Trauma exposure and post‐traumatic stress disorder within fire and emergency services in Western Australia

Abstract

Objective

While it is widely accepted that fire and emergency work is of high risk for potentially traumatic event exposure and post‐trauma pathology, there has been limited published data regarding Australian fire and emergency service workers. The relationship between trauma exposure and mental health outcomes, in particular the significance of social support and coping style was explored.

Method

Participants were 210 Department of Fire and Emergency Services (DFES) career firefighters in Western Australia (WA). This study employed a cross‐sectional, correlational design, with a combination of self‐selection and random sampling.

Results

Results found that DFES career members were exposed to trauma at significantly higher rates than the general population and reported elevated rates of post‐traumatic stress disorder (PTSD) symptomatology. Trauma exposure, social support, and coping style significantly contributed to variation in PTSD symptomatology, with maladaptive coping strategies accounting for more PTSD variance than adaptive coping.

Conclusions

Elevated rates of PTSD identify WA DFES members as a high risk population. There was evidence that trauma exposure, social support, and coping style significantly contributed to levels of PTSD symptomatology. Maladaptive coping strategies, such as distraction, substance use, venting and self‐blame, accounted for more variance in PTSD symptomatology than adaptive coping strategies, indicating that prevention or treatment interventions may be most effective by targeting reduction of maladaptive coping strategies, with a secondary focus on building adaptive coping strategies.

Key words:

• coping
• firefighters
• PTSD
• social support
• trauma

What is already known about this topic

• Fire and emergency work is a high‐risk profession

• International studies of firefighters have shown elevated rates of trauma exposure

• International studies of firefighters have shown elevated rates of PTSD

• There are demonstrated links between social support, coping strategies, and PTSD symptoms.

What this paper adds

• PTSD symptom rates in a Western Australian Fire and Emergency sample

• Exploration of the contribution of trauma exposure, social support, and coping strategy to PTSD symptoms.

• Breakdown of the contribution of adaptive and maladaptive coping strategies in regards to PTSD symptoms.

While it is widely accepted that fire and emergency work is of high risk for potentially traumatic event (PTE) exposure and post‐trauma pathology, there has been limited published data regarding Australian fire and emergency service workers, with no published studies, to date, regarding fire and emergency service workers in Western Australia (WA). This paper outlines data collected in 2013 from career Department of Fire and Emergency Services (DFES) personnel regarding PTE exposure and post‐traumatic stress disorder (PTSD) symptomatology.

PTSD

Firefighters are, by nature of their jobs, exposed to extreme conditions impacting physical, psychological, and emotional stress; they are required to respond to a range of emergency situations, such as residential and commercial fires, medical crises, hazardous material spills, explosions, motor vehicle, train and aeroplane accidents, search and rescue, and large‐scale community disasters (Armstrong, Shakespeare‐Finch, & Shochet, 2014; Bryant & Harvey, 1996). It is likely that emergency service personnel will confront situations that involve human suffering, danger, and death at elevated levels as compared with the general population and firefighters are at elevated risk of PTSD and other mental health issues (such as depression), as a result of duty‐related exposures (Bryant & Guthrie, 2007).

Research suggests that even ‘routine’ emergency work is stressful, and can lead to PTSD (Beaton, 1998), with mounting evidence of a cumulative toll of stressful emergency exposures (Armstrong et al., 2014; Barnes, 2000; Bryant & Harvey, 1996). In addition to personal threats to life and well‐being, fire and emergency service workers attend accidents and observe and/or handle gruesome remains; this exposure to grotesque death has also been shown to be associated with PTSD (McCarroll et al., 1995). The estimated lifetime prevalence of PTSD in firefighters has varied widely, however it is consistently elevated compared with the general population (ACPMH, 2013; Del Ben, Scotti, Chen, & Fortson, 2006). Evidence of frequent and repeated PTE exposure has been replicated in Australian firefighter samples (Bryant & Guthrie, 2007).

