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© Copyright of Ash et al., 2015a
SPOTting
PTSD
A PTSD Toolkit For
First Responders
N. Roaine Ash
Melanie Bartczak
Jessica Monteferrante
Atiya Nurse
Sharon Persad
McGill University
School of Physical and
Occupational Therapy
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SPOTting PTSD: A PTSD Toolkit for First Responders
McGill University
Faculty of Medicine - School of Physical and Occupational Therapy
N. Roaine Ash (Project Initiator, Author, and Secondary Editor)
Master Student, Occupational Therapy
McGill University
Melanie Bartczak (Author and Primary Editor)
Master Student, Occupational Therapy
McGill University
Jessica Monteferrante (Author and Secondary Editor)
Master Student, Occupational Therapy
McGill University
Atiya Nurse (Author and Secondary Editor)
Master Student, Occupational Therapy
McGill University
Sharon Persad (Author and Secondary Editor)
Master Student, Occupational Therapy
McGill University
This document was prepared by the student researchers in partial fulfilment of the requirement
for the degree of Masters of Science (Applied) in Occupational Therapy at McGill University,
under the supervision of Dr. Heather Lambert PhD and Hiba Zafran (PhD Candidate). For all
communications, please contact N. Roaine Ash at: roaine.n.ash@mail.mcgill.ca.
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SPOTting PTSD: A PTSD Toolkit for First Responders
N. Roaine Ash
Melanie Bartczak
Jessica Monteferrante
Atiya Nurse
Sharon Persad
McGill University
Faculty of Medicine - School of Physical and Occupational Therapy
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D e d i c a t i o n
I would like to take this space to dedicate this toolkit to the first responders, volunteer or
otherwise, that tirelessly put others’ health and safety before their own, and to the first
responders I met those many years ago that reminded me that heroes are human too.
Roaine Ash
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T a b l e o f C o n t e n t s
TABLE OF CONTENTS
Introduction ........................................................................................................................................... 1
What is a First Responder and/or Emergency Responder? ............................................................... 1
What is Occupational Therapy? ......................................................................................................... 1
What is Mental Health? ..................................................................................................................... 3
Mental Illness from an Occupational Therapy Perspective ........................................................... 3
Why are Occupational Therapists concerned about the Mental Health of First Responders? ..... 4
Summary of Key Ideas ........................................................................................................................ 5
Post-Traumatic Stress and First responders .......................................................................................... 9
What is Trauma? ................................................................................................................................ 9
What is Mental Injury and Mental Illness? The Legal versus Medical Definition ............................ 10
What is Post-traumatic Stress Disorder (PTSD) and Secondary Traumatic Stress (STS)? ................ 11
Symptoms of PTSD and STS .......................................................................................................... 12
Self-Assessment: SPOTting PTSD Checklist .................................................................................. 13
Risk Factors for PTSD and STS ...................................................................................................... 14
PTSD and STS: Hidden Risk of Suicide .......................................................................................... 15
Life with PTSD or STS: The Power of Post-traumatic Growth .......................................................... 17
Summary of Key Ideas ...................................................................................................................... 17
Strategies for Mental Health Promotion ............................................................................................. 30
Focus on a Primary Prevention Strategy for First Responders .................................................... 30
Resiliency .......................................................................................................................................... 31
What is Resilience? ....................................................................................................................... 31
Building Resiliency ........................................................................................................................ 31
Coping Strategies ............................................................................................................................. 34
What is coping? ............................................................................................................................ 34
What are the different types of coping a person can use? .......................................................... 34
Coping with the unexpected when on duty ................................................................................. 36
Self-Management ............................................................................................................................. 38
What is Self-Management? .......................................................................................................... 38
Strategies for Self-Management .................................................................................................. 38
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T a b l e o f C o n t e n t s
Peer Support .................................................................................................................................... 42
What is Peer Support? .................................................................................................................. 42
Communication strategies to better provide positive support at work ...................................... 42
Stigma in the workplace ............................................................................................................... 49
Summary of Key Ideas ...................................................................................................................... 51
Recovery ............................................................................................................................................... 60
What is recovery? ............................................................................................................................. 60
Recovery Guidelines ..................................................................................................................... 60
How to find recovery-oriented health-care services ....................................................................... 63
How to find a recovery-oriented therapist .................................................................................. 63
How do I know if a therapy program is recovery-oriented? ........................................................ 64
How do I know if I am receiving adequate health services? ........................................................ 64
Summary of Key Ideas ...................................................................................................................... 65
Strategies in the workplace ................................................................................................................. 72
If I have PTSD or STS, what about my job? ...................................................................................... 72
What are some job retention strategies if I have PTSD/STS? ...................................................... 73
What are my rights? ......................................................................................................................... 73
Am I being accommodated appropriately at work? .................................................................... 73
Seeking help from an Occupational Therapy Case-Manager ........................................................... 74
Summary of Key Ideas ...................................................................................................................... 76
Family and Friends ............................................................................................................................... 80
Role and Importance of Family and Friends .................................................................................... 80
What is PTSD/STS? What do I need to look out for? ....................................................................... 81
What can I do if my loved one might have/has PTSD/STS? ............................................................. 82
Strategies for family and friends while supporting someone with PTSD/STS ................................. 83
Summary of Key Ideas ...................................................................................................................... 84
Conclusion ............................................................................................................................................ 88
Resources ............................................................................................................................................. 90
Glossary ................................................................................................................................................ 98
References ......................................................................................................................................... 104
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P r e f a c e
Preface
This toolkit came about following one of the authors, Roaine Ash’s, experience of
interacting with several retired first responders. They shared stories with her of situations they
had encountered in the line of duty as first responders that had significantly affected and
altered their lives. They described to her how these situations, even if they had happened
decades ago, still haunted them and made living a “normal” life difficult. In short, they shared
with her what it was like to be a first responder living with post-traumatic stress disorder
(otherwise known as PTSD).
It is through these shared stories that Roaine Ash came to understand and identify a
very urgent need amongst first responders, who through their daily service to the public,
repeatedly and often unknowingly, place themselves at risk for psychological trauma and PTSD.
The need itself is simple; first responders lack psychological training against the risks of PTSD
and also lack effective prevention strategies to minimize these risks. This toolkit was written in
order to address this need.
