are used that involve rapidly following the therapist’s finger with the eyes or receiving rapid alternating auditory or tactile stimuli. The patient’s task at the time of stimulation is to recall the traumatic event in memory. EMDR therapy aims to completely process the traumatic experience and introduce a new, adaptive one. The process follows three phases: memory of the trauma, current problems, and future actions. The protocol involves 8 phases to be completed with the patient. The first one deals with the past and treatment planning, to move sequentially into the preparation, evaluation, and processing phases. This is followed sequentially by work on desensitization, installation and “body scanning.” Once these steps are completed, closure and reevaluation of the experience takes place. The length of therapy depends on the type of trauma and the patient’s history. Important elements in this method include exposure to the experienced event, as in the previously described methods (recall of images, emotions, cognitive restructuring of beliefs about oneself, the world, and other people) (Pasternak, 2006; Solomon, Shapiro, 2008; Jeśka, 2012; Natcha, Daiches, 2016).

IV. Review of existing research on the effectiveness of cognitive-behavioral therapy in the treatment of PTSD in the professional group of firefighters

The presented analysis includes only the results of scientific research that were accessed via the EBSCO database. This allowed a detailed analysis of their organization and the procedure of the subsequent stages of the studies described. The search phrase “CBT in firefighters PTSD/ cognitive-behavioral therapy for firefighters with PTSD” in the EBSCO database was matched by very few articles after discarding non-trivial results. Hence, the decision was made to replace the word firefighter, in English, with first responder. This phrase refers to a general group of emergency services and is very often used as a substitute in foreign literature. An effort was made to be vigilant and check whether firefighters were actually included in the study group of emergency service members. This expanded the pool of the collected data to 11 studies (Table 1). This quantity showed that despite such a widespread knowledge of the frequency of PTSD among fire-fighters, there has been little long-term research on its treatment methods in this occupational group.

Below, in tabular form, there is an overview of the studies obtained. The table includes information about the author of the study, the year in which the results were published, the country in which they were conducted, and the methods used.

Conclusions

As the findings presented above show, cognitive-behavioral therapy is effective in treating post-traumatic stress symptoms in the occupational group of fire-fighters. However, there is a great need for further exploration of this issue in order to obtain more data.

It is also worth remembering that experiencing traumatic events is not always associated with the development of PTSD. It also happens that such situations are followed by Post Traumatic Growth (PTG). This is an important phenomenon in the perspective of the service performed by firefighters. It gives hope for recovery and even development or reevaluation of one’s life. It is also an invaluable experience for other firefighters who witness their colleague’s recovery. It is a clear signal to pay attention to each other, their own mental and physical condition and care for their well-being. All these activities will contribute to greater job satisfaction and, more importantly, translate into life satisfaction as well (Ogińska-Bulik, 2015; Juczyński, Ogińska-Bulik, 2018).

Table 1. Overview of studies on the effectiveness of CBT in PSTD among firefighters

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