This webinar is delivered by Dr. Abby Morris, a board-certified psychiatrist and medical director at the IAFF Center of Excellence for Behavioral Health Treatment and Recovery. In her three and a half years at the IAFF Center of Excellence, Dr. Morris has worked with more than 1,300 professional fire fighters, paramedics and dispatchers, and has developed unique insight into effective strategies for treating these individuals that will be shared with attendees.

Webinars:

• Trauma in the Fire Service for Clinicians
• Treating Fire Service Professionals: Cultural Competency for Clinicians
• View all webinars

Articles:

• 4 Most Overlooked Signs of PTSD
• Why You Shouldn’t Put Off PTSD Treatment
• How Mental Health Stigma Impacts the Fire Service

Welcome to our Community Education Series, hosted by the IAFF Center of Excellence for Behavioral Health Treatment and Recovery. Everyone, it is 12 o’clock eastern, so we are going to go ahead and get started. My name is Kelly Savage. I’m one of the outreach directors for the IAFF Center of Excellence. I’m joined today by my colleague Myrrhanda Jones, a fellow outreach director and she will be joining us towards the end for Q and A. Molly Jones, our clinical coordinator, you’ll see there. Hi Molly, and our medical director, Dr. Abby Morris is with us today as our presenter.

We are thrilled to have her here. She has a wealth of knowledge and has so much interesting insight to share. You’re being humble, I see it. I’m really excited to offer this presentation to you all today and have her be able to share some insight about what we’ve learned, treating fire fighters, paramedics, and dispatchers over the course of the last three-and-a-half years at the Center of Excellence.

We’re going to go ahead and get started very soon but just wanted to cover a few housekeeping items. At the bottom of your screen, you’ll see a few boxes. One is a Q and A box. We invite you all to ask questions as you may have them as we go along. We are going to try to hold those until the end, as many of those questions may be answered along the way. For those that are not, we’re going to try to allocate some time to address those and give you a chance to ask any questions you may have of Dr. Morris.

Similarly, if you do have questions about logistics or anything related to the Center of Excellence that, myself or Molly may be able to answer as we go, we will respond in the Q&A and take care of those questions as the presentation is ongoing. You’ll also find the chat box at the bottom. We would love for you to tell us who you are and where you’re joining us from.

In the past we’ve had people from Alaska, Hawaii, Florida, Canada. Africa, of course, Maryland and DC. It’s really neat to be able to see where everyone is joining us from. We’d love for you to jump in there. Please do not put questions in the chat because it doesn’t move really fast and we want to make sure that we don’t lose them. If you have a question, put it in the Q and A, so we can keep those organized and make sure that we get to those at the end. Otherwise, I think that we are ready to go.

I’m very pleased to have with us, Dr. Abby Morris. She is double board-certified in psychiatry and neurology and addiction medicine, right? Awesome. Okay. So I don’t have a chance to mess anything else up. I’m going to let you take the introduction further away.

There we go. Hi, everyone. I hope that today finds you how happy, healthy, safe, the world is a crazy place these days. Certainly no matter where you are in the country, everyone is facing challenges. As I can see the numbers kind of increasing, we have 137 people participating right now. I can’t tell you how incredibly honored I am that 138 people have decided to take some time to join me today. I hope I can make that worthwhile and again, I hope everyone is safe.

So who am I?

I’m the medical director at the IAFF Center of Excellence for Behavioral Health Treatment and Recovery. I was employee number one at the Center. I’ve been there since before the Center has opened and helping to organize and plan the Center has been one of the greatest honors of my entire career, of my life to be part of this really great project. I have learned so very much and I hope to share some of that with you today.

I’m also the medical director of Montgomery County, that’s where I live. Montgomery County, Maryland, Montgomery County’s overdose response program. I also volunteer as a medical consultant in the Montgomery County CIT SWAT team. I like to kid at the Center with my fire fighters that I volunteer with the police, but they have to pay me to work with fire fighters.

I’m a psychiatrist in private practice in Kensington, Maryland. That’s actually where I’m sitting now. I’m in my private practice office. It’s a rather boring little office, but that’s where I call home. Other than being a full-time employee at Advanced Recovery Systems, I don’t have any other financial connections to anything that I’m mentioning in my talk.

I am most proud of other than my work at ARS, most proud of being the mom of two fantastic and fabulous, I call them boys, but one is 22 and one is 15. So I’m an old lady. I was going to ask now, if you guys want to fill out your survey of who am I talking to, do I have, fire fighter, paramedic, EMS, dispatcher, clinician, other healthcare provider, administrator, law enforcement, chaplain, spouse, or other. So you have lots of choices and I just want to know how to gear, I guess, my talk.

My talk originally, just so you all know, was originally written as a three-hour talk that was supposed to be given to clinicians to get continuing education credit. Then the first time I gave it, it was like 100% fire fighters. It was really kind of a hoot because he already was trying to teach people how to take care of fire fighters, and who was I talking to? I was talking to fire fighters about themselves. So, I had to pare it down to about an hour and we’ll see how I did with that today. So, Kelly or Molly, how do I find out what the survey shows?

We are going to give people about five more seconds to participate, and then I’m going to close the poll and show you the results. Okay. I’m going to put myself as other healthcare provider, right? Do I take mine now? I can’t take that over. I can’t vote. Okay. Oh, look at that. Oh, so we have like one other healthcare provider that makes me curious. We have a law enforcement one. We have a couple of chaplains! Welcome, that’s exciting.

This is a nice mix. I’m really excited. Hi spouses, I’m so happy you joined us. This is so nice. Okay. this makes me happy. Okay. So this is a really varied group, and I’m hoping that I’m going to cover something for everyone. This really helps me to know what we’re doing. So, I’m going to get back on my slide show.

This is why we’re talking. In mental health intervention and suicide prevention, there is this big gaping hole. It’s not that we’re not all sitting there holding the net. It’s not that we’re not all trying, but you know, damn we lost another one and we’re all sitting around going, “You know, we have just got to get better at this,” and that’s why we’re all here. We all know we need to get better at this, and we were all trying. So let’s keep this up. Let’s kind of look at just a few of unique treatment challenges that I have found to be important.

We’re talking about PTSD because that’s the elephant in the room. Anytime we talk about working with first responders or fire fighters, I think that we need to talk about the unique challenge of chronic or complex PTSD. I’m going to define that, erratic sleep patterns, chronic pain issues, caffeine overuse, and then stimulant overuse, testosterone overuse. Yes, it is overuse people.

Binge eating, sex addiction, social anxiety, which leads to codependency. The fabulous and famous, OCPD, which stands for obsessive compulsive personality. If you don’t know what that is, spend some time in a firehouse and watch people load a dishwasher. Then we’ll go to suicidal ideation or suicide, and then the stigma, or refusal to ask for help. That is really, I think, a unique treatment challenge with first responders, law enforcement, military, and in fixtures in general. So we’re going to go through that pretty quickly and see how we do.

PTSD impacts everything: spirit, mind, emotions, memory, and the physical body. There’s the guilt, shame, fear, anxiety, resentment, depression. It really does sort of cover or coat everything that we do. You have sort of the healthy person and then when a healthy person has an event, there’s, there’s this continuum. So the continuum goes in this case from green to red, from healthy to ill. There’s this continuum of problems, I guess you could say.

So, in the IAFF they often will say, is it really a D? Is there PTSD? Or can we just say PTSI or is it just PTS? And I tell them that it’s really a continuum. You know, it really depends on the function or the dysfunction that comes from an event or comes from a series of events or problems, and so you can go from healthy to ill.