Using a health promotion and recovery-oriented approach towards the prevention and
intervention of PTSD and secondary traumatic stress (STS), we the authors, master’s level
students in occupational therapy, have designed a toolkit that incorporates the following
sections in order to better meet the needs of first responders:
- Introduction – We share with you the basics needed to continue through the toolkit
by answering questions such as: What is a first responder? What is occupational
therapy? What is mental health? We also provide our rationale for occupational
therapists being the authors of this toolkit.
- Post-Traumatic Stress and First Responders – In this section we address all the
relevant questions surrounding “What is PTSD/STS” by highlighting the symptoms to
look out for, discussing the occupational impact and risks of having PTSD/STS,
provide a self-screening tool, and discuss the silver lining of PTSD/STS known as
post-traumatic growth.
- Strategies for Mental Health Promotion – Here we outline four groups of strategies
that can be used to prevent and/or decrease the impact of PTSD in your day to day
life. Pulling from the literature on PTSD, we explore strategies such as resiliency,
coping mechanisms, self-management, and the importance of peer support.
- Recovery – This section is devoted to the concept of recovery because it represents
an important shift in the way that the medical community conceptualizes living with
a mental illness. We provide things to look for when choosing a health-care
professional and a therapeutic approach so that they support the recovery model of
mental health.
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P r e f a c e
- Strategies in the Workplace – We then address some of the big issues surrounding
keeping your job as a first responder, as well as what are the employee's rights, and
the obligations of employers.
- Family and Friends – In this section we want to address the needs and concerns of
the loved ones of first responders. The social support network of the first responders
also needs to feel equipped to assist in the prevention and early identification of
PTSD/STS. Practical tips such as how to help a loved one who has PTSD/STS are
provided.
In addition we have included a guide to all of the resources that are mentioned in this
toolkit as well as stand-alone pages at the end of each section that can be removed for easy
reference. It is also interesting to know that this toolkit for first responders has a companion
version, SPOTting PTSD: A PTSD Toolkit for Organizations aimed at preventing and addressing
PTSD/STS from the organizational and managerial perspective.
We would like to highlight that this toolkit, while largely informed by the current
literature on PTSD/STS, is only evidence-informed. That is not to say that there was not a
rigorous research process behind the information provided in this toolkit. In fact, this toolkit is
the result of a lengthy knowledge translation endeavor to produce a work that incorporated
current literature with the knowledge and opinions of first responders in order for this toolkit
to reflect the real world needs and concerns of first responders while offering the best evidence
from the literature to support concrete solutions.
However, caution is encouraged when making medical decisions based on the content
of the toolkit. Always consult with a mental health care professional when making important
medical decisions. Also, by providing the resources and links in this toolkit, we, the authors and
the McGill School of Physical and Occupational Therapy, are not endorsing the organizations
listed. Rather, included resources are intended to provide you with information to further your
understanding and education about PTSD/STS. The list of resources is not necessarily complete
as new resources are continuously being developed.
At this point we would also like to take the time to thank everyone who has helped us
on the journey to complete this toolkit. Immense gratitude is owed to our supervisors, Dr. H.
Lambert and Hiba Zafran, for their never-ending support, guidance, patience, and
encouragement throughout the research, drafting, and editing stages of the toolkit. Special
thanks is also given to Dr. R. Lencucha for additional assistance with the Resiliency section of
the toolkit. Finally, and most importantly, we would like to thank the first responders who took
the time to share about their experiences of living with PTSD and who, at every step of the way,
have helped inspire and shape this toolkit.
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I n t r o d u c t i o n
INTRODUCTION
Topics Discussed in this Section:
- What is a First Responder and/or Emergency Responder?
- What is Occupational Therapy?
- What is Mental Health?
- Why are Occupational Therapists concerned about the Mental Health of First
Responders?
What is a First Responder and/or Emergency Responder?
Within this toolkit we will be defining a first responder as any person who is trained to
attend to the scene of an emergency and who assists in stabilizing the condition of that
emergency. First responders are generally police officers, firefighters, emergency medical
technicians (EMTs), and paramedics. However, first responders can also be trained volunteers.
As part of their job profiles, these groups fulfill different roles when attending to an emergency.
Despite their chosen field, a first responder is generally an action-oriented person24, who
frequently has a strong desire to help others in their time of need25, and will be among the first
present at the site of the emergency. For example, the Canadian Ski Patrol is a national
volunteer-based first responder organization that is made up of approximately 5,000 volunteers
who all share in the desire to help others during an emergency26.
What is Occupational Therapy?
Occupational therapy provides a healthcare service that promotes independence in
peoples’ homes, communities, and workplaces despite impairments or participation
restrictions27. This is achieved through occupation-based therapy, which uses goal-directed
activities that are designed to increase participation in occupation(s)28. In occupational therapy, an
occupation is defined as any activity that “organize(s) time and bring(s) structure and meaning to
one’s life”27,29. As a result, we, as occupational therapists, are creating this toolkit for first
responders because research has shown that their profession often involves routine exposed to
psychological stressors that can create barriers in their participation at work30-32. This research
suggests that there is an immediate need for the development of occupation-based interventions
to prevent these barriers and to increase first responders’ understanding of how to manage these
psychological stressors in a healthy way33.
One of the guiding models that occupational therapists use to help their clients achieve
their occupational goals is the Canadian Model of Occupational Performance and Engagement
(CMOP-E)11. This model helps visualize the inter-related components that affect a person’s
participation in everyday activities.
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I n t r o d u c t i o n
Here is a quick overview of the components that make up the CMOP-E11. Understanding
these relationships will help you to better grasp how all the different sections of this toolkit
come together to provide support for first responders.
Person: The Person is at the center of the model because, according to occupational
therapy research, a person exists within an occupation and the environment. It is the
interaction between their chosen occupations and the environmental context that
shapes a person. The Person is, therefore, defined as the mental, emotional, physical,
and spiritual reactions to how they are being influenced by their occupation and
environment. These reactions are classified as either healthy reactions or unhealthy
reactions34.
Occupation: Occupations are activities that “organize time and bring structure and
meaning to life”11. These activities are the bridge between the person and their
environment and can be categorized into self-care, leisure, and productivity activities.
- Self-care activities include anything a person does to care for themselves (e.g.,
hygiene tasks, cooking, dressing, etc.).
- Leisure activities includes anything a person does that promotes the enjoyment
of life (e.g., sports, art, reading, etc.).
- Productivity activities include anything a person does that contributes to the
social and economic status of their life (e.g., employment, education,
volunteering, etc.).
