Mental health help-seeking experiences and service use among Australian first responders

ABSTRACT

Objective: This study aimed to determine patterns of help-seeking among first responders for conditions such as post-traumatic stress disorder (PTSD) and psychological distress.

Method: Data from Answering the Call, the Australian national survey of the mental health and wellbeing of police and emergency services, was analysed to determine mental health help-seeking associations, as well as to measure patterns of service use. This encompassed 14,868 employees across the ambulance, fire and rescue, police, and state emergency services sectors.

Results: Over half of employees needing help for a mental health issue neither sought nor received help. First responders with severe mental distress who delayed seeking help reported that they needed a lot more help than they received. Poor help-seeking behaviour and experiences were found to be associated with high levels of PTSD and psychological distress, low levels of mental health literacy, and career concerns. No significant differences were found between the sectors with all employees exhibiting high levels of poor help-seeking behaviour. For organisation-sourced services and programmes, usage levels and perceptions of usefulness were consistently low.

Conclusions: Findings support the importance of early help-seeking amongst first responders with emerging mental health conditions. All sectors exhibited sub-optimal help-seeking behaviour and experiences. The problems go beyond the organisational structures, policies and programmes of any individual sector and are likely to be systemic. While all organisations provide mental health and wellbeing programmes and services, they are either not well taken-up, or are not considered sufficiently useful by the people they are designed to help.

KEY POINTS

What is already known about this topic:

1. First responders are known to be at high risk of developing mental health conditions.

2. The rate of PTSD in Australian first responders is twice that in the general population.

3. Early and appropriate treatment is essential in preventing mental health conditions from worsening or becoming chronic.

What this study adds:

1. This study shows consistently high levels of sub-optimal help-seeking behaviour and experiences among Australian emergency services employees across all sectors.

2. Over half of emergency services employees needing help for a mental health issue neither sought nor received help.

3. Usage and perceived usefulness of organisational mental health and wellbeing programs/services are very low.

KEYWORDS:

• Mental health
• first responders
• help-seeking

1. Introduction

The challenge of protecting those who protect us and ensuring they maintain healthy levels of psychological wellbeing is paramount, both from a social conscience and an economic perspective. However, first responders (ambulance, fire and rescue, police, and state emergency services personnel) are not a homogeneous group of people and their experiences of trauma on the job and their responses to these traumas are equally diverse, with some developing serious mental health outcomes, while others do not (Berger et al., 2012; Jones, 2017). Systematic reviews of factors associated with psychological distress amongst first responders (e.g., Brooks et al., 2016) demonstrate that there is no simple combination of factors which equates to an inevitable outcome of mental ill health. However, one factor which is critical to positive mental health outcomes when mental health problems occur is the need to receive support or treatment which is timely, relevant, and sufficient (Bacharach & Bamberger, 2007). A delay in help-seeking or receiving insufficient help can contribute to significant time off work and a delayed recovery which in turn can lead to long-term harm (Hom et al., 2017).

Apart from funded access to external mental health service providers such as psychologists, psychiatrists and counsellors, all Australian emergency services organisations offer their staff in-house mental health and wellbeing programmes and services (The Commonwealth of Australia, Senate Education and Employment References Committee, 2019). These programmes may include formal or informal debriefings, Employee Assistance Programmes (EAP) and other psychological or psychiatric services, peer support anti-bullying training, training in mental and physical health, mental health first aid, chaplaincy services, and annual mental health check-ups. Similar programmes are offered by emergency services organisations in other countries (Royal Canadian Mounted Police (RCMP), 2020). Nevertheless, it is a challenge for organisations to understand which mental health and wellbeing programmes and services will work the best, and most cost-effectively, for their workforce.

Many programmes and services are underpinned by strategies and frameworks which have been developed specifically to aid emergency services organisations in supporting the mental health and wellbeing of their workforces (Beyond Blue Ltd, 2017; EAP Assist, 2017; NSW Government, 2016; The Council of Ambulance Authorities Inc, 2017). While these strategies are evidence-based and well-intentioned, it is apparent from both a recent Senate Inquiry into the mental health of first responders (The Commonwealth of Australia, Senate Education and Employment References Committee, 2019), and research findings (Beyond Blue Ltd, 2018; Harvey et al., 2016), that these are not always successful, with levels of post-traumatic stress disorder (PTSD) amongst this population estimated at around twice that of the general adult population (Berger et al., 2012; Beyond Blue Ltd, 2018) and deaths from intentional self-harm currently averaging 12 a year (NCIS, 2019). The Senate Inquiry Committee concluded that more could be done to reduce the severity and chronicity of PTSD and distress, and ideally, to prevent mental ill health from occurring at all (The Commonwealth of Australia, Senate Education and Employment References Committee, 2019). They recommended that more needs to be known about the existing programmes and services offered by agencies and by their external providers, and whether these are meeting the needs of their personnel. This study sought to address that knowledge gap by examining the factors associated with the use and usefulness of these programmes and services from the perspective of those employees using them.