As you can see in this slide, our healthy coping mechanisms to our unhealthy coping mechanisms. So if you have a stressor, you might go from healthy to reacting to that stressor. You might have some nervousness or trouble sleeping. What actions do you take? Then you have injured and then you have ill.

I just put this up here because I think people have a real resistance to that D in PTSD or the disorder. And I want to say that it doesn’t really matter where we are on here, as long as we’re recognizing that this continuum exists. So symptoms of, and I’m going to use the D because that’s the world I live in, the symptoms of PTSD. The typical symptoms of PTSD are intrusion avoidance, cognitive changes and arousal.

Intrusion are the classic symptoms you might see in movies or books or on the news. So flashbacks and nightmares, involuntary recurrent memories, and that leads to avoidance: avoidance of thoughts, feelings, certain people or places, activities, situations, cognitive changes, having trouble with memory, distorted blame, diminished interest in activities, we call it aidonia, feeling alienated, inability to feel positive emotions or numbness, and, and then that arousal, hypervigilance, the exaggerated startle response.

Let’s look at the stress brain loop. Maybe we have chronic stress of any kind from inadequate sleep, from poor nutrition, emotional distress, or physical distress. You’ve seen an increase in glucocorticoids. I don’t know if you can see my little mouse here, but increasing glucocorticoids, which leads to cellular changes in a part of your brain called the hippocampus, which I’m kind of pointing to. If you can see that, which leads to a decrease in cortisol regulation, which leads to increased glucocorticoids, which leads to cellular changes.

Now, when you have changes in the hippocampus, what does that lead to? It leads to a decrease in attention span, a decrease in perception, a decrease in memory, a decrease in learning, a decrease in word finding. I mean, this is all very uncomfortable. So how does your brain change with PTS again, D. Your hippocampus again was just sort of right here in the middle, shrinking. This is the area that helps us distinguish between past and present memories, kind of responsible for our flashbacks.

If your brain can’t tell if it’s happening now or in the past, you might have a flashback or make you feel unsafe now. You have a decrease, let’s look at the two down arrows, a decrease in the frontal, the prefrontal cortex that shrinks, and that regulates our negative emotions. That’s why you have the anger, outbursts and negative emotions. You have an increase in an area called the amygdala, just kind of right here in the middle as well. That increase helps us process emotions and makes us feel fear. You have an increase in fear, a decrease in the ability to regulate emotions and a decrease in the ability to be able to tell, now, from then.

Look at this, it’s very interesting. How is that different from other anxiety disorders and why did they take PTSD out of the anxiety disorders? The red is hyperactivation. In anxiety here in the hypothalamus you see this increase in B response that you see in social anxiety or phobias or fear, but in PTSD, you see the decrease, there’s two down arrows, right? The two parts of the brain and the frontal lobe and your, the, the hypothalamus. So you see down, downregulation, not just, upregulation like you see in anxiety and I think that’s an important difference.

Let’s talk about the numbers as a reference to first responders and specifically fire fighters. It’s estimated that about one in five fire fighters and paramedics will suffer from PTSD in their career. That’s probably an underestimation, not an overestimation. This is how many people we can actually wrangle in and actually assess. How does that compare to veterans? Thirty percent of Vietnam war veterans suffer from PTSD, 10% of Gulf war veterans, up to about 20% of Afghanistan and Iraq. There again, one in five, 20% of fire fighters. Pretty high.

Let’s talk about that. Chronic or C, CPTSD. If one traumatic experience triggers PTSD in some people, but other individuals undergo repeated multiple incidences of trauma, this pattern can lead to what many professionals call complex PTSD. It used to be reserved for, as they described here, ongoing domestic violence, commercial sex abuse trafficking, or prisoners of war. So they used to look at people like Holocaust survivors, prisoners of war, sex trafficking victims, and say they had this particular pattern of complex PTSD.

We looked at our patients and saw some of the same pattern of behavior. Well, how do we explain that? We explain it by this. Every day as a fire fighter or police is putting on their shirt and buttoning up your collar, they’re going out to the world and they’re experiencing day after day after day after day of trauma.

What’s the same about a prisoner of war or child sold into the sex trade or someone undergoing domestic violence is you are experiencing persistent daily trauma without control. You don’t know what you’re going to see or hear. You don’t know what you’re going to experience and no matter what you do, no matter if you do everything right; no matter if you follow every protocol from A to Z, exactly correctly, people get hurt and people die and you don’t have control. I think that’s sort of a key variant, a key part of that, that contributes to that chronic PTSD or the complex PTSD.

Let’s look at the symptoms and how they differ. In the regular PTSD, say from one event, you have the re-experiencing, the avoidance and the sense of threat. Most people could manage that or could treat that. They could get help for that sort of on the outpatient side, but the patients who come into our center are dealing with this complex PTSD, and what’s added to that? Affect dysregulation, negative self-concept, and interpersonal disturbance.

Affect dysregulation; I’m going to define this as they define it in the ICD 11, which should be coming out in the next year. Affect dysregulation is a heightened, emotional reactivity, crying outbursts, anger outbursts, violent outbursts, impulsivity, reckless behavior, and even in some people to dissociation, losing time. Then you have this diminished or defeated sense of self.
Feelings of, being worthless, feelings of guilt and shame, feelings of despair. In my patients, what I hear is people say to me all the time, not, “I don’t like myself,” but “I don’t know who I am anymore. I don’t know what people want from me.”

It’s so hard to have somebody cry in my office and say, “I don’t know what people want from me anymore.” It’s just like lack of sense of self, an actual lack of sense of self. Disturbances in relationships marked by difficulties, feeling close to others, having little interest in relationships or social engagement that social isolation, and having difficulties sustaining relationships.

You might have multiple sexual relationships, but not having real, really endearing long-lasting passionate connected relationships with your wife, with your children, with your partner, with your peers. Again, if we look at these complex versus regular PTSD, it’s the top three that people that lead to long-term treatment and also lead to suicide, not the bottom three.

Alright, erratic sleep, let’s talk about that. So what leads to sleep issues in first responders? Shift work, interrupted sleep by calls, by noise, caffeine, group sleeping quarters and respiratory issues, COPD and sleep apnea. We’re going to be seeing a lot more of that I think, given all this, the exposure to smoke, even in people who aren’t first responders with all the wildfires. Oh, man, “I really shouldn’t have had that coffee.” Sleep deprivation.

What does it lead to? Two studies I wanted to point out are heart attacks and cancer. Two things that we know are serious issues with our first responders, both in fire fighters and in police.

Heart attacks, the shorter your sleep, the shorter your life. Forty-five percent of on-duty fire fighter deaths, on-duty fire fighter deaths, result from a cardiac event. We typically will blame heart disease on fitness or diet, but in 2011 an international study concluded that sleep deprivation increases the risk cardiac event by 46%, regardless of diet or fitness. So a 1996 study showed that blood pressure increases following a night of bad sleep due to a higher sympathetic nervous system activity. So that’s the correlation, high sympathetic nervous system, bad sleep, heart attacks.

We all know how high the sympathetic nervous system is in our first responders. Cancer on the other side here, routinely sleeping less than six or seven hours. Six or seven hours, that seems like a lot of sleep to me. So no saying if you sleep less than six or seven hours, this demolishes your immune system, more than doubling your risk of cancer.

To just show that in more detail. In 1996, 1996 was a big year for studies, Dr. Erwin of UCLA kept 42 healthy men awake between just 10:00 PM and 3:00 AM, so it was a really short period of time. He was able to draw their blood and show a 70% reduction of cancer-fighting immune cells after just one night. One night, keeping them awake between ten and three, 70% decrease in their cancer-fighting natural killer cells. So sleep is important.