Environment:
Social, Physical, Cultural, and Institutional
Occupation:
Self-Care, Productivity, and Leisure
Person:
Physical, Affective, Cognitive, and
Spirituality
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I n t r o d u c t i o n
For example, the occupation of being a first responder is classified as productivity. These
occupations can also promote health or illness depending on how they affect the person
and the environment34.
Environment: The environment is by far the broadest component of this model since
individuals are affected by the physical, institutional, and social environments in which
they live and work. The environment is considered to be the background that sets the
tone for the other two components and is an important influence in health and illness –
depending on the ease in which the environment can adapt to a person’s needs34.
Lastly, the role of the occupational therapist is to address each of these components as
interrelated spheres. The occupational therapist facilitates participation in everyday life by
strengthening the interactions between the person, environment and their occupations35.
What is Mental Health?
According to the World Health Organization (WHO), health is “a state of complete
physical, mental, and social well-being and not merely the absence of disease or infirmity”36.
Mental health occurs when you are able to “realize your own abilities, cope with stress, work
productively, and contribute to your community”36. Therefore, mental health is an essential
component of overall health and contributes to the quality of our lives. Positive mental health
can buffer the stressors of everyday life and reduce the risk of developing mental illness17.
Mental Illness from an Occupational Therapy Perspective
The occupational therapy perspective of mental health is very unique as it incorporates
the individual’s needs5 and recognizes that difficulties with mental health can occur from within
each of the areas described in the CMOP-E when one, or more, areas are out of balance. There
are different ways that this imbalance can occur: from within the person, from within
occupations, and from within the environment.
Within the person; thoughts, feelings, and behaviors can
be negatively impacted by a traumatic experience or set of
experiences. When these experiences color a person’s view of the
world, their view of themselves, and/or their view of others; it can
affect their daily activities and their relationship to these activities.
Within the environment, the
elements that make up the environmental setting (see CMOP-E above)
can create imbalance17. For example, the work place environment with
its particular demands on first responders, the social atmosphere of
work, having or not having the right material to do your job, and the
culture that surrounds being first responders can contribute to an
imbalance in mental health.
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I n t r o d u c t i o n
Lastly, within the occupations, imbalance can occur when
different types of activities are either too present in our lives (e.g. we
devote all our time to work), or too little present in our day-to-day (e.g.
not investing in enough “me” time).
The role of occupational therapy in mental health is to address
the barriers that occur and to facilitate participation in meaningful
occupation35 thus re-aligning the interactions between the person,
environment and occupation. Depending on the source(s) of the imbalance, different
occupational solutions are in order.
Why are Occupational Therapists concerned about the Mental Health of
First Responders?
Occupational Therapists are concerned about the mental health of first responders
because when first responders experience mental health issues, such as PTSD, many areas of
occupation and participation are affected37,38 . For example, engaging in once-meaningful
activities with family and close friends become disrupted due to the symptoms experienced by
the person, thus impacting socialization and leisure39. Moreover, PTSD also impacts a person’s
ability to be productive, especially in work environments that are associated to the trauma.
Individuals with PTSD who are unemployed are less likely to obtain competitive employment,
and those who return to their jobs report decreased levels of work productivity and increased
interpersonal conflict in the workplace40).
It therefore comes as no surprise to learn that first
responders, since they participate in high risk professions,
need support in order to learn to cope and live with the
psychological consequences of their work. One of the
ways that occupational therapy is engaged in offering
that support is through health promotion initiatives which
are aimed at “improving overall health and wellbeing so
as to prevent or reduce illness, accidents, and injury in
individuals and groups”41. It is through initiatives like the
making of this toolkit that occupational therapists are
trying to decrease the risk and burden of PTSD for first
responders and those around them.
●●●
Important Reminder!
While many things can
contribute to imbalance in our
lives, it is important to
remember that having an
imbalance DOES NOT mean you
have, or will have, a mental
illness.
●●●
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I n t r o d u c t i o n
Summary of Key Ideas
- A first responder is a trained professional, or volunteer, that arrives on the scene of
emergencies and works to stabilize those emergencies.
- Occupational therapy aims to help individuals be able, continue, and get back to doing
the activities in their live that are important to them.
- Mental health can be understood as an imbalance between the person, their
occupations and their environment.
- An imbalance between the person, their occupations, and their environment does not
mean the person has a mental illness.
- Occupational therapy for first responders aims to prevent this imbalance before it
happens in order to avoid mental illness – such as PTSD.
Relevant Resources
For more information on Occupational Therapy:
o Canadian Association of Occupational Therapists (CAOT) (Website)
www.caot.ca
For more information about Mental Health:
o Canadian Mental Health Association (CMHA) (Website)
www.cmha.ca
o Mental Health Commission of Canada (MHCC) (Website)
www.mentalhealthcommission.ca
o Center for Addiction and Mental Health (CAMH) (Website)
www.camh.ca
o Partners for Mental Health (Website)
www.partnersformh.ca/resources/
o Here to Help (Website)
www.heretohelp.bc.ca/self-help-resources
o Mental Illness Foundation (Website)
www.fmm-mif.ca
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References
5. Canadian Association of Occupational Therapists (CAOT). Occupational Therapy and Mental
Health. 2015; http://www.caot.ca/default.asp?pageid=4128. Accessed June 29th, 2015.
11. Townsend EA, Polatajko HJ. Enabling occupation II: Advancing an occupational therapy vision for
health, well-being & justice through occupation, 2nd Ed. Ottawa, ON.: CAOT; 2013.
17. Mental Health Commission of Canada (MHCC). Changing directions, changing lives: the mental
health strategy for Canada. 2012; http://www.cpa.ca/docs/File/Practice/strategy-text-en.pdf.
24. Flannery RB. Treating Psychological Trauma in First Responders: A Multi-Modal Paradigm.
Psychiatric Quarterly. 2015;86:261-267.
25. Bledsoe BE, Barnes D. Beyond the debriefing debate: what should we be doing? Emergency
Medical Services. 2003;32(12):60-62, 64, 66-68.
26. Canadian Ski Patrol. About Us. 2015; http://www.skipatrol.ca/en/about/. Accessed July 27th,
2015.
27. Rogers S. Portrait of Occupational Therapy. Journal of Interprofessional Care. 2005;19(1):70-79.
28. Rogers S. Occupation-Based Intervention in Medical Settings. OT Practice. 2007;12(15):10-16.
29. Kielhofner G. Conceptual Foundations of Occupational Therapy. 3rd ed. Philadelphia, PA: F. A.
Davis Company 2004.
