EDITOR'S NOTE: This interview first ran in “The Call,” the official publication of NENA: The 9-1-1 Association.
By Anna Raskin
Dr. Michelle Lilly published a groundbreaking study on 911 telecommunicators in the Journal of Traumatic Stress in April 2012 titled “Duty-Related Trauma Exposure in 911 Telecommunicators: Considering the Risk for Post-traumatic Stress.” Bringing to light the PTSD symptomatology in telecommunicators, the study has been instrumental in showing that dispatchers are at risk for PTSD in a similar way as police officers. Dr. Lilly has been at Northern Illinois University since the fall of 2009 and is an Associate Professor of Clinical Psychology. She has a wealth of experience studying victims of intimate partner violence, survivors of sexual and physical assaults, and other survivors of traumatic stress.
What follows is a telephone interview of Dr. Lilly on June 12, 2015, in which she shares her insights and additional study data.
Q: What led you to do this particular study?
A: In 2010, I was having a conversation with an undergraduate research assistant in my lab, Heather Pierce. We were talking about research that I had done with police officers while I was in graduate school when she began describing her previous job as a telecommunicator. Heather had the idea of looking at mental health in telecommunicators, so we developed the first study focusing on telecommunicators. We had a cross-section of 170 telecommunicators from across the country. At first, we thought it would be an interesting one-time project, but after seeing the reactions and interest from the 911 community, I felt drawn in, and decided to do a follow-up study measuring PTSD symptomatology in a different way. In less than a year, my lab recruited over 800 participants for a second study. With support from NENA, the International Academies of Emergency Dispatch, the 911 Wellness Foundation, and APCO, I got connected with people and was able to publish a second paper in April 2015.
Q: How does PTSD in dispatchers look different from other forms of PTSD?
A: It does not look different from other forms of PTSD. Individuals who have been assaulted, in motor vehicular accidents, and in disasters all present the same symptoms as are present in telecommunicators. The rate of PTSD across telecommunicators is somewhere between 18 percent and 24 percent, as this percentage of individuals report enough symptoms of PTSD that they would likely receive a diagnosis if they were seen by a psychologist and were formally evaluated. The only sub-classification of PTSD is called delayed onset, which means that PTSD is not developed until after a subsequent event is experienced down the road. PTSD can develop when people have a lot of cumulative trauma exposure.
Secondary PTSD is a different construct. An example of secondary PTSD would be PTSD-like symptoms that develop from hearing about something bad that happened to somebody. According to the DSM (the “Diagnostic and Statistical Manual of Mental Disorders” published by the American Psychiatric Association), hearing about someone else’s trauma has been removed as a potential traumatic event, unless that event is particularly violent in nature. Yet, the DSM has specifically stated that being continually exposed to graphic, traumatic details of events as part of one’s job does fall into the definition of trauma, which of course fits for telecommunicators. In our recent study, we’ve been looking at PTSD symptoms, and it is very clear that even if it does not happen to the telecommunicator, just the fact that they have this recurrent exposure to very traumatic events can lead to PTSD.
Does the data show that repeated exposure to a high volume of 911 calls with trauma can lead to PTSD?
That is a stress response, and absolutely, when we are repeatedly confronted with stressful events, stress reactions occur. PTSD occurs when people handle calls that are particularly distressing or upsetting and that stick with them for a long period of time. The more of those types of calls a telecommunicator handles, the more they are put at risk for PTSD. PTSD is not a stress disorder; it is a distress disorder, so it is kind of mislabeled in that way. PTSD may develop because you have been exposed to events that are potentially traumatizing, distressing, and emotionally upsetting in some way. People will not develop PTSD simply from having a high-stress job.
Q: What symptoms stood out among dispatchers in the study in your opinion?
A: I reviewed the study data prior to this interview and will explain the data regarding symptoms. PTSD has four symptom clusters: 1) avoidance (avoiding thoughts, memories, or feelings that bring back memories of a particularly upsetting call); 2) numbing (feeling detached, feeling as though the world has changed or that the world is a bad, malicious place); 3) hypervigilance (having a strong startle response, feeling on edge all the time, having trouble concentrating or sleeping); and 4) re-experiencing (flashbacks, unwanted thoughts, thoughts about the call that come up repeatedly).
So, when I looked at the data, the most commonly reported symptom by telecommunicators was hypervigilance: feeling keyed up or agitated; feeling on edge; trouble concentrating and sleeping. Some of that is related to the job—being on high alert all the time. I was surprised because I thought that avoidance would be necessary to do the job, as burying certain experiences could be helpful when having to handle similar calls. In fact, it turned out to be one of the lower symptom clusters. Hypervigilance really stuck out. Given that, telecommunicators who present as really keyed up and who can’t calm down and may use alcohol and drugs to fall asleep stand out as having some of the bigger warning signs when looking for telecommunicators at risk for PTSD.