Chronic pain. So here’s just a graph showing fireground injuries that cause pain, overexertion, strain falls, jumps, extreme weather, hit by something, contact with an object, et cetera. Here’s how it compares to other occupations.

So ambulance, paramedics, fire, police, and others, you guys have a lot more injuries causing a lot more pain. You know, I thought I had another, well we’ll come back. I think I have some other ones. I guess not, I think it’s in addiction. I have some slides in the addiction side later talking about opioids. So pain is certainly an issue. It’s an issue that we need to deal with because it leads to other addictions and we’ll come back to that.

Let’s talk about other unique challenges would be caffeine overuse. So energy drinks, and I’m not going to spend a lot of time, in my three hour talk I spend a lot of time saying don’t, stop it do not, never. I can’t do that with you, I can’t scold you enough in a one hour talk to say, please don’t drink energy drinks. Why? Caffeine larger amounts of caffeine causes blood pressure spikes, blood pressure spikes cause hypertension, hypertension causes heart attacks. Also, you’re going to see with caffeine, a lot of increase in anxiety, sleeplessness, headaches, nausea, dehydration. The last thing you all need wearing a ton of gear is to get dehydrated.

Caffeine is a diuretic, it makes you pee, it doesn’t hydrate you. Energy drinks typically contain very high levels of caffeine, much higher than your typical cup of coffee. Energy drinks also have sugar, a lot more sugar than even a soda might have, which has a lot of non-nutritional calories. It also contains ingredients like guarana, a South American plant that has seeds with 4 to 5% caffeine content. Whereas a coffee bean has one to 2% getting this really high, really intense, really potent amount of caffeine in guarana. Ginseng can trigger side effects because it increases high blood pressure, insomnia, restlessness, anxiety, headache, nosebleeds.

Taurine is something you see a lot in energy drinks and they’re studying it now. We know that it has side effects. It’s unclear what the side effects are, but it’s probably bad. So if I could just say no energy drinks, so stop it. Since I have a lot of fire fighters out there, stop it. Coffee, the burst of alertness you feel after drinking a cup of coffee is often followed by a negative fluctuation. So irritability, agitation, anxiety, and the more you drink, the worse you feel. They’re saying that in nervous symptoms you get from caffeine are almost indistinguishable chemically in your body from an anxiety disorder. Alright, I made my point.

Let’s talk a little bit about stimulants. Stimulants, such as Adderall, Vyvanse, Ritalin, can be really dangerous. They can be really dangerous for your heart health. It’s again, a frequent cause of fire fighter death on the job as cardiac events and Adderall and Vyvanse can worsen underlying problems, can cause sudden death if you don’t need them, and cause erratic behavior and it can increase your risk for suicide. Again, I would spend a lot more time on this, but won’t do it here.

I think that oftentimes people go to their doctor and they say, “I’m tired, I’m having trouble concentrating.” If you do the quick check boxes in a doctor’s office, they’ll say, “Oh, I have ADHD.” What you have is sleep deprivation. What you have is anxiety. What you have is a combination of really high stress. It may not be coming from your frontal lobe. It may not be coming from an executive functioning problem. If we really took the time to figure out what the core problem is, and we treated that core problem versus throwing a stimulant at you to keep you awake, I think you’d be a lot healthier. I’m not saying that some fire fighters don’t have ADHD, they do, but I think too many people are being treated with this that may not have it.

So addiction, that’s a little segue right into addiction. Here’s our addiction cycle; people have pain. It can come from trauma, it can come from physical pain, emotional pain, people feel uncomfortable. They’re looking to avoid or withdraw from pain. They want to get away from it, even if it’s just temporarily. So they go with substances, food, high risk behaviors, sexual acting out, gambling, overworking, overspending, exercise, technology as a way to avoid that pain.

What happens with those things is they provide temporary relief; temporary endorphins. They feel a little better, people feel better when they have sex, when they eat, when they gamble, when they look at their phone for a period of time. Unfortunately that temporarily provides this positive reinforcement for a period of time, which leads to a more continual use, but the continual use leads to life complications. You’re showing up late at work, you’re spending more money so now you’re in financial problems, your credit card bill is high, your wife finds you using porn, and now she’s hurt. You had an affair and your girlfriend wants you to leave your wife, but you love your children and the life complications caused you pain, and then you need to escape your pain. So that’s the cycle, that’s that addiction cycle that we see.

What we see at the center, the drugs of choice we see most commonly to get treatment at the center include alcohol. By far it’s the number one drug of choice of fire fighters. Why? It’s embedded in the culture. You guys are happy, you go get a drink. You guys are sad, you go get a drink. You’re angry, you go get a drink and you do it with your peers. It’s you go to a conference and the day is over, you have a choice of happy hour or an AA meeting. You know, you have a raffle? It’s going to be a raffle for a bottle of alcohol or a shot glass. You want to have a fundraiser? It’s going to be at a bar. I mean, that’s really the reality of the life of a fire fighter. Somebody has a baby, you toast. You have a wedding, you toast. Somebody dies, you toast. I mean, it’s just, it’s embedded in the culture.

Secondly, we see marijuana. I’ll hear it all the time. Marijuana is legal, doc and I’m using it for my sleep, it calms my nerves. Well, alcohol is legal too, but you wouldn’t want to show up at work with alcohol in your system and marijuana stays in your system for 30 days. So you can smoke marijuana on a Saturday and go to work on a Tuesday and guess what? You’ve gone to work with marijuana in your system. No, I cannot give you that excuse. I cannot say it’s good or bad for you. I cannot make those arguments day after day after day about marijuana.

What I can tell you is it has consequences and a lot of them are negative. The American Cardiac Association, the ACA just put out a position paper saying that the damage of marijuana to the cardiac system is much higher than the benefit. I understand that there are benefits and I’m sure that during question and answer time, we’re going to talk about that more, but it has caused problems, and I can tell you that there’s no such thing as a non, as a zero THC CBD oil. Not for your skin, not for your mouth, not for your stomach, not for anything. All CBD oil can be transferred in your body to THC. So anything you use that says zero THC can still come up positive on your urine test.

Alright, we’ll keep going; cocaine and stimulants. They’ll tell me, fire fighters will tell me, it enhances my energy, it enhances my sex drive. Unfortunately it also enhances violence and anger.

Opiates again, pain management. A lot of people are having those fire ground injuries and they’re taking opiates and it also is a great anti-anxiety medicine, so you end up staying on it. Testosterone for muscle mass and confidence, but then it causes problems of its own that we’ll talk about in a bit. There’s also a drug of choice for fire fighters is certainly people. I would say that we deal with codependency a lot in the curriculum, at the Center.

There we go, we talked about the culture. Why are fire fighters more prone to opioid addiction and misuse is a question I get all the time when I do teaching. So here’s the slide that I came up with. Firefighters are high-risk for chronic pain injuries, back shoulders, knees, burns. You guys are trusted members of the society. You often are unchallenged by your doctors or friends when you ask them if you can borrow some of their prescription.

You go to a hospital, you’re friends with the nurses, the ER doctors, you know, you would say, “Hey, I got a toothache, I’ve got a pain in my arm. I really need to go to work, can you write me a script for a month?” They’re more likely to do it for you than they are to do it for other professions or other people out in the community. You have access on the job.

People might bring medications to the fire company to be destroyed, and you might just destroy the antibiotics, but hold on to the opiates. You might go to a scene where somebody has overdosed and there’s a little bit left in the bottle and I know that people might take them. You have anxiety and PTSD, which drives pleasure-seeking behaviors and opiates are strong anxiety analytics or antianxiety medications. You have sleep deprivation and opiates can help with sleep. You have addictive personalities, your personalities are drawn to risks.