The Australian National Survey of Mental Health and Wellbeing found that in the general population less than half of those with a diagnosable disorder access services (Meadows & Burgess, 2009). The Australian National Mental Health Services Planning Framework has set as benchmarks for service use that 50% of those with mild disorders, 80% of those with moderate disorders, and 100% of those with severe disorders should receive services (Allison et al., 2020). Based on the high rates of PTSD in first responders, we hypothesised that their rates of help-seeking would also be lower than recommended levels.

Previously, research into this subject in an Australian context has been limited by a lack of data encompassing multiple sectors and few studies regarding first responders’ mental health treatment behaviours and experiences (Shakespeare-Finch & Scully, 2005; Varker et al., 2018). Answering the Call, the national survey of the mental health and wellbeing of police and emergency services (Beyond Blue Ltd, 2018), recently collected detailed data on mental health help-seeking behaviour and service use in the largest study of its type ever undertaken, and was a world-first in terms of its four sector scope. To test our hypothesis we used data from this survey related to first responders (excluding volunteers) with PTSD, psychological distress and suicidal ideation to examine a range of help-seeking behaviour and service use.

2. Method

2.1. Procedures and participants

Data were drawn from Answering the Call, the national survey of the mental health and wellbeing of police and emergency services. The survey methodology has been described in detail elsewhere (Beyond Blue Ltd, 2018). In brief, the survey was conducted from October 2017 to March 2018, with approval obtained from the Human Research Ethics Committee, The University of Western Australia. Participants were selected using stratified random sampling (or censuses for small organisations) of 33 ambulance, fire and rescue, police, and state emergency services organisations across Australia. Stratification variables included age, sex, length of service, and rank. The survey was voluntary and online, with hard copy questionnaires available on request.

2.2. Measures

2.2.1. Demographic and work characteristics

Demographic and work characteristics included in this analysis are sector, sex, age group, and rank (Supplementary Table 1).

2.2.2. Help -seeking

Help-seeking behaviour and adequacy of support was assessed by asking respondents about their perceived need for help in the past 12 months. Responses included: 1- No, I did not have any emotional or mental health issues, 2- No, I had emotional or mental health issues, but did not need any help or support, 3- Yes. If they sought support or treatment, they were asked about the timing of their help seeking. Possible responses included: 1- Less than 1 month, 2- Within 1-3 months, 3- Within 4-12 months, 4- More than 1 year. If they received help, they were asked if they had received sufficient help. Possible responses included: 1- No, I needed a little more help, 2- No, I needed a lot more help, 3- Yes.

2.2.3. Service use

Two types of service use were measured. The first included general (external) services which had been accessed in the past 12 months for emotional or mental health issues (Supplementary Table 2) and whether the service had been sourced (i.e., funded) through the respondent’s organisation. The second included 12-month use of in-house programmes and courses which are related to improving mental health and wellbeing (Supplementary Table 3). For each programme or course used, they were asked how useful it was. Responses were measured with a Likert scale (1- No use at all, 3- Moderately useful, 5- Extremely useful).

2.2.4. Mental health conditions

Psychological Distress was measured using the Kessler-10 (K10) to assess symptoms of depression and anxiety experienced in the past 4 weeks. The measure consists of 10-items measuring emotional states on a 5-point Likert scale (1 = None of the time, 5 = All of the time), with higher psychological distress representing a greater likelihood of experiencing a mental health condition. The scale has been shown to perform well in screening for mood and anxiety disorders (Furukawa et al., 2003) and had excellent internal consistency (α = 0.92).

