What can I do if I’m not OK?  

Psychological injuries can heal

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Help for common difficulties

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Getting professional help

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The simple answer to this question is that there’s lots we can do when we’re not OK. And recognising that we’re not OK is the first step to getting better.

If we stick with our car metaphor,  then the information provided here is a mixture of tips for the self-taught mechanic and advice from specialists at the garage, including when you should book your car in to get some expert help.

The key thing is that there is always something we can do to get the car back on the road. We have treatments that work for mental ill health. Remember mental health problems are common and can happen to anyone. Don’t struggle on.

Common difficulties explained

Low mood and depression
All of us feel down from time to time, especially after stressful life events, but depression is different. It is an illness that affects how we feel (both emotional and physically), how we think and how we behave.  You can find more information the symptoms of depression and what helps on this NHS website but things to look out for are:

Psychological      
- Persistent feelings of sadness or low mood      
- Loss of interest in things we usually enjoy      
- Feeling hopeless     
- Can’t make decisions or think clearly
- Feeling a failure or worthless
- Wanting it all to stop / thoughts of suicide

Physical
-
Sleep difficulties, especially getting off to sleep and waking early
- No energy
- Changes in appetite (eating more or less)
- Loss of interest in sex
- Aches and pains

Behavioural / social
-
Withdraw from family and friends
- Disengage from social activities
- Use alcohol or substances to cope (self-mediation)
- Self-neglect and self-harm  

One of the hardest things about depression is the fact that often we blame ourselves for feeling this way. We don’t realise that feeling like a failure and having thoughts of suicide are as much a part of depressive illness as high blood sugar levels are a part of having diabetes. It is important to remember that we are not our thoughts. And that when we are unwell with depression it can be a bit like wearing despair-tinted glasses. This wee animated film, Depression is a black dog is a good description of how it feels and what we can do to manage it

Suicidal thoughts are scary. They can trigger feelings of guilt and shame and be very hard to talk about. That’s why we have a national campaign Ask, Tell, Save a Life. to make them easier to discuss. Please don’t give yourself a hard time for having them but do keep yourself safe and reach out for help.  

We have effective treatments for depression, including antidepressant medication and talking therapies like Cognitive Behavioural Therapy (CBT) and Interpersonal Psychotherapy (IPT). Medication helps because if re-sets the hormones which regulate our mood and which are depleted when we’ve been under stress or feeling low for a long time. Exercise really helps here too. CBT and IPT work because they help us to challenge negative automatic thoughts and reconnect us with the people and activities that give us purpose and pleasure.  

Your GP can prescribe antidepressant medication and can refer you for a talking therapy. You can also access these through the SAS Employee Assistance Provider or The Ambulance Services Charity. Details on the Welcome page.

There are also self-help courses available online including Silvercloud, a structured programme based on CBT that focuses on supporting your wellbeing, including managing your mental health, resilience, stress and sleep. Use code Scotland2020.
Burnout and compassion fatigue
Burnout is when people feel physical and psychological exhaustion related to their work over a long period of time. In some jobs, including in the emergency services, this exhaustion may be combined with exposure to distress and human suffering. When this happens, we are at risk of experiencing feelings that have been called compassion fatigue. You may struggle to feel empathy or compassion for others, might question whether you can do your job or feeling detached, shut-down or even angry.  

It is not unusual for people in helping roles to feel some of these things sometimes. It doesn’t mean that you’re not a good person or a competent worker.

If you are experiencing any of these feelings it is important to recognise that they are another occupational hazard of working in a helping role. We are at risk of post traumatic stress if we’re exposed to potentially traumatic events and we’re at risk of compassion fatigue if we’re exposed to human suffering.  Please be kind to yourself and take time to rest. When you are not in work, try to do things that give you pleasure and connect to the people who are important to you. As much as possible, try to maintain a balance between your work and home life.  You can also get support from one of the services listed on the Welcome page.
Anxiety
We all feel anxious from time to time, often in response to stressful life events. Anxiety involves a range of physical and emotional responses triggered by the stress response which is activated when we’re worried or nervous about something.  

If we continue to be under pressure then our body's stress response doesn’t switch off and this then affects how we think and feel.  When our body is tense and ready to respond to threat, our mind thinks there is a threat to respond to. This can become self-fulfilling: the more anxious we feel, the more adrenalin our body produces, so we feel more anxious and overestimate the challenges and underestimate our ability to deal with them.