So let’s go to the next slide. The US Fire Administration describes the personality traits or characteristics of emergency responders as quote “action oriented risk takers.” If you’ve got a problem, you want to fix it, you want to fix it quickly and you want it done and you are willing to take risks to do it. So if someone says here, “take this little pink pill with the blue stripe on it, it’ll make you feel better and you don’t feel well,” you will do it because you’re action-oriented risk takers. Oftentimes that can lead to problems in addiction.

Alcohol. Alcohol and fire fighters compared to the general population. On one side here, we have fire fighters, on the other side, we have the general population. In general people drink way too much, but as you can see fire fighters, this is like, in the past month, you ask people in the past month, have you drunk alcohol? 85% of fire fighters have said, yes, 62% of the general population say yes, In the general population said that in the past month, have you had a binge? They define binge, only 23% of the population will admit to bingeing alcohol, but 50% of the fire fighters will admit to bingeing on alcohol in the past month. Here’s another cartoon where they’re welcoming the killer of fire fighters to their annual convention.

You’ve got obesity, speed and suicide as the killers. Over here, we have alcohol abuse and drunk driving and he goes, “I’m the one that no one talks about cheers”

Testosterone, overuse, and abuse. Well, Mr. Rosenberg, your labs look pretty good. Although I might suggest your testosterone might be a tad high. Advertised in the fire fighter wife magazines, top five signs your husband needs to know his numbers. They’re not only advertising testosterone, external testosterone to fire fighters they’re also advertising it to the spouses.

People are coming to their doctor and they’re saying, doc, I am so tired. So low testosterone, low T while sometimes the culprit of fatigue probably gets more blame than it deserves a great deal of variation in the quote on quote normal testosterone levels. So the fire fighters will come in and say, I want you Dr. Abby, I want you to test my testosterone. I want to know my number and the number of her normal might be anywhere between 300 and 1500. When the level comes back and it’s 350. Oh my God, they freak out. Dr. Abby, you need to fix it, I want to go on testosterone like right now. I say to them, it’s normal. No, no, it’s low. It’s low, normal is 300 and 1500. I should be at least like 800. I say, no, and normal is 300 or 350, you’re in the normal range.

That’s a word no one likes to be: in the low end of normal. Everyone wants to be on the high end of normal when it comes to testosterone. We’ll talk about the risk of that, but they don’t realize that the higher, the normal levels of testosterone can have significant adverse health consequences, stroke, blood pressure, prostate cancer, mood effects, anxiety, and anger outbursts.

Let’s also talk about the psychological risks of high testosterone. Men who produce more testosterone are more likely to be single or divorced. Testosterone is not a sharing enzyme. It’s not a chemical that drives people to hug and share and kiss and, and be part of something. Testosterone is a hunter gatherer enzyme. It pushes people to want to go out and conquer. Not to be home and build a family. Sleep increases testosterone levels. If you want to increase your testosterone level, you need to relax. You need to sleep. You need to meditate. Resistance training increases testosterone levels.

Here we go. Meditation is the best way to boost testosterone levels. Too much testosterone causes men to behave antisocially. Here’s an interesting one. Men who are newly in love seem to drop their testosterone normally naturally than single men because they’re in this sort of mode. Their brain goes into the mode of, I want to join with somebody I’m not in the hunter-gatherer. So starting a family, having a baby. If your wife has a baby, your testosterone levels drop because your brain, your body knows you need to join with somebody.

Sleeping, exercise, and meditation relaxation increase your testosterone levels, right? Too much testosterone shrivels your testicles. I’m looking at you men, they shrivel your testicles so stop it. Taking away all your fun. Low testosterone levels can be linked with poor mental health, but you don’t need to take external testosterone most of the time. Most of the time, your testicles can make its own testosterone, but you’re too stressed, you’re too sleep deprived and you’re not exercising enough to make your own.

At the Center, we have teamed up with Georgetown and GW. We work with sexual health doctors starting this team up, where we can work with them to help diagnose and figure out what’s the healthiest way for someone to get their testosterone back on board, because we cannot keep having you guys get injected with testosterone, because what that does is it stops your normal adrenal gland function and testicular function from doing it all the time. I’m sure there will be questions about this later. I’m going to move on.

Think about your diet. Think about your sleep. Think about your exercise and think about joining with someone, be in love again, and those testosterone levels will do what they need to do. I mean, you don’t need 1500 milligrams of testosterone unless you’re going out to kill the beast.

Binge eating and sexual addiction. So let’s talk a little bit about this, cause this is really important. There’s this autonomic nervous system, everybody has it. The sympathetic versus the parasympathetic nervous system. People who are first responders live, breathe, sleep, eat, sympathetic nervous system. It just simply, isn’t healthy. You’re constantly in this fight-or-flight fight-or-flight, fight-or-flight, fight-or-flight. You eat and in any minute that you have to throw the fork down and run and go on a call when you’re sleeping, that the tone might go up and you have to jump in your boots and you have to go off on a call.

You know, that even when you’re home, you’re still living in fight-or-flight. You’re at a restaurant. You choose the table. Your back is against the wall. You’re counting how many people are in that restaurant. You’re ready for anything. You’re not sure what could happen. You’re never relaxed. You’re living in the sympathetic nervous system. Your body is uncomfortable.

Our bodies are meant to be in balance and our bodies will fight us to get into balance. All it wants is to be in balance. So the body doesn’t like to be in sympathetic nervous system all the time. It’s exhausted. So it’s going to drive or push us towards a balance. The balance of sympathetic nervous system or fight-or-flight is parasympathetic nervous system, which is feed or breed.

Let’s talk about feed cause it’s a little easier to talk about then breed. I have eaten many a meal at a fire station. You guys eat big chunky meals like meatloaf and mashed potatoes, and I’ll be damned if you ever chew it. You take these big, huge chunks. You swallow them down quickly.

One, because you don’t know when you’re going to have the tone is going to go off at you, it’s the way you eat. When you eat these big chunky meals, it sits in your stomach and it stretches the stomach. When the stomach stretches, it sends a message to your brain and it says “brain, I have food in my stomach and I need to digest it.” The brain says, “well, I can’t run from a tiger and digest the food.” So what the brain does, it shuts down the sympathetic nervous system. It turns on the parasympathetic nervous system and all of a sudden by eating you’re in balance, at least a little bit more in balance than you were before the meal.

Your brain and your body are pushing you or driving you to eat these big carby chunky meals. What’s the other part? If you don’t want to eat and you don’t want to gain weight and you want to look good for people and you want to look good in the mirror and you don’t want to feed, the other part of it is breed.

The two things that we deal with a lot at the center are binge eating, and porn and sex disorders. We end up with this feed or breed issue. If you don’t believe me, we can look at some of the research about it.

Pleasurable behaviors reduce stress, via the brain reward pathways. So there is lots of research out there that show that people who are in this high sympathetic zone, can you use pleasurable behaviors such as eating, such as gambling, such as porn, such as sex to drive the body out of the sympathetic zone, to drive the body out of the anxiety, and to have those endorphins, those happy chemicals. It leads to behavioral addiction. So types of behavioral addictions, internet, shopping, work, love, sex, gambling, food, and codependency. Okay. Wasn’t that fun.