30. Laffaye C, Cavella S, Drescher K, Rosen C. Relationships among PTSD symptoms, social support,
and support source in veterans with chronic PTSD. Journal of Traumatic Stress. 2008;21(4):394-
401.
31. Regehr C, Goldberg G, Hughes J. Exposure to human tragedy, empathy, and trauma in
ambulance paramedics. American Journal of Orthopsychiatry. 2002;72(4):505-513.
32. Rees CS, Breen LJ, Cusack L, Hegney D. Understanding individual resilience in the workplace: the
international collaboration of workforce resilience model. Frontiers in Psychology. 2015;6:73.
33. Haugen PT, Evces M, Weiss DS. Treating posttraumatic stress disorder in first responders: a
systematic review. Clinical Psychology Review. 2012;32(5):370-380.
34. Leclair LL. Re-examining concepts of occupation and occupation-based models: occupational
therapy and community development. Canadian Journal of Occupational Therapy.
2010;77(1):15-21.
35. Canadian Association of Occupational Therapists (CAOT). CAOT Position Statement Occupational
Therapy and Mental Health Care. 2008; http://www.caot.ca/default.asp?pageID=1290. Accessed
August 2nd, 2015.
36. World Health Organization (WHO). WHO definition of Health. 2003;
http://www.who.int/about/definition/en/print.html. Accessed July 27th, 2015.
37. Seedat S, Lochner C, Vythilingum B, Stein DJ. Disability and Quality of Life in Post-Traumatic
Stress Disorder: Impact of Drug Treatment. PharmacoEconomics. 2006;24(10):989-998.
38. Zatzick DF, Jurkovich GJ, Fan MY, et al. Association between posttraumatic stress and depressive
symptoms and functional outcomes in adolescents followed up longitudinally after injury
hospitalization. Archives of Pediatrics and Adolescent Medicine. 2008;162(7):642-648.
39. Galovsky T, Lyons JA. Psychological sequelae of combat violence: A review of the impact of PTSD
on the veteran’s family and possible interventions. Aggression and Violent Behavior.
2004;9:477-501.
40. Alden L. Factors that predict return-to-work in workers with PTSD. 2012;
http://www.worksafebc.com/contact_us/research/funding_decisions/assets/pdf/2007/RS2007_
IG25.pdf?_ga=1.1999794.2082542950.1438968983. Accessed October 21st, 2014.
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41. Brownson CA, Scaffa ME. Occupational therapy in the promotion of health and the prevention of
disease and disability statement. The American Journal of Occupational Therapy : Official
Publication of the American Occupational Therapy Association. 2001;55(6).
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I n t r o d u c t i o n
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Post - T r a u m a t i c S t r e s s a n d F i r s t R e s p o n d e r s
Traumatic Event
Trauma
Mental Illness/Injury
PTSD/STS
OSI
Progression for a traumatic event towards the development of PTSD.
POST-TRAUMATIC STRESS AND
FIRST RESPONDERS
Topics Discussed in this Section:
- What is Trauma?
- What is Mental Injury and Mental Illness? The Legal versus Medical Definition
- What are Post-traumatic Stress Disorder (PTSD) and Secondary Traumatic Stress (STS)?
- Symptoms of PTSD
- Self-Assessment: SPOTting PTSD Checklist
- Risk Factors for PTSD and STS
- PTSD and STS: Hidden Risk of Suicide
- Life with PTSD or STS: The Power of Post-traumatic Growth
What is Trauma?
Trauma is a physical or mental injury caused by something that tests a person's ability to
cope in a healthy way42. Once someone has experienced trauma it may become more difficult
for them to carry out their everyday activities. This can come from a disruption of the balance
between the person, their occupations, and their environment. This is important to know
because when you understand trauma, you are better able to understand what causes PTSD
and secondary trauma stress (STS).
The “something” that tests a person's
coping is often a traumatic event, where the
person may be “exposed to a situation involving
death, serious injury, or sexual injury”43. It is
important to note that experiencing a single
traumatic event is not usually enough to cause a
case of full blown trauma, rather, it tends to be
repeated exposure to these types of events that
make the next BIG traumatic event lead to a
traumatized state.
We are using the term traumatic event and not
critical incident in this toolkit, despite its
common use with first responders. The reason behind this is that critical incident it is a term
used within the Critical Incident Stress Management7 program and this program has been
shown to be harmful because it increases the symptoms associated to trauma20,22,23.
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Post - T r a u m a t i c S t r e s s a n d F i r s t R e s p o n d e r s
What is Mental Injury and Mental Illness?
The Legal versus Medical Definition
Psychological Injury or Mental Injury is a legal term that was recently has been adopted
by the Supreme Court of Canada from the United States Department of Veterans Affairs. In
Canada, psychological injury is defined as a diagnosable psychological condition that is caused
by an event that leads, or may lead, to legal-related claims, for example, in workers'
compensation44.
The legal recognition of psychological injury is important; the use of the term is
currently laying the foundation for PTSD and STS to be legally considered an occupational stress
injury (OSI). OSI is “the non-medical term used to describe psychological problems resulting
from mentally and/or emotionally traumatic circumstances that occur while at work”45. As it
stands, OSI is not yet a legal term in Canada. However, it is being used by the Canadian Armed
Forces and some first responder organizations in Canada to formally recognize that a mental
injury can occur while performing one’s duties at work45.
We stress understanding the legal implication of a mental injury because if you, or
someone you know, develops PTSD or another mental injury on the job, there is legislation
being put forward to protect your mental health rights in the workplace44,46. Mental health
services are available that are tailored to occupation and trauma related mental illness. See the
Guide to Evidence Based Therapies and Therapists who provide them on page 67.
Mental Illness or Disorder is a medical term for a condition caused by the interactions
between biological, personal, and environmental factors which can cause adverse effects on
your mood, thoughts, and behavior. This adverse reaction often hinders your function in
ordinary life due to the symptoms of the illness. These symptoms may be temporary or chronic
in nature47.
In fact, mental illness indirectly affects all Canadians at
some time or another, either through a family member,
friend, or colleague48. It is important to note that while there
is a distinction between physical and mental disorders in
order to promote accurate diagnoses, the definition of a
mental disorder is virtually the same as the definition of a
physical disorder. That is to say, both have physiological and
environmental components to them that create functional
disability in everyday life regardless of whether it be PTSD or a
broken leg. Equally important, is to bear in mind that the
consequences of “mental” illness are equally impacting as
those of a “physical” illness. Many disorders that are
considered to be purely “in the mind” present with very real
physical symptoms that are easily observable to others.