Probable PTSD and severity was assessed using an adaptation of the PCL-5 PTSD screening scale (Blevins et al., 2015). The scale was modified to be more appropriate to the emergency services sector where cumulative trauma rather than a single incident may be common, and to assess impairment of functioning and severity. The PCL-5 screening scale has shown to have strong psychometric properties (Blevins et al., 2015), and the adapted version had good internal consistency in the survey (α = 0.89). The descriptor “probable PTSD” was used to distinguish this measure from the PCL-5, however, in this paper, it is described as PTSD.

Suicidal ideation was measured through the use of six questions which asked whether participants had seriously thought about taking their own life, planned to take their life, or attempted suicide, both ever and in the last 12 months. Respondents were given the option of “prefer not to say” for each question, and were not asked subsequent questions after the first time they chose this option. Approximately 7.5% chose this option at the first question, therefore, the estimates of suicidal ideation from this data likely underestimate the true prevalence of suicidal thoughts and behaviours for this population.

2.3. Data analysis

Weighted frequency tables were created using the surveyfreq procedure with the weight option included using SAS Version 9.4. Confidence intervals were calculated using the method of linearisation in Taylor Series (Wolter, 1985). Univariate associations were calculated between the perceived need for support/treatment, service use and usefulness with each type of mental health condition, sex, age group, rank, and sector. Tests of association between help-seeking categories and sector, age group, sex, and rank were calculated using the Rao-Scott chi-squared test (Rao & Scott, 1981).

3. Results

The overall response rate was 22% or 14,868 employees (see Supplementary Table 1). Analysis of the sample found that it was largely representative based on comparisons with other sources listing demographic information about the emergency services sector, such as the Australian Productivity Commission’s Report on Government Services (Productivity Commission, 2018) and the 2016 Australian Census of Population and Housing. The sample had a slightly higher proportion of females (e.g., 47.9% females compared to 43.6% in the Census) and older employees (e.g., 16.6% 55 years or older, compared to 15.3% in the Census). These and other minor differences were taken into account during weighting.

At least three out of every five employees felt they needed help in the previous 12 months (Supplementary material, Table 4). However, less than half actually sought help. Associations were observed between slightly lower reported levels of help-seeking and those aged under 35 years, aged 55 years or older (age group χ² = 17.0, df = 6, p = 0.009), and males (sex χ² = 22.5, df = 2, p = 0.001). There were no associations between patterns of need for help among the sectors (χ² = 9.2, df = 6, p = 0.161), or rank (χ² = 4.1, df = 6, p = 0.659).

Levels of perceived need for help for emotional or mental health issues within the previous 12 months increased with the level of severity of PTSD or psychological distress (Table 1). A large proportion (71.9%) of those with severe PTSD sought and received help compared with only 46.5% of those with sub-threshold PTSD symptoms. There were a concerning number of people exhibiting symptoms of serious mental health conditions who recognized they had a problem, but who did not think they needed any help (5.9% with severe PTSD; 27.9% with high and 18.5% with very high psychological distress; and 15.5% who experienced suicide ideation in the previous 12 months).

While the largest proportions of those with a mental health condition sought treatment within a month, nearly a quarter of those with severe PTSD (24.6%), very high psychological distress (22.8%) or suicidal ideation (24.1) delayed seeking treatment for over a year (Table 2).

Table 1. Perceived need for help, by indicators of mental health need

Mental health condition		(n)	Did not have a problem	Did not need help	Did not seek or receive help (†)	Sought help
PTSD –
Sub-threshold	(%)	1570	9.3	24.5	19.7	46.5
	(95% CI)		(7.3 – 11.3)	(21.7 – 27.3)	(17.1 – 22.4)	(43.3 – 49.7)
Mild	(%)	612	4.0	23.7	22.4	50.0
	(95% CI)		(1.8 – 6.2)	(19.3 – 28.1)	(18.2 – 26.5)	(44.8 – 55.2)
Moderate	(%)	369	2.2	16.9	21.7	59.2
	(95% CI)		(0.3 – 4.1)	(11.7 – 22.1)	(16.0 – 27.4)	(52.5 – 65.9)
Severe	(%)	407	0.2	5.9	22.0	71.9
	(95% CI)		(0.0 – 0.5)	(3.2 – 8.6)	(16.8 – 27.2)	(66.3 – 77.5)
Psychological distress –
High	(%)	3097	12.0	27.9	19.0	41.1
	(95% CI)		(10.4 – 13.5)	(25.8 – 30.0)	(17.2 – 20.9)	(38.8 – 43.3)
Very high	(%)	1314	2.4	18.3	21.8	57.6
	(95% CI)		(1.3 – 3.4)	(15.5 – 21.1)	(18.9 – 24.7)	(54.0 – 61.1)
Suicidal ideation in previous 12 months
Yes	(%)	802	4.9	15.5	19.4	60.1
	(95% CI)		(2.7 – 7.2)	(12.4 – 18.7)	(15.8 – 23.0)	(55.7- 64.6)

† Includes those who did not seek support or treatment and those who sought help but did not receive any support or treatment. Of this group 88% did not seek help, and 12% sought help but did not receive it.