Alright. So we talked about binge eating, sex addiction and gambling and porn. I will also mention, I don’t really have it here in this talk, but I will also mention that one thing, unfortunately, that we also have noticed in our work at the center is that I think that there’s an enormously high number of fire fighters who have had a history, sexual abuse, sexual trauma, either before they became fire fighters, usually in childhood, adolescence, or even when they were fire fighters. I think that leads them perhaps to be fire fighters. I think the number or the rate of sexual abuse and fire fighters seems to be higher than the general population.

How do I explain that? Why would fire fighters have a history of sexual trauma more than the general population? The way that we look at that psychologically is that we say that if somebody has been hurt, somebody has been sexually harmed as a child, they weren’t protected.

Someone in their childhood didn’t protect them and it leads them to want to be protectors. It leads them to want to protect others from harm. So they go into the protection fields. They go into being police and fire fighters. They want to protect others. They want to be fixers. they don’t want to see bad things happen to other people.

We also see the sort of confusion around being, especially in men, being sexually abused in childhood and those gender roles. There’s the question about, sort of sexual health and sexual roles and when you were young and wanting to go into very masculinized fields, military, firefighting, police as being very, I think it helps them to feel less confused and it makes them feel like less victims. No one’s going to harm me if I am a big strong fire fighter; if I’m a police officer. No one’s going to be able to hurt me. No one’s going to see me as a victim. I’m big and strong and no one’s going to see me as someone that they can hurt.

I think that that’s something that I can’t talk too much more about because it would take up so much more time, but I think that’s something to pay attention to, but it also leads to other kinds of sexual disorders, sex addiction, porn addiction, things along those lines. We have, at the center, teamed up with Johns Hopkins Hospital Sexual Disorders Clinic, and our patients have the opportunity to go up and work with Dr. Chris and doctors up there, and work through some of their issues, both at the center and with specialists that are nearby.

Social anxiety, another thing that we see that’s much higher diagnosis for fire fighters than we really ever expected, or that’s higher than in the general population is social anxiety.

So what is social anxiety? Social anxiety is different from being shy. Social anxiety is when people feel that people may not like them, people may be judging them. They may be doing something that makes people think badly about them. Before social situations, they may have these autonomic automatic thoughts of “I’m going to embarrass myself.” “I’m going to do something terrible.” “I’m going to say something stupid.” “I can’t go someplace because something bad is probably going to happen.”

During a social situation they’re going to say, “I look stupid,” “I’m dressed stupid,” “everyone else is doing the right thing and I’m not.” “I’m sweating” or “my eyebrow is twitching and everybody’s going to notice.”

When they’re in social situations, they feel almost like cellophane. like people can see through them that people can see past the front that they want to put it out there and that somebody is going to out them as not being what they want people to see. It’s very uncomfortable. Then when they leave the social situation after a social event, they spend hours sometimes going over in their head, everything they said everything they did everywhere they sat, thinking they must have done something wrong and now people aren’t going to like them. It can be a very uncomfortable feeling.

A fire fighter who’s in their uniform and is working, can talk to anybody, can do anything, little old ladies, you know, big, tough guys, people in bars, but it’s when they’re at home with their family, that they feel that vulnerability and that rawness and as a very high rate would go.
My experience is that 60% of fire fighters that walk into my office at the center have social anxiety. We’ve come up with actually being able to diagnose with the criteria for DSM 5, 40% of people at the center have been diagnosed with social anxiety. I believe that social anxiety predates the decision to become fire fighters, that people go into being fire fighters because they have social anxiety. They need the structure, the protocol, the instant acceptance, the clear hierarchy, and maybe the identity.

When somebody with social anxiety becomes a fire fighter, they can walk into a room and say, I’m a fire fighter, and people respect them pretty much right away. They don’t have to explain themselves. They don’t have to explain what they do for a job. People have a sense of who they are as being something very important and respected. Again, they often have difficult childhoods. They’re seeking respect, they’re seeking validation, but this also leads to that codependency.

The definition of codependency is right here. It’s a condition or state of being that results from adapting to dysfunction or addiction to a significant other. Needing somebody to define you, needing someone to validate you, being unable to draw the line between where you end and someone else begins.

It’s a learned response of stress that happens over a lifetime, and can lead to development of every external focus, repressed feelings, comfort with crisis boundary conflicts, isolation, stress-related illnesses, and compulsive behaviors. So you can see codependency kind of falls where you’re trying to control someone’s behaviors, needing to be needed, and activities done to excess and right in the middle is codependency. So it’s kind of a combination of bad habits, manipulation and insecurity.

How many people know fire fighters like that? Spouses? I think the spouses might be raising their hands a little bit, that insecurity, that manipulation and those bad habits, those bad habits, as they relate to other people.

Unfortunately, when a person has that neediness, has that codependency, needs that validation and their fixers, they can often be taken advantage of. Individuals with codependent tendencies are prone to fixing others for approval. So it’s not surprising that narcissists gravitate towards co-dependence because there’s no greater challenge to fix than an individual with a narcissistic personality disorder.

No offense spouses. I’m not saying that spouses are narcissists. I’m saying that oftentimes, when they meet a nice person and they get divorced, they end up getting pounced on by all these narcissists, you know, these women with like five children who need to be saved, the codependent has great empathy.

They wish to make everyone else’s life easier and more functional, truly does seem to be altruistic, but the truth is that many codependents want to sort out everyone else’s lives in an attempt to make themselves feel safer, more emotionally healthy, and valued and lovable rather than facing and working on their own insecurities. Unfortunately, a lot of these fixers, a lot of these fire fighters, end up being preyed upon now, again, often in their second, third, fourth marriages by people with really strong narcissistic personalities.

Alright, let’s talk about the other relationship killer in the world of first responders. I’m gonna check my time real fast. I’m going to hurry up. Alright. So, anyone who recognizes this person will recognize what I’m talking about. He’s saying I have OCPD and I’m an asshole.

So it’s a little bit of a misnomer in the sense that most people with obsessive compulsive personality disorder seem like assholes, but they’re actually some of the nicest humans ever.
They are people who do things the right way and they don’t understand why everyone else doesn’t get it. They’ve done hours, days, months of research to figure out the way things should be done. They think they’ve done this for everyone else’s goodness.

Like they’ve had this great intent that like, “Hey everyone, I’ve just helped you figure out the best way to skin the cat.” They don’t understand what you’re still skinning the cat your way. Their intentions are always good. People with obsessive compulsive personality disorder always have good intentions, but they come off with such rigidity and such, I want to say inflexibility that they come off like assholes.

These are the people who say like, “God damn it. How many times did I tell you to load the dishwasher with the spoons facing to the left? It won’t get clean unless the spoons are facing to the left.”

It’s only because they want to give you the best possible clean spoons you could have, but you know, you’ve loaded the dishwasher with the spoons facing to the right. It looks good to you. So why can’t they just shut up and eat?

So, anyway, let’s look at the symptoms of OCPD. Perfectionism to the point that it impairs the ability to finish a task. So in other words, “I cannot turn this in until it’s perfect,” and it’ll never be perfect. So they keep putting it off and putting it off and putting it cause it has to be perfect, it has to be perfect. It has to be perfect. “I can’t finish it until it’s perfect.”

So in a family situation, “I can’t stop fixing the washing machine,” or “I can’t finish the renovation of our bathroom until it’s perfect.” So the bathroom stays completely unfinished for months until they find the exact right thing, but it’ll never be right. You may have stiff, formal or rigid mannerisms, so they’re not, they’re not impulsive. They’re not, they don’t just, they don’t just bring home flowers any Tuesday. They’ll bring you roses on Valentine’s Day. They just have, they do the right thing, but they’re not spontaneous, right?