●●●
Quick Stats
- One in FIVE Canadians will
develop a mental illness over
their lifetime.2,3
- 43% of Canadians suffer poor
health because of stress.
- 8% of adults will experience
major depression throughout
their life.
- Mental illness affects people
of all ages, educational and
income levels, and cultures.
●●●
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Post - T r a u m a t i c S t r e s s a n d F i r s t R e s p o n d e r s
What is Post-traumatic Stress
Disorder (PTSD) and Secondary
Traumatic Stress (STS)?
Post-traumatic stress disorder (PTSD) is
a mental illness caused by being involved in, or
witnessing, a traumatic event that is life
threatening to yourself or others, or threatens
your personal values43. Similarly, secondary
traumatic stress (STS) is a mental illness caused
by hearing and empathizing with a person’s
traumatic experience which might involve life-
threatening events or threatens the listener’s
values 49,50.
There are two types of PTSD and STS: acute and chronic. Acute PTSD and STS, also
known as acute stress disorder, are mental injuries that persist for a time period between 3
days to 1 month after trauma exposure. After this time, the trauma survivor will experience a
remission of symptoms without a relapse. Chronic PTSD and STS is defined as a mental illness
which can persist anywhere from 1-6 months, to a lifetime. In chronic PTSD and STS, it is
common for the trauma survivor to experience a cycle where there are periods of symptom
remission, a recurrence and/or intensification of symptoms due to triggers of the original
trauma or new trauma, followed by another remission, and so on43.
PTSD commonly co-occurs with other mental illnesses. The National Comorbidity Study
in the United States51 reported that almost half of people with PTSD may also develop major
depressive disorder. In the study, men were twice as likely as women to develop alcohol abuse
or dependence. Lastly, a third of men and a quarter of women with PTSD may develop
substance abuse or dependence.
PTSD and STS can have a large impact on a person’s life. In the Introduction section of
this toolkit we discussed the Canadian Model of Occupational Performance and Enablement
and how the components of the Person, Occupation and Environment interact. With specific
regards to PTSD and STS, all areas of the CMOP-E can be affected by an experience with
trauma52:
●●●
If you suspect that someone you know might be suffering from one of these associated conditions,
please see the Relevant Resources at the end of the Section for more information on how to help
them.
●●●
●●●
Quick Stats
- The rate of PTSD in first responders has
been reported to be 37% in the United
Kingdom1-3
- According to the Paramedic Association of
Canada, 27% of first responders reported
suicidal thoughts due to mental injury 8
- An estimated 12-35% of police officers
may meet the diagnostic criteria for PTSD
at any given point15 18-20
●●●
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Person
Cognitive: Difficulty concentrating, losing touch with time and space,
and experiencing unwanted images or thoughts.
Affective: Fear, anger, guilt, grief, numbing, loss of trust, and loss of
self-esteem.
Physical: Difficulty falling or staying asleep, loss or excessive
appetite, loss or changes in libido, and hyper-arousal
(being more vigilant, on edge).
Spiritual: Loss of hope and greater meaning in the world.
Occupation
Across all three elements of occupation (self-care, productivity, and leisure) there can be a
disruption of activity, loss of and/or isolation from everyday activities, leisure, school, work,
social participation, and valued life roles.
Environment
Cultural: Negative attitudes of others can result in victim blame and stigma against the
person with PTSD or STS.
Social: Lack of individual and community supports can contribute to social isolation. Low
socioeconomic status can limit access to services.
Institutional: Policies/laws within hospitals, governments, and/or employers may be
deterrents to seeking help.
Physical: Inability to access services (physical location of services, stigma attached to
mental health facilities)
Symptoms of PTSD and STS
If you develop PTSD or STS after a traumatic
event, your mind and body go into shock and you are
not able to use your usual coping mechanisms to heal.
As a result, you develop symptoms that negatively
impact your life. These symptoms are your
brain telling you to slow down and take care
of yourself and is a normal reaction to trauma.
The following flowchart lists the main categories
of PTSD symptoms53; keep in mind, symptoms of
secondary trauma are nearly identical to PTSD and
should be considered as impactful as PTSD symptoms.
Also, because people react to trauma differently, there
are many different types of PTSD and STS symptoms - we
have only listed a few of them here.
PTST/STS
Symptoms
Avoidance and
Numbing
Avoid discussing
events
Emotional
numbness
Adverse to
activities done in
the past
Intrusive Memories
Flashbacks
Disturbing Dreams
Anxiety and
Emotions
Anger and
Irritability
Guilt and Shame
Substance Abuse
and Destructive
Behaviors
Easily Startled
Extreme Cases:
Violent or Suicidal
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As shown in the flow chart above, the three main symptom categories of PTSD and STS
are avoidance behaviors, uncontrollable intrusive thoughts or memories, and increased anxiety.
Here are some examples of how they can affect you53:
1. Avoidance: Things that remind a person of the traumatic event can trigger avoidance
symptoms and may cause a person to change thier routine. For example, after a traumatic
event involving a car, a person who usually drives may avoid driving or riding in a car.
2. Intrusive thoughts or memories: Things that remind a person of the traumatic event can
trigger intrusive thoughts or memories and will put the person back into the traumatic
event (i.e. reliving the event). Re-experiencing symptoms may cause problems in a person’s
everyday routine as the person may become stressed, angry, or feel threatened. For
example, if someone heard a siren during their traumatic event and then heard it again
while at work, the siren could trigger a very strong memory that could cause the person
distress.
3. Anxiety: This symptom is usually constant, instead of being triggered by things that remind
one of the traumatic event. Anxiety causes a person to feel on-edge, easily startled, and
irritable. Increased anxiety can also make it hard to do daily tasks such as sleeping, eating,
or concentrating, because the person is unable to relax.
If you or someone you know is experiencing the symptoms listed below, please contact a
healthcare professional (see the Guide to Evidence Based Therapies and Therapists who provide
them on page 67).
Self-Assessment: SPOTting PTSD Checklist
It is because first responders are routinely exposed to traumatic events in the course of
their duties that they are at an increased risk for long-term problems from traumatic stress54.
As a result, self-screening and early intervention are vital, given that the symptoms may
contribute to coping problems in family, social, and work settings54. Self-screening also works to
prevent the development of other mental health issues such as substance abuse; self-
destructive behavior; aggression toward others; substantial disability and other comorbidities55
56. By identifying first-responders who are at risk for developing PTSD we improve their overall
outcomes after trauma57 and their quality of life. Screening for PTSD can ensure that timely
help and support is received, which could prevent normal stress reactions from getting worse58.