Coping strategy

Lazarus and Folkman (1984) indicated that coping strategy may influence how a stressful or PTE is perceived and managed. Approach‐oriented coping has been identified as a protective factor while avoidance‐oriented coping (i.e., escapism, rumination, or emotion focus) has been linked to poorer mental health outcomes (Silverman & La Greca, 2002). Beasley, Thompson, and Davidson (2003) directly tested the role of coping style in buffering individuals against negative life events and found that emotion‐focused coping, avoidant coping and negative life events have a direct impact on measures of psychological and somatic distress and maladaptive coping strategies, such as avoidant coping, have been linked to increased PTSD symptoms following PTE exposure (Brown, Mulhern, & Joseph, 2002). A study involving trainees at the Australian Army Recruit Training Centre demonstrated a link between coping strategy use and levels of emotional distress (Dawson, 2000). Specifically, avoidant coping styles (i.e., self‐blame, denial, rumination, and venting) were predictive of poorer psychological adjustment, while recruits who engaged in problem‐focussed strategies (i.e., planning and problem solving) reported less emotional distress and were more likely to complete training (Cohn, Hodson, & Crane, 2010). Cognitive avoidance (e.g., thought suppression) has typically been considered a mechanism underlying the intrusive thoughts inherent to PTSD (Feldner, Monson, & Friedman, 2007).

It has been argued that an avoidant coping style reinforces avoidant behaviours and can precipitate and perpetuate PTSD symptoms. Maladaptive coping styles have been linked with experiential avoidance, which is itself a risk factor for developing PTSD (Fledderus, Bohlmeijer, & Pieterse, 2010). High levels of cognitive avoidance have been shown to predict greater post‐PTE symptom severity among persons with a history of traumatic exposure (Marx & Sloan, 2005). Efforts to suppress PTE‐related thoughts appear to increase the frequency of the suppressed thought (Davies & Clark, 1998) and may maintain PTSD symptoms. Some models posit that cognitive processing of an event will only take place effectively when avoidance is low enough to allow activation of the fear network (Creamer, Burgess, & Pattison, 1990).

Social support

The protective effects of social support in the prevention and/or reduction of psychological disorders relating to stressful life events and trauma exposure have been found in a number of studies (Brewin, Andrews, & Valentine, 2000; Charuvastra & Cloitre, 2008; Lepore, Ragan, & Jones, 2000; Ozer, Best, Lipsey, & Weiss, 2008). Those at high risk of PTSD have been shown to report lower perceived social support, and past research has demonstrated that social support is predictive of PTSD (Meyer et al., 2012; Mitani, Fukita, Nakata, & Shirakawa, 2006). A sense of being supported, by an organisation, peers and other social contacts, leads to lower levels of distress (Regehr, Hill, Knott, & Sault, 2003).

Recent research involving firefighters has confirmed links between multiple trauma exposures, coping strategies, social support, and post‐trauma outcomes (Armstrong et al., 2014). Longer time in the fire service has been associated with lower levels of social support, which is also associated with traumatic stress and depressive symptoms (Regehr et al., 2003). While past research consistently reports links between social support and mental health outcomes, the reported prevalence of low social support varies, with some studies stating that as few as 4% of career firefighters report poor social bonding (Carey, Al‐Zaiti, Dean, Sessanna, & Finnell, 2011). Further exploration of the association between perceived social support and post‐trauma outcomes is warranted.

Summary

Although it is widely accepted that firefighters are at increased risk of PTSD and other stress‐related conditions, there has been limited research focussing on Australian Fire and Emergency Service workers. Elevated trauma exposure and associated elevated rates of PTSD and mental distress within Australian firefighters is consistent with data collected from international samples. The aim of this study is to gather information about PTE exposure in Western Australian Department of Fire and Emergency Service (DFES) workers and the associated impact on mental health and well‐being. The relationship between PTE exposure and PTSD, in particular the significance of social support and coping style will be explored.

Hypotheses

Hypothesis 1: More DFES members will be exposed to PTEs than the general Australian population.

Hypothesis 2: Members of DFES will report elevated rates of PTSD symptoms as compared with the general Australian population.

Hypothesis 3: Exposure to trauma, level of social support, and coping style will be significant predictors of PTSD symptoms.

Method

Participants

Participants were 210 DFES firefighters in WA. Participation was anonymous and voluntary. Currently, DFES has 963 career firefighters; this survey represented 21.8% of the career firefighter population. This is the expected response rate for this population, based on past research (Bryant & Harvey, 1996; Kaplowitz, Hadlock, & Levine, 2004).

All age groups were represented, with the majority of participants aged 31 to 50. A chi‐square test was conducted to determine whether the participants responding to the study represented the age demographics present at DFES. The chi‐square test indicated that age was similarly distributed in the participants responding to the study as the DFES career firefighter population (χ²(3) = 6.23, p = .101).

