When it comes to hiring people to provide psychological services for first responders, administrators fall into one of three groups. First there are those who don’t really care. Second are those who want to be seen to be providing services for their people, known as the box tickers.
Finally there are those who want to provide the best services possible for their people. I assume I am talking to that latter category. If you are in the first two categories, please change, retire, or resign. You have already done enough damage, we don’t need you doing any more.
The administrator who wants to provide the best care possible for their people is confronted with a number of issues, and while it is impossible to cover all of them fully in a single article, let me outline a few of the things that need to be considered.
First of all, is the question of why you are hiring/ contracting a psychological services professional? Is it to provide counselling services for your people, or provide fit for duty (FFD) assessments, or both? It is only natural for first responders to be reluctant to open up completely with people who will be reporting back to their organizations as to whether or not they are fit for duty. There are some therapists I know who are effective at both roles, but often the demands of one role can come in conflict with the other. One therapist I know who is effective in both roles emphasizes that complete candour with the client is essential. As he puts it “If you are an accountant, and you go to work drunk, I am not going to report you. If you are a cop, and you carry a gun, and go to work drunk, I am going to report you.” Both roles are essential, but if you are asking one person to do both, make sure they are up to the task. Those who are up to the task will be able to articulate the contradictory nature of both roles and will be able to explain how they can navigate the issues with integrity. If not, both roles will be compromised, and their effectiveness will be seriously impaired.
Do I contract with an individual or individuals, or an organization?
Employee assistance programs (EAPs) and Employee and Family assistance programs (EFAPs) are attractive to the already overworked administrator for several reasons. They offer the prospect of dealing with all of the mental health, as well as administrative issues, at lower cost. But the question is, do they? Beware that short-term cost savings may turn out to cause greater long-term, even more expensive, liabilities.
Ideally, EAPs or EFAPs provide a vetted pool of qualified counsellors with some administrative support to facilitate connecting the first responder with the right therapist. Unfortunately, the reality is often far from the ideal. All too often they act like closed union shops, where clinical considerations are secondary to: litigation avoidance, turf protection, revenue stream protection, and the protection of their members. A question to ask yourself is: are big business interests always in line with providing the best quality care?
Not all EAPs/EFAPs are created equal. Some do very good work, others do not. The ones that do tend to be smaller, have carefully selected their counsellors for suitability, pay their counsellors a significantly higher rate than the others, and take pains to make sure the client is matched up with an appropriate counsellor. With larger organizations a significant part of your dollar goes to building and administrative costs, plus executive salaries/bonuses. Their criteria for hiring counsellors has nothing to do with their competence in working with first responders, and often they make no effort to make sure the client counsellor paring is in fact appropriate. When dealing with an organization, ask them how much they pay their therapists per hour. If it is less than $100/hr, you will have an indication of how much of your therapy dollar is going to provide care, and how much of it is going for administration, and executive remuneration. It will also give you an indication as to how they value their therapists, and how significant they find their clients. An organization which pays its therapists $25/hr is taking neither its clients nor its therapists very seriously. While higher pay per hour for therapists is not a guarantee of quality, ask yourself, do you want to be responsible for entrusting the care of those who face the worst that our world has to offer to cut-rate rookies?
Unfortunately, almost every first responder I know who has gone to an EAP/EFAP assigned counsellor has a horror story to tell. As one first responder put it:
“I am trying to find a nice way to tell my therapist that he can’t bring a gun to a knife fight and be upset if he gets a little bloodied after the unprecedented and ample forewarning. And no, we can’t find a way to work together again after the last appointment that was a shit show. Thoughts? SUGGESTION? You really can’t make this shit up.:) I am thankful every day for the gift of finding humour in almost anything. Gets me in trouble a lot ;)”
In another case, a 15 year veteran goes to an EAP assigned counsellor, and as the officer put it:
“In the very first session, they had me in a sandbox!”
Now, what he is referring to is known as a “sand tray” which can be very effective when working with children, and those with a limited emotional vocabulary, but should only be used in particular cases with adults, after a great deal of preparation. In this case, to use it in the very first session was malpractice! Fortunately the officer did not give up on counselling altogether, as so many would, and went on to find the help he needed with another counsellor.