Table 2. Employees who sought support or treatment for an emotional or mental health issue: length of time taken to seek support or treatment, by indicators of mental health need

Mental health condition		How soon did you seek out support or treatment the first time you felt you needed it?
		< 1 month	1-3 months	4-12 months	> 1 year
PTSD –
Sub-threshold	(%)	42.9	18.4	20.1	18.6
	(95% CI)	(38.3 – 47.5)	(14.8 – 22.0)	(16.3 – 23.8)	(14.9 – 22.2)
Mild	(%)	33.1	18.6	23.1	25.2
	(95% CI)	(26.2 – 40.0)	(12.2 – 25.0)	(17.0 – 29.2)	(18.6 – 31.8)
Moderate	(%)	36.6	17.9	21.8	23.6
	(95% CI)	(28.1 – 45.2)	(11.2 – 24.6)	(14.4 – 29.3)	(16.4 – 30.8)
Severe	(%)	37.0	16.4	22.0	24.6
	(95% CI)	(29.6 – 44.4)	(10.9 – 21.9)	(15.6 – 28.3)	(18.2 – 30.9)
Psychological distress –
High	(%)	40.3	17.4	22.4	19.9
	(95% CI)	(36.8 – 43.8)	(14.6 – 20.1)	(19.4 – 25.4)	(17.0 – 22.8)
Very high	(%)	37.9	19.0	20.3	22.8
	(95% CI)	(33.2 – 42.6)	(15.1 – 22.9)	(16.4 – 24.1)	(18.9 – 26.8)
Suicidal ideation in past 12 months –
Yes	(%)	34.4	14.7	26.8	24.1
	(95% CI)	(28.8 – 40.0)	(10.4 – 18.9)	(21.3 – 32.3)	(19.0 – 29.2)
All employees who sought support or treatment for an emotional or mental health issue –
All employees	(%)	46.4	17.5	19.0	17.2
	(95% CI)	(44.3 – 48.4)	(15.9 – 19.0)	(17.4 – 20.6)	(15.7 – 18.8)

Well below half of those with mental health conditions felt they received sufficient help for their condition, and the more severe the condition, the fewer who felt they received sufficient help (33.5% with severe PTSD; 44.0% with sub-threshold PTSD) (Table 3). Similarly, 44.8% with severe PTSD stated they needed a lot more help than they received, compared with 23.3% with sub-threshold PTSD. Patterns of perceived need were similar across all sectors, sex, age, and rank.

Table 3. Perceived adequacy of care among those who received support or treatment, by mental health and demographic characteristics