Of the 210 participants, 201 were male and nine were female. A chi‐square test indicated that gender was not similarly distributed in the participants responding to the study as the DFES career firefighter population (χ²(1) = 2.010, p = .156).

Measures

Demographics and consultation

A brief demographic questionnaire was designed to gather information relating to age and gender.

PTE exposure

The Traumatic Stress Schedule (Norris & Hamblen, 2004) is a 9‐item instrument developed to examine lifetime exposure to nine types of PTEs and has been shown to have good stability, test–retest validity and symptom reliability (Norris & Hamblen, 2004).

PTSD symptoms

The PTSD Checklist—Civilian Version (PCL‐C; Blanchard, Jones‐Alexander, Buckley, & Forneris, 1996) was used to assess PTSD symptom presence and severity. The PCL‐C is a 17‐item inventory that assesses the specific symptoms of PTSD; it has been tested for internal consistency, test–retest reliability, convergent validity, and discriminant validity (Ruggiero, Del Ben, Scotti, & Rabalais, 2003). Cronbach's alpha coefficients (.94, .85, .85, and .87 for the PCL‐C total, re‐experiencing, avoidance and hyper‐arousal scales, respectively) indicate high internal consistency (Ruggiero et al., 2003). Scores on the PCL‐C may be reported as a total, indicating PTSD symptom severity with an overall cut‐off warranting further assessment (Orsillo, 2001). The diagnostic efficiency of the PCL‐C can be improved by individually interpreting item scores and assessing positive endorsement of each symptom cluster rather than a total score (Blanchard et al., 1996). This scoring method more accurately reflects the Diagnostic and Statistical Manual of Mental Disorders‐IV (DSM) diagnostic criteria. The PCL‐C was designed in‐line with DSM‐IV diagnostic criteria for PTSD and data collection for the current study commenced before the release of the DSM‐5 in 2013 (APA, 2013). As such, a symptom cluster breakdown according to the DSM‐5 diagnostic criteria was not conducted.

Perceived social support

The Social Support Questionnaire—Short Form (Sarason, Sarason, Shearin, & Pierce, 1987) is used to quantify the availability and satisfaction with social support. It is a 27‐item self‐administered scale that has demonstrated high internal consistency reliability and test–retest reliability. A support score for each item is calculated by the number of individuals the participant listed (number score). The overall support score (SSQN) is calculated by the mean of this score across the items. The overall satisfaction score is calculated by taking the mean of the satisfaction scores.

Coping strategies

The Brief Coping Orientations to Problems Experienced (Brief COPE) scale is a 28‐item scale used to measure a broad range of coping strategies (Carver, 1997). It includes 14 subscales: active coping, planning, positive reframing, acceptance, humour, religion, emotional support, instrumental support, self‐distraction, denial, venting, substance use, behavioural disengagement, and self‐blame. Cronbach's alpha‐coefficients ranged between .74 and .96 (Carver, 1997). There is evidence that the Brief COPE may also be divided into ‘adaptive’ or ‘maladaptive’ subscales. The adaptive subscale includes the active coping, planning, positive reframing, acceptance, humour, religion, emotional support, and instrumental support subscales. The maladaptive subscale comprises the self‐distraction, denial, venting, substance use, behavioural disengagement, and self‐blame subscales (Moore, Biegel, & McMahon, 2011).

Procedure

The sample for this study was collected using two procedures. First, an electronic survey invitation was extended to all DFES career firefighters via an internal newsletter. Clicking on the survey link took participants to an information page where they could choose to consent to participate and commence questionnaire completion.

Additionally, three fire stations in the Perth metropolitan area were randomly selected for participation. At the consent of the station officer, all career firefighters on shift were personally invited to participate by a member of the DFES Wellness Team. All surveys, free of any identifying information, were returned via sealed envelope. This study was approved by the Human Research Ethics Committee at Curtin University (HR113/2011).