Feelings of anxiety can spiral until we feel panicky and out of control. We feel anxious about being anxious. We worry other people can see that we're anxious. It's horrible.

Living with constant anxiety is exhausting and will have a huge impact on your quality of life. Try using exercise and relaxation to get your stress response under control and do things that keep your mind focused on the present moment.
The best treatment for anxiety is cognitive behavioural therapy where you will learn:
  • to calm your internal alarm system through breathing, exercise and relaxation
  • how your thoughts and attitudes affect how you feel and what you can do to manage them
You can find tips for coping with anxiety in this NHS Scotland self-help guide or you can try the  Daylight app, an evidence-based anxiety management programme based on CBT that is free to Scotland’s emergency responder community.
Panic
A panic attack happens when our body experiences a rush of intense psychological (mental) and physical symptoms. We may experience an overwhelming sense of fear, apprehension and anxiety. As well as these feelings, we may also have physical symptoms such as:
  • nausea   
  • sweating
  • feeling faint
  • shaky limbs, like our legs have turned to jelly
  • a sensation that our heart is beating irregularly (palpitations)
  • feeling like we can’t breathe and /or chest pains
  • feeling like you’re not connected to your body
Panic attacks are not dangerous, but they can be very frightening and cause us to feel even more anxious and panicky. How often they happen varies from person to person.  You might have one panic attack and never have another, you might have an attack once a month or have several a week. They usually last between 5 – 20 minutes but if it feels like they go on for longer, then you may be having one attack after another, or feeling frightened after the first one.

The best treatment for panic disorder is cognitive behavioural therapy where you will learn how:
  • to calm your internal alarm system through breathing, exercise and relaxation   
  • how your thoughts and attitudes affect how you feel and what you can do to manage this

You can also use an NHS Scotland self-help guide on coping with panic attacks or you can try the Daylight app, an evidence-based anxiety management programme, based on CBT, which is free to Scotland’s emergency responder community.

If these things don’t help then it’s a good idea to get some professional help. You can do this via your GP or from the SAS Employee Assistance Provider. Find the the support services available on the Welcome page.

Insomnia
Sleep problems can be caused by lots of things including stress and physical health conditions, and when that’s the case the best plan is to address these things first. However, sometimes we’re doing OK, but we just can’t get a good night’s sleep. Shift work doesn’t help with this!

If you're having problems with insomnia please try Sleepio, an evidence-based sleep improvement programme (based on CBT) that is free to Scotland’s emergency responder community.

For more information on improving your sleep you can also look at this NHS guide on how to improve your sleep, the Sleep Council's 10 Commandments or this NHS24 video on how to improve your sleep.  
Bereavement and grief
At some point we will all lose someone we love. Bereavement can trigger lots of different emotions from grief and longing to fear, confusion, guilt, anger or numbness. We may feel all these things at the same time or none. They are all normal reactions to the pain of loss.

Our bereavement may be complicated by being unexpected, sudden, prolonged or perhaps happening when we’re estranged from the person who has died. Child deaths and those involving a traumatic incident are always harder to cope with, not least because other people don’t know what to say to us when this happens.

It’s also difficult if we’re not able to be with our loved ones as has been the case for some of us during COVID19. Bereavement and grief are difficult enough in any situation but if you’re cut off from the people who would normally support you, or you haven’t had the chance to say goodbye to your loved one, this is going to feel even harder.

If you've experienced a bereavement, please don’t be telling yourself that there’s a right way to be or a time when you should be “over it”.  You’ll grieve in your own way, at your own pace. There is no “grieve by date”.

Often one of the hardest things for the bereaved person is dealing with other people’s reactions; often they struggle to know what to say and might even try to avoid talking to you in case they say something wrong. This is hard, particularly if you want to talk about your loved one or about the circumstances in which they died.

If you don’t find the support you need from family and friends, and you want to talk to someone in confidence, you can access help through the SFRS Employee Assistance Provider (details on our welcome page) or the bereavement charity Cruse. Cruse have some specific resources for emergency responders – You Behind the Uniform.
The way that grief affects children and young people can be very different from the way it affects adults, so knowing what to say or where to find the right services can really help. Useful websites for children, young people, parents and professionals are Child Bereavement UK and NHS Scotland’s Support After Death.
Moral injury
We all have a set of values that help us function in the world and many people working in the emergency services have deeply held personal convictions about duty, service and helping others. Moral injury is the psychological distress we feel if our actions, or lack of them, go against our ethical values or moral code.  