	(n)	Needed a lot more help		Needed a little more help		Received sufficient help
		(%)	(95% CI)	(%)	(95% CI(	(%)	(95% CI)
PTSD –
Sub-threshold	767	23.3	(19.2 – 27.4)	32.6	(28.4 – 36.9)	44.0	(39.5 – 48.6)
Mild	304	33.5	(26.4 – 40.6)	30.5	(23.6 – 37.4)	36.0	(29.1 – 43.0)
Moderate	230	38.6	(30.1 – 47.2)	27.8	(20.5 – 35.1)	33.6	(25.1 – 42.0)
Severe	286	44.8	(37.4 – 52.3)	21.6	(15.3 – 28.0)	33.5	(26.3 – 40.8)
Psychological distress –
High	1327	21.2	(18.2 – 24.2)	33.5	(30.1 – 36.8)	45.3	(41.8 – 48.8)
Very high	756	38.3	(33.7 – 42.9)	29.4	(25.0 – 33.7)	32.3	(27.8 – 36.7)
Suicidal ideation in past 12 months –
Yes	484	36.4	(30.6 – 42.1)	25.4	(20.5 – 30.3)	38.2	(32.5 – 44.0)
Sector –
Ambulance	1101	15.9	(13.5 – 18.2)	24.9	(22.1 – 27.6)	59.3	(56.1 – 62.4)
Fire and rescue	752	20.8	(16.5 – 25.1)	31.8	(27.0 – 36.6)	47.4	(42.3 – 52.5)
Police	2075	19.9	(17.6 – 22.1)	27.5	(25.1 – 29.9)	52.6	(49.9 – 55.4)
SES	101	7.6	(2.5 – 12.7)	35.0	(25.3 – 44.6)	57.4	(47.5 – 67.4)
Sex –
Male	2108	20.9	(18.6 – 23.1)	28.9	(26.4 – 31.5)	50.2	(47.4 – 53.0)
Female	1921	16.8	(14.4 – 19.1)	25.9	(23.2 – 28.5)	57.4	(54.4 – 60.4)
Age group –
Less than 35 years	770	15.4	(12.2 – 18.6)	30.7	(26.6 – 34.9)	53.9	(49.4 – 58.3)
35-44 years	1192	20.9	(17.7 – 24.2)	28.5	(25.1 – 31.9)	50.5	(46.8 – 54.3)
45-54 years	1468	20.4	(17.6 – 23.1)	25.2	(22.3 – 28.2)	54.4	(51.0 – 57.8)
55 years and over	599	18.6	(14.4 – 22.8)	25.2	(20.9 – 29.5)	56.2	(51.1 – 61.4)
Rank –
Senior executive/middlemanagement	349	18.8	(13.1 – 24.4)	24.2	(18.4 – 29.9)	57.1	(50.2 – 64.0)
Other management	1045	17.8	(14.6 – 21.0)	27.0	(23.5 – 30.5)	55.2	(51.2 – 59.2)
Field operative, frontline responderor administrative operative	2583	19.6	(17.5 – 21.7)	28.5	(26.2 – 30.8)	51.9	(49.3 – 54.4)
Trainee/recruit	52	23.5	(10.6 – 36.5)	16.5	(4.5 – 28.6)	59.9	(44.8 – 75.0)

Those who waited longer to seek treatment were less likely to report having received sufficient help for their condition (Table 4). Around half of those who received sufficient help (51.9%) sought treatment within a month after identifying the need for it, compared with 15% who waited over a year to seek treatment. Over a quarter (26.5%) of those who reported they needed a lot more help had delayed seeking treatment for over a year.

Table 4. Employees who sought support for an emotional or mental health issue: Delay in seeking treatment by perceived need for help

Amount of help needed	How soon did you seek out support or treatment the first time you felt you needed it
	< 1 month		1-3 months		4-12 months		> 1 year
	(%)	(95% CI)	(%)	(95% CI)	(%)	(95% CI)	(%)	(95% CI)
Needed a lot more help	37.2	(32.2 – 42.1)	17.9	(13.8 – 22.0)	18.4	(14.6 – 22.2)	26.5	(22.0 – 31.0)
Needed a little more help	41.8	(37.8 – 45.8)	18.6	(15.5 – 21.7)	23.5	(20.0 – 26.9)	16.2	(13.2 – 19.1)
Received sufficient help	51.9	(49.1 – 54.7)	16.2	(14.1 – 18.3)	17.0	(14.8 – 19.1)	15.0	(13.0 – 17.0)

GPs (66.8%) and psychologists (62.6%) were the most commonly used services, with around half (50.7%) of respondents using psychologist services provided through their organisation (Table 5). However, overall, services provided through organisations had relatively low usage.

Table 5. Service use by employees using services in the past 12 months for an emotional or mental health issue, including where the service was provided through their organisation

Service	Used the service		Provided through organisation
	(%)	(95% CI)	(%)	(95% CI)
GP	66.8	(64.9 – 68.7)	(a)
Psychologist	62.6	(60.6 – 64.6)	50.7	(48.2 – 53.2)
Psychiatrist	19.0	(17.3 – 20.7)	34.3	(29.7 – 38.8)
Telephone counselling	11.6	(10.3 – 12.9)	67.3	(61.9 – 72.7)
Other professional providing mental health services	10.7	(9.5 – 12.0)	53.3	(47.5 – 59.1)
Complementary/alternative therapist	7.0	(5.9 – 8.0)	5.8	(3.0 – 8.6)
Face-to-face self-help or support group(s)	7.1	(6.1 – 8.1)	47.5	(40.6 – 54.4)
Admitted to hospital	2.7	(2.0 – 3.4)	(a)
Mental health nurse	2.4	(1.8 – 3.0)	14.6	(6.3 – 22.9)
Alcohol or drug counsellor or support service	1.5	(1.0 – 2.0)	24.4	(9.2 – 39.6)