Study design

This study employed a cross‐sectional, correlational design, with a combination of self‐selection and random sampling, as outlined below. Rates of PTE exposure and PTSD as reported by DFES members were compared with rates measured in the general population. Bivariate correlations were used to test the predicted relationships between variables along with a hierarchical regression to examine how much variance in PTSD symptoms measures of trauma exposure, social support, and coping style could account for. An ordinary least squares multiple regressions was then run using a breakdown of the maladaptive coping subscales on the Brief COPE to examine how much variance in PTSD symptomatology each coping strategy accounted for. Due to inherent problems in coping measurement (Coyne & Gottlieb, 1996), there was a possibility that the data may be confounded if measurement of maladaptive coping strategies or behaviours is simultaneously a measurement of PTSD symptomatology. For example, endorsing the use of avoidant coping strategies on the Brief COPE may not be functionally or clinically different from endorsing symptoms within the avoidant symptom cluster for PTSD (APA, 2013). In order to explore this potential confound and clarify whether avoidance coping strategies could be distinguished from PTSD symptoms, an exploratory factor analysis was conducted including the maladaptive coping subscales from the Brief COPE, and a symptom cluster breakdown of PTSD symptoms from the PCL‐C was run to confirm that PTSD symptoms and coping behaviours, as measured here, were two distinct constructs.

Based on an estimated population of 963 career fire and emergency workers in WA, a minimum of 209 participants were required to estimate population responses with a confidence interval (CI) of 6.0 (α < .05) (Israel, 1992; Krejcie & Morgan, 1970). The achieved sample of 210 participants provides a CI of 5.98 for this population.

Results

PTE exposure

In total, 203 respondents (96.7%) endorsed the personal experience of at least one PTE over the past five years, as measured by the Traumatic Stress Schedule (TSS; (Norris & Hamblen, 2004). Exposure to more than one PTE type was common; 82.9% (n = 174) reported exposure to two or more PTE types and nearly half (45.2%; n = 95) reported exposure to four or more PTE types. This is compared with an estimated 50.0–65.0% prevalence of PTE exposure in the Australian general population (Creamer, Burgess, & McFarlane, 2001).

PTSD symptoms

The PCL‐C has a recommended screening clinical cut‐off of 44 (Terhakopian, Sinaii, Engel, Schnurr, & Hoge, 2008; Weathers, Litz, Herman, Huska, & Keane, 1993). The mean score for this sample was M = 27.20 (SD = 10.51). Ninety‐one per cent of the sample scored over the cut‐off of 44. This is compared with 44, as compared to the Australian general population 12 month prevalence has been estimated at 4.4% (McEvoy, Grove, & Slade, 2011).

Using the DSM‐IV cluster‐based breakdown of scores (as outlined above), 21.6% of participants met the diagnostic criteria for at least one symptom cluster; however, only 5.0% participants met the threshold for all symptom clusters and were considered (for the purposes of this study) to meet the diagnosis for PTSD.

Explaining PTSD symptoms

Bivariate correlations were used to assess the relationship between variables. As seen in Table 1, the bivariate correlations demonstrated that PTSD symptoms were positively correlated with age, gender, trauma exposure, adaptive coping, and maladaptive coping. PTSD symptoms were negatively correlated with perceived social support.

Table 1. Bivariate Spearman's correlations between dependent and predictor variables

	1.	2.	3.	4.	5.	6.	7.
1. PTSD	1	.37^**	.11^**	.37^**	−.13	.22^**	.56^**
2. Age		1	−.04	.18^**	−.26^**	−.08	.17^*
3. Gender			1	.12	.06	.08	.16^*
4. Trauma exposure				1	.05	.16^*	.22^**
5. Social support					1	.22^**	.08
6. Adaptive coping						1	.56^**
7. Maladaptive coping							1

Note. PTSD = post‐traumatic stress disorder.

* p < .05,

** p < .01.

To test the hypothesis that trauma exposure, perceived social support and coping style can account for a significant proportion of variance in PTSD symptoms, a hierarchical multiple regression analysis was conducted. Data were checked to ensure that the assumptions of normality, multicollinearity, linearity, homogeneity of variance and homoscedasticity of residuals were met. As none of these assumptions were violated, a hierarchical regression was conducted.

Step 1 of the hierarchical regression included the demographic variables of age and gender, as both younger and being female have been identified as risk factors for PTSD (Meyer et al., 2012; Ozer et al., 2008). Step 2 included trauma exposure, as trauma exposure is essential to the diagnosis and aetiology of PTSD (Criterion A; APA, 2013). Perceived social support was included in step 3 of the hierarchical regression, as past research has identified clear links between low perceived social support and PTSD, particularly in high‐risk populations (Meyer et al., 2012; Mitani et al., 2006). The links between adaptive and maladaptive coping strategies and PTSD, based on prior research, are less clear (Coyne & Gottlieb, 1996; Silverman & La Greca, 2002), and so coping strategies were entered at Step 4.