They might be frugal with money, although fire fighters will literally give you the shirt off their back. Like literally the shirt off their back. I think I made a comment at a conference. to a fire fighter that I loved his tee shirt and he started taking it off to give it to me. I’d say, “no, no, no, no, I’m good.” But, they can be frugal with money. I mean, they can watch their money and it can run in the families of these fire fighters.

An overwhelming need to be punctual, which can make families crazy because the fire fighter is waiting at the front door, like 45 minutes before they have to be down the street for the picnic. You know, when you have four kids, you cannot be 45 minutes early, let alone, you know, lucky if you’re five minutes late, because you’ve got to find the people’s shoes and the things, but there’s this overwhelming need to be punctual, extreme attention to detail, excessive emotion to work, expensive family or social relationships.

You know, fire fighters go, “oh I don’t horde. I don’t have worn or useless items.” Then I ask them to think about their garage and the time they may have had to take something apart, like a vacuum or something like that. I asked him, “do you keep everything in a little jar? All the little pieces in the jar, on the shelf of your garage.” Most of the time, they’re like, “Oh yeah, I do do that.”

An inability to share or delegate work because of a fear that it won’t get done right. So they’ll do it themselves. They’ll do everything themselves. They won’t give the work to other people because they know how to do it right, and every time I give it to somebody else, they mess it up.

Okay, a fixation with lists so they’re writing things down, they’re always writing things down.

A rigid adherence to rules and regulations, which is great for fire fighters cause you guys have protocols up the wazoo. An overwhelming need for order, a sense of righteousness about the way things should be done and a rigid adherence to moral and ethical codes, justice, you know, you’re all about justice fairness. It’s not fair. It’s not right. It’s not the way it should be done.

I’m constantly telling fire fighters in my center that they have to stop “should-ing” on themselves– to not with the shoulds. If we could replace a few shoulds with it would be nice if then they would have so much weight lifted off of them.

So I’m not saying every fire fighter has over OCPD, but I’m saying that it does run pretty heavily in the world of fire fighters. Clinicians, I would be paying attention to this list because, and spouses, because I would say that a lot of them are diagnosed with OCD, but I would say most of the OCD is probably closer to OCPD this personality disorder.

Alright, suicide. We talked a lot about addiction and we know that there’s a high rate of addiction in fire fighters. If you have patients who are untreated in substance use disorders, you have a high rate of suicide and that’s not suicidal thoughts, that’s not suicidal ideation, that’s not suicide attempts. I mean, 45%. According to the psychology today, people with untreated substance use disorders may end up committing suicide.

Suicide is the biggest killer of men ages 29 to 40 that’s more than accidents, cancer, and coronary artery disease. What we’re talking about, that young, young middle age group, that’s 20 to 40, we’re talking about predominantly male disease. Eighty-percent of completed suicides in the United States are men. Women attempt suicide at a higher rate, but men complete suicide more.

For the FBHA total validated suicides this is up until October 2018, is 11,845. I’m going to get in some controversial areas here. I want everyone to take a deep breath. I want everyone to, relax a little bit and let me just, let’s talk about the gestalt of suicide. I’m going to give numbers because they’re important. I’m going to give numbers because they’re big and I think big numbers make an impact, and we need to understand the impact of suicide, but the numbers are controversial. There’s no one out there who can tell me exactly how many fire fighters have committed suicide.

Jeff Dill and his group have been trying to track this for a long time, but it’s not scientific. I mean, they’re doing a great job, they’re trying. There, there are groups trying to track police suicides, but the reality is, people who commit suicide don’t always leave a note. Even if we know there were suicides, people might be ashamed of it and families might be ashamed of it and it might be reported as something else, an accident and overdose. So we don’t have good numbers, and so these numbers might be low.

These numbers, some may argue that they’re too high, but let’s just look at them. The number of fire fighters, EMT’s and officers who took their lives, outnumbers all of line of duty deaths. This is from 2017. Again, Jessica Shalt sees that the number of suicides, both in law enforcement and in fire fighters is higher than in line of duty deaths, again. Rates of suicidal thoughts and behaviors. These are two studies from 2008 and 2015. It’s the comparison between fire fighters– career fire fighters, and the general population.

We have the difference between how many people in the general population have thought about suicide, having an ideation or a thought about suicide in the general population, it’s up to 15%. How many fire fighters have thought about suicide? Forty-seven percent, according to these two studies.

Two studies, how many people have made a plan to commit suicide? So they gathered up their pills. They’ve thought about, well, I could hang myself from the, my garage, I would use this rope. I would drive my car off the bridge. There’s not just like, it would be nice if I killed myself, maybe I’ll do it someday, but they have actually made a plan. Four percent of the general population, almost 20% of fire fighters have had a plan in mind of how to commit suicide. How many attempts? So in the general population, 2 to 9% of people have admitted to having a suicide attempt in their lifetime. In career fire fighters, 16% have admitted to an attempt. Again, we think that’s on a lower side, that’s not completed suicides, but you can see the difference.

The difference is that more fire fighters think, plan and attempt suicide than the general population, and that suggests something. What does it suggest? Does it suggest that we have more men and men are at higher risk? Does that suggest that we have more stress and that suggests a higher risk? I think all of the above. PTSD is a risk factor.

We’re gonna talk a little bit more about that and being mad as a higher risk factor. having PTSD, having addiction is a higher risk factor and we know fire fighters have all of those things. Okay. Fighters with PTSD are six times more likely to attempt suicide. Again, add addiction to that and it increases their risk even more. Last one and everybody, hopefully everybody’s still with me and I’m right at one o’clock. Woo. Alrighty.

Stigma. What did my talk, my talk today was about barriers or special topics that make it difficult to treat fire fighters. Well, this is the way to end, because this is what we have to be talking about. We can talk about all the things that are wrong with fire fighters, where we talk about why we aren’t making more of a dent in the mental health of fire fighters then we have to talk about stigma.

So the biggest concern, what’s the biggest concern that creates stigma? The biggest concern is “I’m going to be seen as weak.” “I’m going to be seen as unfit for duty.”

The reality is that when I’m trying to send fire fighters from my center back to work and I clear them, I know what fire fighters do. They send me their job description and I write a letter saying, “Hi, I Dr. Abby Morris, medical director at the Center of Excellence, who knows this person has this job description sees that this person who has been treated for PTSD, depression, bipolar, whatever it is, is ready to go back to work.” They’re still not sent back to work and they’re still sent through hoops. That’s the problem, is that people are afraid that if they have a diagnosis, they’re going to be seen as unfit or weak. They’re concerned that their supervisors see them that way, and they’re concerned that their peers are going to see them that way.

In a poll that was done by, IAFF 83% admitted to being concerned that they will look weak. 70% were concerned about cultural stigma, about mental health, 60% worried their colleagues wouldn’t trust their judgment under pressure after they sought treatment. 46% were worried about losing their job.

I think that these are all really valid concerns. If only it were this obvious, if only somebody could know that the person next to them has been thinking about suicide and needed help, and if only we knew that seeking help is not a sign of weakness. Ninety-two percent of fire fighters say that stigma is a barrier to seeking treatment. This is my least favorite slide and my most favorite slide in a lot of ways it’s least favorite because I don’t like what it says. It’s my favorite, because I think it speaks volumes to what the issue is.

This was a question we had when again, IAFF and I think NBC got together and did a poll and they asked fire fighters, are you aware of the behavioral health services offered by your employer? Almost 90% said, yeah, I know that there are mental health services that are offered by my employer. It might be EHP. It might be other mental health services and I’m aware of them. Okay. Have you used your employers programs for mental health support? Well, look at how that number changes. Well, almost 80% said, “no, not me. I’m not going to use it.” Maybe because they don’t need it, or maybe if I needed it, I still haven’t used it. So, the majority of people have not used it.