Beware of organizations with conflicting mandates. Those organizations who claim to provide services, while at the same time having a mandate to deny claims/services are in an inherent conflict of interest, and if they are going to err on the side of providing services or denying services, which side do you think they will err on? Also, while malingering can be an issue in certain contexts, what person is going to spend the time and effort to try and get counselling services that they don’t need?
Beware of those organizations which require participants to sign disclosure agreements. This adds yet another impediment to first responders seeking counselling, and also indicates that the organization has priorities other than providing first responders with the best care possible.
Beware of organizations which arbitrarily require clients to switch therapists after x number of sessions. I know one organization which requires clients to switch therapists after five sessions. Not only is there no good clinical reason to do this, all the respected literature I know on the subject indicates that such a practice is not beneficial, but in fact harmful. One has to ask why they would do such a thing. The reasons can be many, but one thing is for certain, providing the best care for their clients is not their top priority.
Beware of the PTSD industry and PTSD profiteers. Unfortunately there are those who are seeking to cash in on the growing awareness of the psychological needs of first responders. Those who are in it primarily for the cash have compromised themselves and their effectiveness at a number of levels. The best and most effective therapists I know who work with first responders, when asked why they do it say things like: “I’m here, because, because of you, my daughters can sleep safely at night.” or “I want you to be healthy, because I cannot do the work you do.”
When it comes to contracting with individual counsellors, just having been a first responder in a previous career does not guarantee that they will be effective working with first responders. As one first responder put it:
“Ok. So after they randomly assigned me a limited English speaking female who was only available on Saturdays, I was allowed by EAP, through _’s work, to pick another one. I chose another female, under duress because they seemed to believe it would be better for me, who was a former federal cx. Thinking she would get it. Turns out, no. All she wanted me to do was to join a women’s group and get rid of the man. Which I refused, as CPTSD is not a women’s issue. How patronizing and ineffective. At least she realized I was intimidating to her and referred me to the new one. I think he has a crush on me and a bit of a foot fetish, but I can deal with that!”
I know therapists who are very effective in working with first responders who were not first responders themselves, and other therapists who have retired from one segment of the first responder community or another who I will not refer clients to.
Another question to consider is; how do they get along with others? This may seem odd, but I know of a number of situations where this is an issue. Do you have an effective chaplaincy? If so, how does the therapist view their role vis-a-vis the chaplain. I know situations where the chaplains and therapists work together very effectively. A first responder can be in conversation with the chaplain, and after a while the chaplain will suggest that they might be better off taking those issues to the therapist, and visa versa. Other situations I know the therapists view their relationship with the chaplaincy as adversarial for various reasons, such as ego, turf protection, or an anti-religious bias. I know situations where chaplains are trusted and the psychologists are not, and for good reasons. When interviewing the prospective therapist, find out how they will get along with the rest of the community, and don’t be shy about asking questions designed to determine their attitude.
If the services in your area are not up to the task, then ask the therapists and service providers “why?” The only way that we will see improvement in the services available is by not letting those claiming to provide the services hide behind their legal status, advertising, and degrees.
If you are tempted to go with an EAP/EFAP because it seems like a good way to get a complex issue out of your overflowing in-basket, be careful. As with anything, don’t accept their claims about the service they can provide until you have been able to examine the work they do more closely. While some EAP/EFAPs do good work, others do not. As I mentioned above, the sad reality is that every first responder I know who has gone to an EAP counsellor has a horror story to tell. At a recent conference the head of a major EAP admitted that their counsellors were capable of working with people in the green and yellow zones, but not the orange or red zones. While his candour was appreciated, most first responders won’t consider counselling before they are already well into the orange zone if not the red zone. When a first responder is in a crisis, and encounters an incompetent therapist, it reinforces their perception that counselling is BS, and adds another impediment toward their seeking the help they need.
One of the issues to consider is, “what happens when something goes wrong?” If an individual counsellor turns out to be unsuitable, the clients can simply stop going to them. If they are a member of an organization, then things get more complicated if not completely untenable. In a context where members are reluctant to admit they are getting counselling in the first place and they feel their confidentiality will be violated, they will find themselves in the position of complaining about the therapist, the organization the therapist is associated with, and the employer for contracting with that organization.
You owe it to your people to do the best you can to make sure that the people or organizations you contract with are in fact able to deliver the goods, and a reasonable amount of customer caution may help avert disasters in the future.