It could also prevent chronic outcomes and maximize the chances of recovery59. The
consequences of having PTSD that goes undetected are serious and affect both the individual
and their immediate family and friends60.
Attached to this toolkit is a self-screening tool that we have provided in order to
monitor symptoms and their impact on day-to-day life (see SPOTting PTSD Checklist at the end
of the section). The screening tool is based on the PTSD Checklist (PCL), a self-screening tool
which was originally developed by Frank Weathers and his colleagues in 199361,62, and recently
updated to meet the updated criteria for PTSD from the Diagnostic and Statistical Manual of
Mental Disorders Fifth edition (DSM-5)63. This updated version, the PCL-5, is a 20-item scale and
has a 5-point severity scale63.
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The SPOTting PTSD Checklist is a modified version of the PCL-5. It was selected over
other self-screening tools because it is currently the only DSM-5 PTSD screening tool available.
Additionally, the psychometric properties of the PCL-5 are also promising, even if they have not
yet been published, and so provide a sound base from which to adapt a first-responder specific
screening tool. The SPOTting PTSD Checklist incorporates criteria for PTSD that were not
originally included in the PCL-5. Additional modifications include adjustment to the language
used to better reflect the first-responder population. The reading level has also been simplified
and the questions were put in a more standard format in order to simplify self-administration.
Remember that this screening tool is exactly that, a screening tool. There is no diagnostic value in
the tool! It cannot tell you if you have or do not have PTSD. Also, this version has not been tested
for reliability or validity and so cannot be used for treatment planning.
We strongly recommend that individuals who choose to use this screening tool do so
for their own well-being and self-management. Individuals may also choose to share the results
of their screening tool with a trusted health care professional who can then guide them
towards appropriate services (see the Guide to Evidence Based Therapies and Therapists who
provide them on page 67).
Risk Factors for PTSD and STS
While there is no fail-proof way to say who will develop PTSD/STS and who will not
there are many documented risk factors that can increase the likelihood of developing PTSD
and STS.
One of the key risk factors is the type of trauma that a person is exposed to. A study by
the University of Toronto in 200231 studied trauma exposure in paramedics where the goal of
the study was to identify call characteristics that the paramedics found to be most traumatic. A
key finding from this study, which applies to everyone who experiences a traumatic event, is that a
person is more likely to find a situation traumatic if the event challenges one of their core values or
beliefs. For example, many paramedics reported that witnessing the abuse or the death of a
child was considered traumatic - especially if they themselves have children31. Other situations
that paramedics found to be traumatic included: death of a child, experiencing a line-of-duty
death, having a near-death experience, death of a patient, cases with multiple casualties, cases
of violence against the self, cases involving motor vehicle accidents, cases involving cardiac
arrest, and cases of violence against others31,64.
Other significant risk factors for the development of PTSD/STS following exposure to a
traumatic event include having:
- Repetitive exposure: Going through a series of traumatic events that cause an
accumulation of stress31.
- Inexperience: Risks for developing PTSD/ STS are higher for first responders who have
recently joined the profession. This risk decreases as the person gains experience65.
- Previous history of trauma: Experiencing a physical or mental injury as a result of a
personal or work-related traumatic event in the past31.
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- Previous history of mental illness: Pre-existing anxiety or depression as well as a family
history of anxiety or other mental illness66.
- Burnout: physical or mental deterioration caused by overwork, stress, low job
satisfaction, and feeling powerless at work 32,67.
- Compassion fatigue: emotional strain caused by working with, or being exposed to,
people who are suffering32,67.
- Negative or no social support: Having no social support or having a social support
network that reacts negatively to a trauma survivor’s expression of their trauma has
been shown to be a risk factor for PTSD and STS30.
PTSD and STS: Hidden Risk of Suicide
The risk for suicidal behavior is complex and we do not know why some people with
PTSD commit suicide and others do not. Suicide is not a normal response to stress. It is a sign of
extreme distress and is not a harmless bid for attention. For more information about suicide and
suicide prevention please see the Suicide Prevention Resource and Emergency Number List at
the end this section.
Here are some suicide warning signs that are important to look out for68,69:
- Suicidal Ideations (thoughts)
- Talking about wanting to die or to kill oneself
- Looking up different ways to kill oneself
- Talking about feeling hopeless or having no reason/purpose to live
- Talking about feeling trapped, or in unbearable pain
- Talking about being a burden to others
- Increased use of drugs or alcohol
- Acting anxious or agitated; behaving recklessly
- Sleeping too little or too much
- Withdrawing, feeling isolated
- Showing rage; talking about seeking revenge
- Displaying extreme mood swings
- Giving away prize possessions and/or making a will
- Reconnecting with old friends and extended family as if to say goodbye
What is a Crisis Situation – What Do I Do?
A crisis is an emergency that is an immediate threat to a person’s physical, emotional,
and mental health. Extreme stress (e.g., violence and trauma) can lead to crisis. A crisis can
happen when a person's usual coping strategies are overwhelmed and they need urgent
support70.
People can display symptoms of a crisis against themselves or others. Being at risk to
themselves can include behaviors such as talking about suicide or risky behaviors such as
●●●
IMPORTANT! If someone around you one voices thoughts or plans of suicide, or is experiencing
a crisis situation, please contact 911 immediately!
●●●
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drinking and driving. A risk to others happens if they are becoming aggressive or have described
plans that act out violence within the community.
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Life with PTSD or STS: The Power of Post-traumatic Growth
There is little research available on what life with STS looks like. However, we’ve
mentioned that STS is nearly identical to PTSD, and there is research on life with PTSD. Research
has shown that trauma can lead to negative outcomes (e.g., PTSD and STS) but it can also lead
to positive outcomes such as post-traumatic growth (PTG)71. Post-traumatic growth is defined
as the positive changes within a person that results from an event which disrupts one's view of
the world. PTG is the result of altering your worldview in the aftermath of the trauma72,73.
How does PTG work?
The results of research on PTG are varied. One study suggests that 30-70% of trauma
survivors will say that they have experienced positive changes of one form or another74.
Another study on PTG75 reported that after experiencing a traumatic event people often report
three ways their quality of life increased:
Relationships became enhanced - they come to value their friends and family more;
Their view of themselves changed – they developed wisdom, strength, and/or gratitude;
Their philosophy of life changed – they deepened their spirituality.