On step 1 of the hierarchical regression model, age, and gender accounted for a significant 15.0% of variance in PCL‐C scores, F(2,195) = 17.412, p < .001. On step 2, trauma exposure was added and accounted for an additional 4.9% of variance in PCL‐C scores, ΔF(3,197) = 11.912, p < .001. On step 3, perceived social support was added and accounted for a further significant 1.8% of the variance in PCL‐C scores, ΔF(4,196) = 4.45, p < .05. On step 4, coping style was added and accounted for a further significant 17.4% of the variance in PCL‐C scores ΔR² = .17, ΔF(5,195) = 27.575, p < .001. Only maladaptive coping made a significant contribution to the variance in PCL‐C scores (see Table 2). DFES members who were older, reported higher trauma exposure, lower perceived social support, and more maladaptive coping strategies reported more PTSD symptoms at the time of data collection. In combination, the predictor variables explained 39.1% of the variance in PCL‐C scores, R² = .391, adjusted R² = .37, F(2, 196) = 31.55, p < .001.

Table 2. Unstandardised (B) and standardised (β) regression coefficients, and squared semi‐partial correlations (sr²) for each predictor variable on each step of hierarchical regression predicting PCL‐C score (N = 210)

Variable		B	β	sr^2
Step 1	Age	4.19^**	.36	.13
	Gender	8.82^*	.16	.03
Step 2	Age	3.78^**	.33	.11
	Gender	7.45^*	.14	.02
	Trauma exposure	1.43^**	.24	.05
Step 3	Age	3.35^**	.29	.08
	Gender	7.98^*	.14	.02
	Trauma exposure	1.50^**	.25	.06
	Social support	−.72^*	−.15	.08
Step 4	Age	2.28^**	.20	.03
	Gender	5.10	.09	.01
	Trauma exposure	1.07^**	.18	.03
	Social support	−.82^**	−.17	.03
	Maladaptive coping	1.04^**	.50	.15
	Adaptive coping	−.13	−.09	.01

Note. PCL‐C = PTSD Checklist—Civilian Version; PTSD = post‐traumatic stress disorder.

* p < .05,

** p < .01.

Using Cohen's (1988) conventions, a combined effect of this magnitude can be considered a medium to large effect size (ƒ² = .73). Unstandardised (B) and standardised (β) regression coefficients and squared semi‐partial correlations (sr²) for each predictor on each step of the hierarchical regression are reported in Table 2.

To estimate the proportion of variance in PTSD symptomatology that can be accounted for by the maladaptive coping strategies of self‐distraction, denial, venting, substance use, behavioural disengagement and self‐blame, a standard multiple regression analysis was performed. Once again, data were checked to ensure that the assumptions of this analysis were met. As none of the assumptions were violated, a multiple regression analysis was conducted.

In combination, self‐distraction, denial, venting, substance use, behavioural disengagement and self‐blame accounted for a significant 30.9% of the variability in PTSD symptomatology R² = .309, F(6, 195) = 14.62, p < .001. Unstandardised (B) and standardised (β) regression coefficients, and squared semi‐partial (or ‘part’) correlations (sr²) for each predictor in the regression model are reported in Table 3. The maladaptive subscales of self‐distraction, substance use, venting, and self‐blame accounted for a significant proportion of the variance in PCL‐C score.

Table 3. Unstandardised (B) and standardised (β) regression coefficients, and squared semi‐partial correlations (sr²) for each predictor in a regression model predicting PCL‐C score (N = 210)

Variable	B [95% CI]	β	sr^2
Self‐distraction	1.30 [.330–2.27]	.180^**	.025
Denial	.816 [−1.74–3.37]	.039	.001
Substance use	1.07 [.155–1.98]	.153^*	.019
Behavioural disengagement	1.13 [−.786–3.15]	.083	.005
Venting	1.10 [.150–2.05]	.145^*	.018
Self‐blame	1.94 [.821–3.06]	.245^**	.041

Note. CI = confidence interval; PCL‐C = PTSD Checklist—Civilian Version; PTSD = post‐traumatic stress disorder.