Here’s the last part, if you used it, was it helpful? Again, like 60 some percent said, “yep. I used it and I didn’t like it, or I didn’t find it helpful.” So this is the key: if we’re going to have services and we’re going to offer things, it has to be done well.

I mean, the next people, it has to be something that’s helpful. If it’s EHP, let it be good EHP. If it’s not EHP, let it be something that’s connected to fire fighter or first responder help. Let people and if we do these webinars, instead of, instead of it having to be 90% fire fighters, where are my clinicians, let’s have more clinicians who understand these issues, and have more providers know about these issues. Let’s vet people, let’s train people, and let’s have the quality of healthcare that you guys all need and deserve so that we can have it be helpful. It’s not rocket science. It’s complicated because you all are complicated, as you can see by that list that we’ve just gone through, but we can do this. I think that the more we learn about it, the more we can do.

This is the biggest barrier. The biggest barrier is because of, well, the stigma, because of all the issues you have in reaching for help, you don’t think you can do it because “I don’t need help. I can rescue myself.”

You’ve got this sense of pride that’s constantly pulling you down and you’ve got marital stress and PTSD and depression and suicide. These are the sharks that are circling the waters, and they’re just waiting for the opportunity. You’ve got this pride. I mean, I can’t tell you how many times I do an intake with a patient who may have just flown like six hours and their eyes are leery and red and they are, are in withdrawal and they’re exhausted, and they just been kicked out of the house and maybe they have a legal issue and they sit in front of me and I say to them, “Hey, how are ya?” And they go, “Oh, good.”

Bullshit, I’m sorry, you just flew six hours just to give up 30 days plus maybe of your life to get intensive mental health treatment. I want you to stop saying you’re good. You’re not good, and it’s okay not to be good for a change. You know, it’s just so ingrained in the first responder, like, you know, mental thoughts that like I’m good. Oh, well, I’m here to tell you, you don’t need to be good anymore, like it’s okay.

So anyway, that’s what the IAFF was beginning to say in the winter of 2015, then they reached out and said, you know, we need to bring PTSD of the shadows. We need to say that, it exists, we need to fight the stigma, and we need to get help. That’s when we came about with the IAFF Center of Excellence for Behavioral Health Treatment and Recovery. We opened in 2017 and, and that’s me and it’s five after one. Woo. Any of you who don’t know me, I’m from Philadelphia and in Philadelphia we talk fast, we walk fast and if you couldn’t keep up with me I apologize, but that’s why I got through the presentation. I’m very open to questions and I can expand on anything I said.

Today, you did the impossible, you didn’t think you would get through it and you made it. I think I breathed like four times during that. Well, we appreciate the speed because there are a lot of questions and I’m sure more are going to be coming in. So if you have questions, drop them in the Q&A, and we’ll have Dr. Morris try to answer them.

There are things more so less of a question more, maybe something you could elaborate on. What’s the question? So the first one is, have you had much interaction with retirees? Maybe you could speak a little bit about it.

Oh, absolutely. I would say that, how do I get back to your screen? I would say that a good number of retirees. In fact, when we first opened, I would say that our average age was probably closer to the retiree age and then it goes in waves. Or sometimes we have a bunch of young people at the center, but now I think our average age is probably in the forties. It’s funny to say retiree, but in the fire fighter world, that’s closer to retiring.

I think retiring is a big milestone where we see mental health become an issue. If you guys stay busy, if you stay purposeful, when you’re going, going, going, going, and going, the monsters of trauma kind of stay at bay. But when you get to the point where you hit retirement and, you’ve had your, your, at that point, you’re a really big onion.

You have layers upon layers upon layers upon layers upon layers of trauma. You have disconnected, you have that complex trauma, so you’ve disconnected from your spouse, you’ve disconnected from your peer support. The only thing you do with peers is drink and you’re kind of done with it.

You’re maybe gotten into some financial difficulties. You are cranky and you don’t, you leave the fire service because you cannot do one more suicide call. You cannot take one more dead baby to the hospital. You cannot take one more frequent flyer who’s got a pitch on her butt to the ER anymore and get yelled at by the ER nurses there. I think you leave thinking you’re going to be happy to be done, but then you have no purpose.

You’re the most purposeful human beings I’ve ever met, and then all of a sudden you don’t have that purpose and you’re, you’re bereft, you’re lost. And so we definitely, definitely, definitely see the increase in rate of alcohol and drug use and pain issues and increasing rate of like marital problems and coming to the center at retirement.

So, we have a lot of interaction with retirees. Now I would say that the issues are similar with retirees than they are with young people. I don’t think there’s too much difference other than that, some of those bad habits have become really solidified. and that we have to kind of rebuild some of those peer networks. A lot of, and there’s also probably a lot more, medical issues by then. We’re dealing with more of the issues with that, adrenal fatigue, you know, maybe some, pancreatic issues and diabetes and hypertension and, and things like that in the retirees.

Thank you. Yep. One quick mention, we’re getting a few questions about recordings. This recording of this presentation will live on our website, under the community education page under past recordings. So yes, it will be archived and you will be able to find it later and share it with anyone who may be interested. So thank you all. It will live in infamy. It sure will.

What else do we have? Okay. So, regarding stimulant use, you spoke about, some, factors of other things perhaps being misinterpreted as ADHD. What if there is an ADHD diagnosis as far as stimulant use goes?

Yeah, and for sure there are patients who come in, who’ve done their due diligence and have excellent psychiatrists who aren’t just getting their stimulants from their primary care docs and they have done the neuro psych testing, and they were diagnosed when they were in second grade, and they absolutely have ADHD. We do use the stimulants in that case because their frontal lobe and their executive functioning is definitely off. The stimulants don’t cause the agitation and the anxiety, it actually helps them to stay focused and calm.

Well, they certainly don’t need like 70 milligrams of, you know, Vyvanse. They’re usually needing the low doses, or they’re needing it as a part of a regimen of health that might be good diet, good sleep, et cetera. As long as it’s used in a way that’s functional and healthy and they’re paying attention to their sleep, their exercise, their diet, we have a nutritionist who’s on call for us that we use.

You know it’s all of that as a whole person. So everything’s individual, we don’t just say no stimulants ever, no way. You know, it’s, that’s one of the things that we see as a pattern of overuse and a pattern of abuse, we understand why it’s over-prescribed. We just wish that people understood these issues better.

Same with the testosterone. There are people who definitely need it, people who have a level that’s 30. Somebody who had an injury to their testicles or their adrenal glands, or you may have cycled, you know, really high doses of, you know, elephant, you know, steroids when they’re in high school and have done damage.

Which is why we tend to want to make these collaborations with people who are specialists, because I wouldn’t know how to treat that. So we are working with other specialists who can help us with that. All of it comes as an individual treatment plan, you have to look at it individually. I’m afraid when we have these advertisements, these people would come into the fire stations and say you have low T, and you have low T, you have low T, that’s not individual.

Even if you test, it’s not individual, like if you just test and go, you have low T you need testosterone. They’re not looking at the whole picture. You should spend like an hour or two hours with somebody and go over an entire history of that person’s stress, that person’s mental health, that person’s history, their person’s surgical history, before you really get into a regimen that includes something that’s going to shut down their adrenal function. I just don’t think that’s happening as much as it should.

So perfect segue, regarding the testosterone, with male fire fighters, finding low testosterone levels, what about female fire fighters? Yeah, I tend to, I tend to use like the, I see a question. I tend to use the word guys. I mean, guys, it’s like a general guys.