However, one thing that PTG research does agree on is that PTG does not occur in the
absence of suffering. Personal reflections on trauma and the aftermath of the traumatic event
are unpleasant. This reflection is required for the person to adapt their life story to the trauma
since this trauma will have changed them in one way or another. Therefore, post-traumatic
growth does not necessarily yield less emotional distress76. However, at some point after the
trauma, trauma survivors may be able to engage in personal reflection of their own life process
and the events that took place. This reflection process becomes part of their life story and
includes an appreciation for new ways of coping with life events76. This process is called the
recovery process which is discussed in the next section of the toolkit.
Summary of Key Ideas
- Trauma is a physical or mental injury caused by something that tests a person's
ability to cope in a healthy way.
- Post-traumatic stress disorder (PTSD) is a mental illness caused by being involved in,
or witnessing, a traumatic event.
- Secondary traumatic stress (STS) is a mental illness caused by hearing and
empathizing with a person’s traumatic experience.
- There are three main symptom categories of PTSD and STS: avoidance behaviors,
uncontrollable intrusive thoughts or memories, and increased anxiety.
- Self-screening is important to monitor symptoms of trauma and their impact on day
to day life.
- While trauma can negatively impact your life, it can also create positive changes
through post-traumatic growth.
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Relevant Resources
Additional Information on PTSD/STS
o PTSD from the Canadian Association of Mental Health (Website)
http://tinyurl.com/camh-ptsd
o Trauma from the Canadian Association of Mental Health (Website)
http://tinyurl.com/camh-trauma
o PTSD from the Canadian Mental Health Association (Website)
https://www.cmha.ca/mental_health/post-traumatic-stress-disorder/
Additional information about the associated mental health issues surrounding PTSD:
o Acute Stress Disorder from the Canadian Association of Mental Health(Website)
http://tinyurl.com/camh-acutestressdisorder
o Addiction from the Canadian Association of Mental Health (Website)
http://tinyurl.com/camh-addiction
o Alcohol Abuse from the Canadian Association of Mental Health (Website)
http://tinyurl.com/camh-alcoholabuse
o Anxiety Disorders from the Canadian Association of Mental Health (Website)
http://tinyurl.com/camh-anxiety
o Anxiety from the Canadian Mental Health Association (Website)
https://www.cmha.ca/mental-health/understanding-mental-illness/anxiety-
disorders/
o Anxiety Disorders Association of Canada (Website)
www.anxietycanada.ca
o Anxiety and Mood Disorders from Revivre (Website)
www.revivre.org
o Depression from the Canadian Association of Mental Health (Website)
http://tinyurl.com/camh-depression
o Depression from the Canadian Mental Health Association (Website)
https://www.cmha.ca/mental-health/understanding-mental-illness/depression/
o Mood & Anxiety Disorder from Revivre (Website)
www.revivre.org
o Stress, Trauma and Substance Use Disorders (PDF)
http://tinyurl.com/ccsa-substanceabuse
Additional Information on Suicide and Suicide Prevention:
o Canadian Association for Suicide Prevention (Website)
www.suicideprevention.ca
o Reason to Live
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Provides information on suicide, how to cope with suicidal thoughts, as well as
how to support a loved one that may be suicidal or who has lost someone to
suicide. (Website)
www.reasontolive.ca
o Suicide from the Canadian Association of Mental Health (Website)
http://tinyurl.com/camh-suicide
o Suicide from the Canadian Mental Health Association (Website)
https://www.cmha.ca/mental-health/understanding-mental-illness/suicide/
o Suicide Prevention Webinars
The Mental Health Commission of Canada created a free webinar series on
suicide prevention and intervention, and postvention. The interactive webinars
are held monthly by people with lived experience, researchers, and service
providers. There are several opportunities during the webinars to engage in
conversation with the presenter to ask questions. (Website)
http://tinyurl.com/mhcc-suicidewebinars
o Suicide Prevention Guide for First Responders
The World Health Organization created a guide for first responders on how to
prevent and intervene in suicide and how to recognize suicide risk factors. (PDF)
http://www.who.int/mental_health/prevention/suicide/resource_firstresponder
s.pdf
o Toolkit for Survivors of Suicide Loss and Postvention for Professionals
The Mental Health Commission of Canada has created several guides as part of
the free Toolkit for Survivors of Suicide Loss and Postvention Professionals. The
guides are available to anyone and the topics range from how to cope with grief
to how to discuss the loss with children and healing after suicide. (PDF)
http://tinyurl.com/mhcc-suicidetoolkit
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SPOTting PTSD CHECKLIST
A modified ve rsion of the PCL-5
Name: _________________________________________ Date: ___________________________
Instructions: Below is a list of problems that people may have in response to a very stressful event.
Please read each line carefully and circle one of the numbers to the right to indicate how much you have
been bothered by that problem in the past month.
Remember this is only meant to be a screening tool; it cannot provide a diagnosis of PTSD.
In the past month,
how much were you bothered by:
Not at
all
A little
bit
Moderately
Quite a
bit
Extremely
1. Having memories of the stressful event
that you do not want, that disturb you,
and/or that come back again and again?
0
1
2
3
4
2. Having the same dreams of the stressful
event over and over?
0
1
2
3
4
3. All of a sudden feeling or acting as if you
were living the stressful event over again?
0
1
2
3
4
4. Feeling very upset when something
reminded you of the stressful event?
0
1
2
3
4
5. Having physical signs of stress when
something reminded you of the stressful
event (e.g., pounding heart, trouble
breathing, sweating)?
0
1
2
3
4
6. Avoiding memories, thoughts, or feelings
related to the stressful event?
0
1
2
3
4
7. Avoiding reminders of the event (e.g.,
people, places, conversations, activities,
objects, etc.)?
0
1
2
3
4
8. Having trouble remembering important
parts of the stressful event?
0
1
2
3
4
9. Having strong negative beliefs about
yourself, other people, or the world (e.g., I
am bad, there is something very wrong with
me, no one can be trusted, the world is very
dangerous)?
0
1
2
3
4
10. Blaming yourself or someone else for
the stressful event or what happened after
it?
0
1
2
3
4
11. Having strong negative feelings such as
fear, horror, anger, guilt, or shame?
0
1
2
3
4
12. Having less interest in activities that you
used to enjoy?
0
1
2
3
4
13. Feeling distant or cut off from other
people?
0
1
2
3
4
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14. Trouble experiencing positive feelings
(e.g., being unable to feel happiness or have
loving feelings for people close to you)?
0
1
2
3
4
15. Acting irritable or aggressively, having
angry outbursts?