* p < .05,

** p < .01.

To investigate the underlying factor structure of the maladaptive coping subscales and PTSD symptom clusters, 210 participants were subjected to principal axis factoring with promax rotation. Prior to running the principal axis factoring, examination of the data indicated that not every variable was perfectly normally distributed. Given the robust nature of factor analysis, these deviations were not considered problematic (Field, 2013). Furthermore, a linear relationship was identified among the variables.

Two factors (with Eigenvalues exceeding 1) were identified as underlying the maladaptive coping subscales and PTSD symptom clusters (see Table 4). In total, these factors accounted for around 44.3% of the variance. The maladaptive coping strategy of venting did not load on either of these factors.

Table 4. Promax rotated factor structure of brief COPE maladaptive coping subscales and PCL‐C PTSD symptom clusters

Item	Loadings
	Factor 1^11	Factor 2^12
Coping method: distraction		.334
Coping method: denial		.376
Coping method: alcohol/substance use		.431
Coping method: disengagement		.777
Coping method: venting	–	–
Coping method: blaming		.533
PTSD symptom cluster B (re‐experiencing)	.893
PTSD symptom cluster C (avoidance)	.778
PTSD symptom cluster D (arousal)	.926
Percentage of variance:	36.62%	7.66%

Note. PTSD = post‐traumatic stress disorder.

PTSD symptoms.

Coping strategies.

Discussion

It has been well documented that fire and emergency service work is characterised by frequent PTE exposure (Bryant & Harvey, 1996; Tuckey & Scott, 2013). Consistent with previous research, hypotheses one and two were supported, with DFES firefighters reporting higher rates of PTE exposure and PTSD than the Australian population. There was evidence that trauma exposure, social support, and coping style significantly contributed to levels of PTSD symptomatology. Exposure to trauma was the best predictor of PTSD symptoms, a finding that fits with previous research and current conceptualisations of the aetiology of PTSD, in which trauma exposure is a necessary precursor to a diagnosis of PTSD (APA, 2013).

Exploration of the coping style data showed that maladaptive coping strategies accounted for more variance in PTSD symptomatology than adaptive coping strategies. Further investigation revealed that distraction, substance use, venting, and self‐blame are specific maladaptive coping strategies that accounted for a significant amount of variance in PTSD symptomatology in this sample. Cognitive avoidance (using external distracters to ‘take my mind off things’), use of alcohol and other drugs, verbal catharsis, and self‐directed blame and criticism contributed to the development of PTSD symptoms. Fire and emergency service work has notably elevated alcohol use (Haddock et al., 2012); problematic alcohol use is commonly comorbid with PTSD diagnoses (McFarlane, 1998) and as such links between reported use of alcohol or other drugs as a coping strategy and PTSD symptoms may equally reflect an outcome of PTSD rather than a contributing factor. The direction of this relationship could not be clarified with the current, cross‐sectional dataset. Other avoidance strategies (such as distraction) and rigid self‐blaming beliefs have also been identified as significant factors in the aetiology and maintenance of traumatic stress disorders (Foa, Keane, & Friedman, 2000). The links between avoidant coping strategies, such as alcohol use, and self‐distraction, and distress in firefighters is consistent with previous research (Bacharach, Bamberger, & Sonnenstuhl, 2002; Carey et al., 2011; Chamberlin & Green, 2010).

It seemed possible that the contribution of maladaptive coping strategies to PTSD symptomatology could be the result of an inherent confound. That is, the measure of maladaptive coping strategies may have been detecting avoidance strategies that are intrinsic in PTSD. An exploratory factor analysis confirmed that this was not the case in the current dataset and that maladaptive coping strategies and PTSD symptoms could be treated as two separate (but correlated) constructs. People who are prone to using avoidance to cope are at higher risk of developing psychopathology (Fledderus et al., 2010), and people under stress have a higher need to employ coping mechanisms than non‐stressed individuals (Coyne & Gottlieb, 1996). It seems likely that people who develop PTSD symptoms are more likely to engage in avoidant coping strategies at each stage of the disorder, and a tendency towards avoidance is often present at all stages of the case formulation for clients with PTSD. For example, a person who tends towards avoidance of uncomfortable thoughts and feelings will be more likely to experience peri‐traumatic dissociation and use avoidance of triggers, reminders, location, or environment in order to manage distress following a trauma exposure (Brown et al., 2002; Kashdan, Barrios, Forsyth, & Steger, 2006; Marx & Sloan, 2005). Avoidance of thoughts typically increases the frequency and intensity of those thoughts (Lavy & van den Hout, 1990), thus resulting in an escalation of distress, rather than the desired management of distress, which could lead to the application of more avoidant strategies. If such strategies continue to be applied to manage distress, avoidance of reminders or triggers could start to significantly impact daily functioning and escalate the intrusion and avoidance symptoms clusters of PTSD.