This injury might be triggered by something we did or didn’t do, or something the service did or didn’t do. For example, a feeling that a body recovery wasn’t done with dignity or that organizational decisions prevented us from responding in the way we think we should. If this happens, we may feel guilt or anger which can lead to more distress and shame.

Moral injury isn’t a mental health condition but it increases the risk of PTSD and depression because it makes us less likely ask for support, because we feel morally culpable or because we’ve lost trust in others.

The things that will help a moral injury are similar to those that work for PTSD. We need to find a way to “process” the experience and to make some sense of it. It may be that we’re judging ourselves or others too harshly, but it may also be that we need to find a way to right the wrong, to learn from what’s happened so that things are different in the future.  

Another kind of moral injury is the one staff can experience if they feel betrayed by the organization. Examples of this might include bullying by colleagues of feeling let down by a manager after confiding that they have a psychological injury. This “service injury” can be devastating for staff who have put their lives at risk for the organisation in the belief that it “had their back”. It is important to access support from someone you trust if you're experiencing these feelings.
Relationship Difficulties
Our relationships are central to our wellbeing and when they're not going well we struggle. Separation, custody battles, step-families, whatever the relationship issue, there will be help available through your EAP or the services below:

Relationship advice
Parenting advice

If you’re concerned about an abusive relationship please have a look at the help and advice available from the organisations listed under National support services

Post traumatic stress
In the days and weeks after we’ve experienced something frightening or shocking, we go through a natural recovery process. Our body’s alarm system re-sets, we file the experience away in our memory and gradually we come to terms with what has happened. While this is happening, we’re likely to feel more emotional than usual, find ourselves frequently thinking and dreaming about it and may have some unpleasant physical sensations. To understand more about these normal reactions to trauma exposure have a look at Understanding my response to trauma and stress.

Emergency responders are at risk of post traumatic disorders because you have repeated exposure to potentially traumatic incidents but don’t always have enough time in between to recover and “process” them.  

Post traumatic stress disorder (PTSD) is only one of the injuries people sustain after trauma exposure. Others include post traumatic depression, traumatic bereavement and anxiety or panic. You can find out more about coping with these on this page.

PTSD is sometimes described as a disorder of memory. It develops when our brain can’t fully “process” the trauma experience leaving the memory of it vivid and fresh, as if it’s just happened or is happening again. This means the instinctive / survival part of our brain don’t know the threat has passed and keep us either in fight or flight (ready to respond to danger) or freeze mode (to avoid harm). We’re either on red alert or numb and detached with the associated biological and psychological reactions.

Our brains are complex machines and even when part of it is stuck on red alert, another part knows that time has passed and there’s a memory to be processed. That’s why it brings the details of the trauma experience into our minds during the day and when we’re sleeping. Sometimes there’s a reminder that prompts this remembering. Other times the memories just pop in as our brain tries to process and digest them.  

Sometimes we can’t bear to remember the traumatic experience. Perhaps it was too frightening or distressing. Maybe we thought we were going to die or witnessed the death or injury of others. Perhaps we’re blaming ourselves for what happened or are ashamed of how we reacted. When there are these kinds of thoughts and feelings, coupled with super vivid memories, then it’s not surprising we avoid remembering, thinking and feeling them.  Unfortunately, the more we try not to remember, the more frequently and powerfully the memories will intrude as our brain tries harder and harder to process the experience.

PTSD is when this process is stuck on a negative feedback loop. Our brain tries to process the memory (re-experiencing), we try to avoid this (avoidance and numbing) and our alarm response stays switched one (hyper-arousal). To recover we need interrupt the feedback loop and help our brain process the memory.

Our 5 steps to recovery are detailed in the section below.

Recovering from PTSD

Step 1: Understand what’s happening

PTSD, like other psychological injuries, is aggravated by stigma and shame. Take time to read the information on post traumatic stress above and in the pages on Understanding your response to trauma and stress and your Protective Armour to learn more about our reactions and why you might have been injured by this incident at this time. It is important to understand that our brains and bodies are not letting us down.
Man in Ambulance treating patient

Calm your alarm system down and reconnect with your body...