(a)GP and hospital services in Australia are funded under Medicare

In general, use of in-house programmes/services was low (Table 6). The most commonly used programme/service was formal or informal debriefings (38%), with 56.4% of users finding it quite/extremely useful. Only 12.1% of employees used peer support programmes, with around half of those finding it quite/extremely useful (55.3%). Similarly, 11.4% attended mental health first-aid training, with less than half (48.7%) finding it quite/extremely useful. Anti-bullying training had the highest proportion (17.4%) finding it not at all useful.

Table 6. In-house programme/service use and rating of usefulness of the programme/service among those who used it in the previous 12 months

Programme/service	Used the programme/service		How useful was the programme or service
			Not at all useful		A little bit/moderately useful		Quite/extremely useful
	(%)	(95% CI)	(%)	(95% CI)	(%)	(95% CI)	(%)	(95% CI)
Formal or informal debriefings with a manager or work colleague	38.1	(37.1 – 39.1)	4.5	(3.8 – 5.2)	39.1	(37.5 – 40.8)	56.4	(54.7 – 58.0)
Online training for mental and physical self-care	15.4	(14.6 – 16.1)	12.9	(11.1 – 14.7)	59.1	(56.5 – 61.7)	27.9	(25.6 – 30.3)
Employee counselling service or assistance programme	13.7	(13.0 – 14.5)	12.0	(10.1 – 13.8)	40.4	(37.7 – 43.2)	47.6	(44.8 – 50.4)
Peer support programme	12.1	(11.4 – 12.8)	5.2	(4.0 – 6.4)	39.5	(36.6 – 42.4)	55.3	(52.4 – 58.2)
Mental health first-aid training	11.4	(10.7-12.0)	6.5	(5.0 – 8.1)	44.8	(41.7 – 47.8)	48.7	(45.7 – 51.7)
Anti-bullying training	10.2	(9.6 – 10.8)	17.4	(15.2 – 19.6)	53.7	(50.8 – 56.7)	28.9	(26.2 – 31.6)
Face-to-face training/programme for mental and physical self-care	7.0	(6.5-7.5)	5.8	(4.0 – 7.7)	45.4	(41.6 – 49.3)	48.7	(44.8 – 52.6)
Well checks or annual mental health check-ups	6.3	(5.7 – 6.8)	10.3	(7.7 – 13.0)	41.3	(37.0 – 45.5)	48.4	(44.1 – 52.7)
Chaplaincy service	5.7	(5.2 – 6.2)	9.7	(7.2 – 12.2)	38.7	(34.4 – 43.0)	51.6	(47.2 – 56.0)
Suicide awareness and prevention education/programme	5.4	(4.9 – 5.8)	8.3	(6.2 – 10.5)	48.0	(43.8 – 52.2)	43.7	(39.4 – 47.9)

4. Discussion

Study findings revealed a concerning pattern of less than optimal help-seeking behaviour and confirmed our hypothesis that first responders exhibit lower than recommended levels (Allison et al., 2020) of help-seeking. Notably, over half of those who felt the need for help for an emotional or mental health issue neither sought nor received help. There were no significant differences in perceived need for help or levels of dissatisfaction with treatment across sectors, sex, age or rank. Studies of the general population (Meadows & Burgess, 2009; World Health Organization, 2013) and combat veterans (Brown et al., 2011) have also reported low levels of help-seeking among people with mental health problems. While related studies in Australia have focussed mostly on individual sectors or individual organisations, they have resulted in similarly negative findings, with only some exceptions confined to single organisations (Haugen et al., 2017). This supports our finding that these problems are common across the emergency services sector, and possibly mediated by poor psychosocial work environments, which are known to impact severely on mental health help-seeking behaviour in this sector (Skogstad et al., 2013; Varker et al., 2018).