What was very interesting was data that seemed to link job longevity with positive beliefs about the world. Assumptions about the benevolence of the world and people seem to be more positive in veteran dispatchers than in new hires. That said, veteran dispatchers also have the highest rate of PTSD and the lowest job satisfaction. It might suggest that they hold onto those assumptions in order to stay in the job. It also might suggest that people who don’t have compassion or feel that the world is a terrible place cannot survive in the job because their assumptions are attacked on a daily basis.
Q: Did you obtain any data comparing smaller agencies to larger agencies?
A: Every participant in the study was asked how many telecommunicators were in their communication center. Across the board, the data showed that there were no differences in mental health, physical health, job satisfaction, and coping as a function of agency size. There were very small differences between urban and rural centers. People in urban centers had slightly higher job satisfaction and world assumptions. People in rural settings reported worse mental health (depression). When people were asked if they would quit their job, the No. 1 reason they wouldn’t was pinned to the job benefits and the role of the telecommunicator as the family financial breadwinner.
Q: What type of scenario seems to be a key trigger for telecommunicators?
A: Definitely kid calls. When asked, “What is the worst call you have ever taken?” nearly a quarter of the participants reported an incident involving a child, regardless of whether it was the death of a child, child-related injuries, sexual assault of a child, etc. Those telecommunicators are at the highest risk for adverse mental health and functioning. Certainly, those calls involving kids would be the types of calls where follow-up with the telecommunicator is warranted. The next-highest incident cited was officer-involved shootings or line-of-duty deaths. The third-highest was “other”: Some other type of call that was particularly unique, hard to classify, but also conferred higher risk for poorer outcomes.
Q: Did you acquire any data on physical health complaints common among dispatchers?
A: Obesity is incredibly high. About 83 percent of telecommunicators in the study were obese or overweight. Fifty-three percent alone fell into the obese category. The U.S. is an obese place, but the U.S. general population has an obesity percentage in the low 30s, so this is 20 percent higher than the general population. On average, there were 17 different health complaints with an occurrence at least once a month, all the way up to once a week. In addition to obesity, the most common complaints were headaches, backaches, insomnia, heartburn, and upset stomach.
Cortisol dysregulation may be a major factor in some of these symptoms. My plans for next steps in studying the 911 field include cortisol functioning as one topic of interest. Looking into cortisol functioning with a telecommunicator sampling in Chicago could provide some hard data regarding why some of these health symptoms are occurring. It may specifically link cortisol to recurrent stress in this job.
The other piece is the shift work schedule, which can have a significant impact on physical health. Shift work interferes with sleep, specifically impacting metabolism and the hormone ghrelin that is released when the body does not get enough sleep. Ghrelin prompts hunger signals. So stress, poor sleep patterns, dysregulated cortisol, and the sedentary nature of the job can all impact the health of the telecommunicator.
Regarding ideas on how to handle some of these symptoms, there is a lot of interest all over the U.S. in installing treadmills and bikes at telecommunicator workstations. Incentivizing some of these habits might create interest in using these machines.
Q: Do you have any conclusions about treatment for telecommunicators after PTSD has set in?
A: As a licensed clinical psychologist, I have seen a number of very well-supported treatment approaches for PTSD. Two of the approaches with the most support are prolonged exposure and cognitive processing therapy. Both treatments have been proven effective across a spectrum of cases: veterans, sexual assault victims, assault victims, vehicle accident survivors, etc. These treatments do not require long therapy but are specifically focused on helping the person alleviate their PTSD symptoms. If people could get access to those types of treatments, they would be in a good position to recover from their PTSD.
Q: Knowing that some of these things can help people, do you have an opinion on how to help telecommunicators notice their symptoms and treat them?
A: Any way to get people on board would be a start. For example, a communication center finding an online PTSD screener quiz and telling employees, “Hey, if you go online and take this quiz, you can have an extra break.” By having telecommunicators actually do some of the online quizzes and engage in wellness checks online, the results could provide telecommunicators with some feedback on their functioning. It may provide some feedback such as, “Hey, you might be at risk for depression.” Incentivizing people to get involved might at least show them that they may have an issue. Extra days off would be a great incentive, although communication centers are chronically understaffed. That would be the first step. I have suggested offering continuing education credits through some of the major 911 organizations to telecommunicators who participate in online interventions. That would be one way of ensuring they would continue being taken care of. Peer support programs have promise: Leaders within the call center who are more informed front-line people and know about the resources, but are not supervisors, might be a less threatening way to bring support to employees.
Dr. Lilly published a new study titled “Psychological Inflexibility and Psychopathology in 9-1-1 Telecommunicators” in the April 2015 issue of the Journal of Traumatic Stress. The interview was by Anne Raskin.