Once we understand the physiology of our stress response then we can try to get things back in balance. We can do this through exercise, to use up the excess stress hormones, and relaxation, to slow down their production. Watch out for high adrenalin exercise (because you don’t need any more in your system..) and aim for something gentle and steady. Relaxation can be hard to achieve when your brain thinks you’re in danger so don’t be surprised if your body reacts against attempts to relax. Take this as a sign that you’re on the right track and persevere.
You can try the exercises Belly Breathing / Quick relaxation or take a moment now to breathe in gently through your nose and out through your mouth, keeping the pace slow and regular. Try raising your shoulders to your ears as you breathe in and lower them as you exhale to release the tension.  

Because PTSD involves our brain being unsure whether the traumatic event is over, it is helpful to “ground” yourself in the here and now. To do this take a moment to notice what you can see, hear, feel, touch right now. Name 3 of each. This gives your brain the information it needs to orient itself in this present moment.

Avoid avoidance...

Avoidance is an understandable response to trauma. We try not to think about what happened, avoid talking about it or going near people and places that remind us of it. We sometimes switch off all our feelings to avoid the painful ones.  

Although this all makes sense, it is the thing that keeps our trauma response going. The more we try not to remember, the more likely the memories will intrude when we try to sleep and the more we avoid reminders, the more likely our brain will conclude that there is danger everywhere.

To recover, we need to gradually expose ourselves to the things that remind us of the trauma.
In step 4, we describe how to do that with the memories but we need to do this also with the external reminders (people, places, objects, sounds etc) that cause us to feel anxious.

We do this by gradually confronting the reminders to help our brain re-learn that these things don’t equal danger and that we're safe now. For example, rather than taking a different route home to avoid passing the scene of the fatal RTC, we park somewhere nearby and allow ourselves to remember and experience the feelings connected to the memory of the event.

If we stay until the feelings settle down (you mustn’t leave if when you feel anxious) then our brain will recognise that the event is over and in the past and will signal the alarm system to switch off.  

Process the memory

The key task here is to allow ourselves to remember the traumatic event. If we can do this, then our brain will be able to give the experience a time code and file it in our memory bank.

The memory of the traumatic event will always be more vivid than other memories, but we will recognise that it is in the past. This means our brain doesn’t need to keep bringing the information up for processing and can switch off our alarm response.  

If you understand your reactions and can calm your stress response down, then you may be able to do the memory processing without professional help. You could talk about it to someone you trust or could write it down.
Once the memory has processed and your alarm has switched off your sleep should improve. If it doesn’t, and you’re still having nightmares, you could try the techniques described in this animation on the Dream Completion Technique.

If all this feels impossible, please ask for professional help. We have effective treatments for post traumatic reactions that you can access through the SAS EAP (details on welcome page) or through your GP.

In the films below, Dan and Andy explain what it's like to go for treatment and how it helped them.

Come to terms with what it means

Once our brain has processed the memory, we need to learn from it and review any assumptions we made about us, others, and the world. These need to be realistic; we’re not looking for false optimism. If we previously thought we were invincible, we will need to accept that we’re human. If we blamed ourselves for not doing more, we may need to recognise there was no more we could do.
If we decided that other people can’t be trusted, we will need to work out if there are any exceptions to this. If we made a mistake, we will need to find a way to live with this.  

This can be a painful process, but it can lead to something called Post Traumatic Growth where we have a new appreciation of our own resilience and for the things and relationships that are important to us.

Getting professional help

Most of us would seek help for a physical health problem but lots of us don’t seek help for mental health problems.

Here are some of the reasons why:

we don’t realise we’re unwell
we worry we’ll lose our jobs
we feel ashamed, weak, a failure or undeserving of help
we don’t know what treatment involves and may even fear we’ll be locked up in psychiatric hospital
if we do, we don’t know that there are effective treatments for psychological ill health

There is still much stigma about mental ill health which is unfortunate because feeling bad or blaming ourselves for being ill doesn’t help. You can find out more about this in our section Stigma stops people getting help.

Dan and Andy's films on this page share their experiences of treatment.

Please don’t struggle on. There is support available and treatments that work. Remember:

“Psychological injuries can heal ”

LIFELINES ESSENTIALS #6

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