Barriers to help-seeking are manifold and have been explored in detail elsewhere (Brooks et al., 2016; Haugen et al., 2017). While they were not the focus of this study, we did find certain factors associated with reduced help-seeking which illustrated how some barriers might manifest. For example, poor mental health literacy is known to play a deterrent role in help-seeking (Bamberger, 2009; Britt & McFadden, 2012; Kantor et al., 2017), and indeed, a concerning proportion of those with high or very high psychological distress thought they did not have a problem requiring help or treatment. There is a known association between a lack of recognition of a mental health problem and a lack of interest in mental health care (Brown et al., 2011; Kessler et al., 2001). The study showed this may have had detrimental outcomes, as those with severe mental distress who delayed seeking help the longest felt they needed a lot more help than they received. This is troubling given that early intervention is vital in preventing problems from worsening (Hom et al., 2017) or from developing into secondary chronic morbidities (Davidson et al., 2004). Of note, a very small proportion of respondents had attended mental health first-aid training in the previous year, with only half of those finding it quite/extremely useful. Contextually appropriate mental health literacy interventions are recommended (Kutcher et al., 2016) and perhaps this is an area of future focus.

There was little take-up of externally-provided services in the past 12 months when they were funded or sourced through organisations. It should be noted that organisation-funded services cannot be used anonymously, as they require a referral or record of payment. Confidentiality concerns, stigma, and career concerns are well-known barriers to help-seeking amongst first responders (Britt & McFadden, 2012; Gulliver et al., 2019; Haugen et al., 2017), and offers a plausible explanation for this preference to seek outside help rather than use what is available to them. This reluctance to make use of freely-provided support carries over into use of in-house mental health and wellbeing services/programmes.

Despite limited research on use of in-house health and wellbeing services/programmes, a recent study revealed that use of in-house professional support was the lowest help-seeking option among firefighters (Tamrakar et al., 2020). Levels of use and usefulness from this study were also low, particularly compared to extant Australian research (Shakespeare-Finch & Scully, 2005). This was particularly notable in relation to peer support services, which have previously been evaluated as an effective intervention for this population (Richardson et al., 2008; Shakespeare-Finch & Scully, 2005; Substance Abuse and Mental Health Services Administration (SAMHSA), 2018). There are a number of possible reasons, including poor training or selection of peer support officers (PSOs), perceived confidentiality breaches, and PSOs seeking to provide counselling “above their level of competency”, all of which have been previously substantiated (Shakespeare-Finch & Scully, 2005). Importantly, the most useful type of programme reported was formal or informal debriefings, with around half of respondents finding them to be quite or very useful and a very small proportion finding them of no use at all. The literature is divided on the effectiveness of this particular intervention, with some finding it helpful (Sattler et al., 2014) and others not (Carlier & Voerman, 2011). As informal support from colleagues is by far the most preferred intervention (Jeannette & Scoboria, 2008; Tamrakar et al., 2020), the informal debriefings may have proven the more helpful in this instance.

5. Future implications and limitations

5.1. Future implications

Recent research (Newland et al., 2015) has shown that support from peers and management with respect to mental illness, and encouragement from them to use formal support mechanisms is likely to increase the use and perceived usefulness of these mechanisms. This evidence supports the notion that the usefulness of organisation-provided services and programmes could be significantly enhanced by targeting this behaviour in staff and management alike. The low mental health literacy and career concerns identified in this study also provide compelling proof for organisations to consider a) the introduction of services and educational programmes which are tailored to address the behaviours and symptoms specifically associated with the development of PTSD and psychological distress in emergency workers, and b) addressing confidentiality concerns and perceived career impacts as a matter of urgency. Since tailoring interventions for this sector is desirable (Kutcher et al., 2016), a partnership approach between researchers and organisations may be beneficial, leading to appropriate, evidence-based interventions. Longitudinal studies to evaluate this approach could provide a novel body of research to assist in the design of future interventions.

5.2. Limitations

This study was a cross-sectional design, therefore, causality could not be established. Mental health conditions were assessed based on self-reported diagnostic measures and not through clinical interviews. Although other mental health-related conditions were collected in the survey, only results for PTSD, psychological distress, and suicidal ideation are reported here. Respondents were asked about service use for help with a non-specific emotional or mental health condition, therefore, we do not know if the service use was due to work-related or other issues and for what type of condition. The list of services and programmes provided by organisations is a generic list, designed to apply to most emergency services organisations in Australia. The survey data do not allow an assessment of the suitability of those services and programmes for treating or preventing specific mental health conditions. Similarly, we do not know if the low levels of perceived usefulness of these services influence their take-up rate or vice versa. The conflation of the term “formal or informal debriefings” in the survey wording means it is not possible to tell which type of debriefing situation was being assessed by the respondent.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed here.