0
1
2
3
4
16. Taking too many risks or doing things
that could cause you harm?
0
1
2
3
4
17. Being "super alert" or watchful or on
guard?
0
1
2
3
4
18. Feeling jumpy or easily startled?
0
1
2
3
4
19. Having difficulty concentrating?
0
1
2
3
4
20. Having trouble falling or staying asleep?
0
1
2
3
4
The following information can be filled at your discretion. If you are choosing to bring this checklist to a
mental health care professional, this information will be useful to them when you first meet them.
If possible, please briefly describe the traumatic event or events that lead you to fill out the SPOTting
PTSD Checklist. Please add dates if you can: _________________________________________________.
_____________________________________________________________________________________
_____________________________________________________________________________________
Approximately how long have you been experiencing the problems described in the above chart as a
result these event(s)? __________________________________________________________________.
Please read the following list and place an (X) next to the areas of functioning that you find are impacted
by the problems described above.
Area of Functioning
Comments:
Self-Care
(e.g. hygiene, cooking, etc.)
Work
(e.g. both paid and non-paid work)
Social Activities
Leisure Activities
Other: (Please specify)
Scoring: If you have scored “moderately” or higher (scores of 2 or more) on more than half of the
items, or if you have concerns about your score, please contact a mental health professional for more
information. Keep in mind that an accurate diagnosis for PTSD can only be made by a qualified mental
health professional after a complete evaluation.
Note to Clinician: This screening tool has not yet been tested for reliability or validity and so cannot be
used for treatment planning or diagnostic purposes.
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Suicide Prevention Resources and Emergency Number List
Due to the high-risk nature of first responder jobs, we strongly recommend that that
first responders utilize the follow emergency contact numbers77 to better inform themselves
about suicide and suicide prevention.
REMEMBER: If you or a person you know is seriously contemplating suicide or is in crisis, call 911
immediately to get them to the nearest hospital.
Emergency Contact Numbers:
o Alberta:
St. Paul & District Crisis Center: 1-800-263-3045
Distress Line of Southwestern Alberta: 1-888-787-2880
Distress Center Calgary: 403-266-4357
Crisis Support Network (The Support Network): 1-800-232-7288
o British Columbia:
Suicide Line across all BC 24/7: 1-800-784-2433
Canadian Mental Health Association Crisis Line: 1-800-667-8407
Crisis Centre for Northern BC: 1-888-562-1214
Crisis Intervention & Suicide Prevention Centre of BC: 604-872-3311 and
1-866-661-3311
o Manitoba
Manitoba Suicide Line: 1-877-435-7170
Mental Health Crisis Service: 1-888-310-4593
Crisis Stabilization Unit: 204-940-3633
Interlake Regional Health Authority Mental Health: 204-482-91272
o New Brunswick
Chimo Helpline: 1-800-667-5005
o Newfoundland & Labrador
Mental Health Crisis Centre: 1-888-737-4668
o Northwest Territories, Yukon and Nunavut
Nunavuat Kamatsiaqtut Help Line: 1-800-265-3333
NWT Help Line: 1-800-661-0844
o Nova Scotia
Eastern Regional Help Line: 1-800-957-9995
Mental Health Mobile Crisis Team: 1-888-429-8167
Pictou County Help Line: 902-752-5952
o Ontario (Note: In the province of Ontario all the crisis numbers are divided by
area)
Cambridge : 519-658-6805
Durham County: 1-800-452-0688
Hamilton: 905-522-1477
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Kingston: 613-544-1771
Kitchener Waterloo: 519-745-1166
Lanark, Leeds and Grenville Counties: 1-800-465-4442
London & District: 519-433-2023
Niagara Region: 905-688-3711
North Halton: 905-877-1211
Oakville: 905-849-4541
Ottawa & Region: 1-866-996-0991
Peel Region: 1-800-363-0971
Sarnia & Lambton County: 1-888-347-8737
Six Nations Crisis Line: 1-866-445-2204
Toronto: 416-408-4357 (Survivor Support Program: 416-595-1716)
Waterloo Region: 519-745-1166
Wellington and Dufferin Counties: 1-877-822-0140
Windsor & Essex County: 519-256-5000
o Prince Edward Island
Island Helpline: 1-800-218-2885
o Quebec
Centre de prévention du suicide de Québec : 1-866-277-3553
Suicide Action Montréal : 514 723-4000
Tel-Aide: 514-935-1101
o Saskatchewan
Hudson Bay & District Crisis Centre: 1-866-865-7274
Mobile Crisis Service (Saskatoon): 306-933-6200
North East Crisis Intervention Centre: 1-800-611-6349
Prince Albert Mobile Crisis Unit: 306-764-1011
Regina Mobile Crisis Services: 306-525-5333
Resources on Suicide and Suicide Prevention:
o Canadian Association for Suicide Prevention (Website)
www.suicideprevention.ca
o Reason to Live
Provides information on suicide, how to cope with suicidal thoughts, as well as
how to support a loved one that may be suicidal or who has lost someone to
suicide. (Website)
www.reasontolive.ca
o Suicide from the Canadian Association of Mental Health (Website)
http://tinyurl.com/camh-suicide
o Suicide from the Canadian Mental Health Association (Website)
https://www.cmha.ca/mental-health/understanding-mental-illness/suicide/
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o Suicide Prevention Webinars
The Mental Health Commission of Canada created a free webinar series on
suicide prevention and intervention, and postvention. The interactive webinars
are held monthly by people with lived experience, researchers, and service
providers. There are several opportunities during the webinars to engage in
conversation with the presenter to ask questions. (Website)
http://tinyurl.com/mhcc-suicidewebinars
o Suicide Prevention Guide for First Responders
The World Health Organization created a guide for first responders on how to
prevent and intervene in suicide and how to recognize suicide risk factors. (PDF)
http://www.who.int/mental_health/prevention/suicide/resource_firstresponder
s.pdf
o Toolkit for Survivors of Suicide Loss and Postvention for Professionals
The Mental Health Commission of Canada has created several guides as part of
the free Toolkit for Survivors of Suicide Loss and Postvention Professionals. The
guides are available to anyone and the topics range from how to cope with grief
to how to discuss the loss with children and healing after suicide. (PDF)
http://tinyurl.com/mhcc-suicidetoolkit
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References
1. Clohessy S, Ehlers A. PTSD symptoms, response to intrusive memories and coping in ambulance
service workers. British Journal of Clinical Psychology. 1999;38(3).
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