Recent research has explored the efficacy of teaching new and different coping strategies to at‐risk populations to decrease depression, with reported success (Day, Kane, & Roberts, 2003). In the current study, 10% of the sample presented with significant symptoms of PTSD by scoring over the cut‐off on the PCL‐C. The entire sample reported being at risk, by endorsing multiple PTE exposures. The current results indicate that coping strategies and social support would be well placed within a programme aimed at the primary prevention of PTSD. Specifically, these data indicate that a program targeting the prevention of PTSD should place a priority on decreasing maladaptive coping strategies such as substance use, distraction, venting, and self‐blame. This may be achieved via psycho‐education and a focus on decreasing maladaptive coping strategies and/or by equipping firefighters with more adaptive coping skills, thus providing opportunity for adaptive strategies to be used and diminishing maladaptive approaches.

The demographic variables, age, and gender also contributed a significant portion of the variance in PTSD. Gender differences in trauma literature have been well studied; females in the general population are more likely to be exposed to PTEs (Feldner et al., 2007) and display greater symptoms of anxiety, depression, and distress after experiencing a trauma (Foa et al., 2000; Nasky, Hines, & Simmer, 2009; Silverman & La Greca, 2002). Similarly, links between age and mental health issues, such as PTSD and depression, have been found in high‐risk samples (Beaton, 1998). As age and time spent working in a high‐risk profession increases, the potential for PTE exposure (including repeated PTE exposure) also increases. The cumulative impact of trauma exposure is well documented (Bryant & Harvey, 1996) and is well demonstrated in replications of increased mental health symptomatology covarying with increased age within high‐risk professions.

Limitations

Even though responses were completely confidential and anonymous, participants may have been reluctant to portray themselves or their profession in a negative light, and thus may have minimised negative responses. It is possible that firefighters minimise symptoms reporting (Bryant & Guthrie, 2007; Wagner, Heinrichs, & Eklert, 1998), and past research has reported that non‐participation due to fear of stigma is an issue in firefighter populations. For example, Bryant and Harvey (1996) noted that numerous firefighters declined an invitation to participate in a research survey as they believed ‘admission of stress in their duty represented inadequacy as a firefighter’ (p. 60).

Self‐selection in response to an electronic invitation to the online survey may have also skewed results. An attempt was made to enhance the representativeness of the sample by randomly selecting Perth metropolitan fire stations for participation. A response rate of under 25.0% may appear conservative; however, the response rate achieved in the current study is representative of survey response rates in similar populations and with similar methodologies (Bryant & Harvey, 1996; Kaplowitz et al., 2004).

DSM‐IV (APA, 1994) diagnostic criteria were used initially, as opposed to the recently published DSM‐5 diagnostic criteria (APA, 2013), as the prevalence rates published by the Australian Centre for Posttraumatic Mental Health were calculated following DSM‐IV diagnostic guidelines. It is unknown whether changes to the diagnostic criteria for PTSD in DSM‐5 will have a significant impact on prevalence rates of this disorder.

Future research

This paper outlines a ‘snapshot’ of DFES members in 2013. It has informed knowledge of current presenting issues for fire and emergency service workers in Western Australia, but conclusions regarding causality or meaningful relationships between variables cannot be drawn from these data. A longitudinal study of fire and emergency services workers, including careful measurement of PTE exposure (frequency and time), PTSD symptoms, depression, stress, and anxiety could provide meaningful connections between these variables, and shed light on the aetiology of mental health issues in relation to trauma exposure. Additional indicators of well‐being, such as substance use, quality of relationships, and coping mechanisms would also be of interest to this field of research. A significant gap within fire and emergency research is lack of clear data regarding diagnosis rates of depression and anxiety, as distinct from PTSD. Future research focussing on gold standard diagnostics within this population would be well founded.