We have female fire fighters at the center. A lot of these patterns exist in female fire fighters. OCPD is huge in female fire fighters, chronic and complex PTSD for sure in female fire fighters. Especially in PTSD, their symptoms are bigger than female fire fighters. I think in female fire fighters, caffeine is an issue when female fire fighters, I’m looking at my list. I mean, I don’t think there’s that much in the sense of being different.

I’m going to pull up my list here. Hold on a second. I’m gonna go back up to the list here. Erratic sleep is an issue, chronic pain is an issue, caffeine overuse is an issue. I think that adrenal fatigue is certainly an issue with female fire fighters. It may not be expressed as much as testosterone overuse, but I think there’s definitely an imbalance that happens with estrogen, testosterone, cortisol is all women as well.

Binge eating and sex issues, still an issue, social anxiety, very much an issue with female fire fighters. They have, I think, a larger background typically of the sexual trauma, as well as the codependency and bullying and bullying that exists, throughout their history as fire fighters as well, which I don’t think that people are beginning to talk about, or ready to talk about that needs to be addressed, that has to be addressed.

I think it is going to be kind of the next big thing we talk about when bringing PTSD out of the shadows, I think it’s time to bring bullying out of the shadows, both with women and men. I think men are being bullied too, but I think it’s so much more obvious and so much more, I think it’s gonna be easier to start talking about it when it comes to women, because it’s so much more in their face so much more, you can see it point at it.

Women are being bullied and I think it starts in childhood and continues in the fire world. So excuse me, when I use the term guys, I think it’s just a term that I use. I raised boys. I was friends with all boys growing up and I’m still dealing with boys in my world. So I just didn’t tend to use the term guys to mean in general people, so I apologize.

We’ve gotten a few questions regarding CEU’s if you’re a clinician or social worker. At this time we don’t have the accreditation to offer them online. We’re working on it. If you’re a fire fighter that is looking for a certificate to utilize for whatever the process you all may have in your state department, peer support team, my colleague Myrrhanda Jones can help you out with that. She’ll drop her email on the chat. If you’re a fire fighter looking for a certificate of completion, we can help you out with that, after the training.

I’m looking at a couple of the questions and I want to answer one of them. It says treatments most helpful for PTSD? I think CBT is, it’s huge. I think that’s been a really big keystone of a lot of what we do. I also think EMDR, but EMDR, you really want to be able to do it when the person is in the right stage of their treatment. It can’t just be done at any old time in the treatment.

The person has to be really prepared and ready and you have to be able to be prepared to really invest that time in them. I really worry about the tele-health aspect of a lot of what’s going on now. A lot of people have started some EMDR and then like they go home and they’re very raw and it’s not working out too well.

We use ART as well, and I think when we talk about complex or chronic PTSD, it’s very similar if you look at the symptoms of borderline personality, oddly enough. I think if you, why that is, is probably because there’s a lot of trauma in borderline personality and in complex or chronic PTSD. So I think DBT, I think DBT is going to play a larger role in the future to a lot of the complex or chronic PTSD, just to just a thought.

Thank you very much. Okay, so we have one question. We’re not supposed to say names on the webinar. I don’t know, it’s like it’s some legal thing. Hi, we’ll let you get away with it this time. so we’ll take his question. Maybe you can chime in on that, and then we’ll move back to the other ones.

Regarding child sexual abuse, generating feelings of abandonment and betrayal, could that later be exacerbated by administrative or personal betrayal? Oh, absolutely. I mean, I’m going to joke. So Mark runs this fantastic program, of course, in the West coast and I, for sure know that he has dealt with a lot of these topics. I mean, I have great respect for what he does and as he has taught me a lot about this topic as well.

So I’m sure that he understands these as well as I do. Yes, absolutely. I think that unfortunately people bring from the emotional insults they have from childhood to whatever we do, right. To our future relationships, to our job relationships, and I think that’s for sure, we see that, translated into our professional lives.

I think recognizing that and being able to address that in treatment. So if we look just at PTSD and we ignore the sexual stuff, if we don’t ask those questions for the clinicians out there, if you don’t ask questions about sexual trauma and sexual abuse in childhood. If you missed that somehow, because I don’t think a lot of people, guys, women are gonna necessarily bring it up unless you ask. If you miss that, then I think you’re going to always wonder why these people aren’t getting better. Why people seem to have something missing, that could be what the something missing is.

So we have a clinician who says that they’re concerned with research that claims that a certain percentage of fire fighters struggle with PTSD. Could you clarify the difference between a clinical diagnosis and symptoms consistent with PTSD, or like you talked about PTSI. In other words, many of these studies are often self-reported symptoms, but not clinical diagnoses or evaluations. This translates to feeling or perhaps could that there is a much higher rate of PTSD across a workforce than may actually.

It’s funny, because I talked to a lot of patients who come into the Center who don’t have PTSD and it’s totally fine to come to the Center and not have PTSD. I have fire fighters who feel embarrassed that they don’t have PTSD. I’m like, “you know, it’s okay not to have PTSD. It’s like, you don’t have to have that, just because you’re a fire fighter, just because you’re exposed to trauma doesn’t necessarily mean you’re going to have a disorder because of it. It doesn’t necessarily mean you’re going to have symptoms of it.”

In fact, you might notice that you have acute distress after something happens that’s particularly traumatic, but it’s not there a month later. People forget that for the actual clinical diagnosis, there’s actually a timeline that has to happen. It has to last for a long enough period of time. The symptoms can’t just be for a week or a night, you might have nightmares for a week. It doesn’t mean you have PTSD. If you have nightmares for six months, probably that means there’s something dysfunctional going on that needs to be addressed.

I think that it’s not just the fact that some of these things exist alone, It’s that they exist in a group or are a group of symptoms together. They exist at a certain amount of dysfunction or severity of dysfunction and that they exist over a certain amount of time. So you have to kind of meet all levels of those criteria to call it the D, right? If you look at that and like, I have to kind of go back to see if I can go back to it. I don’t know if you can, can you still see my slides, but I’m scrolling through, I’m trying to find it. That continuum is about that. So you might be reacting to something, but it doesn’t end in an injury and doesn’t end in an illness. I think that has to do with, it has to do with, do you have symptoms?

Do you have severity? Do you have dysfunction and has it lasted over a period of time? Is it staying with someone, right? So does that, is that helpful? Yeah, I think so, absolutely. Thank you.

In your experience, and I know we cover this in some of our other webinars with Molly, in her role. What is the best way to reach out to providers who can relate or connect with first responders, like you have been able to do as a medical professional? What is the best way to, what is the question, the best way to out to providers, I guess if someone were trying to find a clinician or a medical professional that was well equipped to, to treat them, what would they do?

I think that that might be better geared for our outreach team, or the IAFF. You know, they have a mental health division at the IAFF, and I think on their website, they may have some resources. Yeah. So we’re going to lead the charge for them on identifying culturally competent clinicians. Molly Jones is our clinical coordinator. She’ll put her information in the chat, and if you’re interested in connecting with her and finding culturally competent or experienced first responder clinicians in your area, she can help you with that.

You guys might not like it, but I also, sometimes when I’m dealing with someone on the west coast, I will often go on to the WCPRS website for it with Mark Amina, and they also have California, Oregon, Washington State. I’ll look at some of theirs as well because they not only have fire fighters. They also work with police and prison guards who are the other kinds of first responders. We use the first responders work forces all the time, and they’re part of our vetted clinician lists. So, please reach out to us, please reach out to them, as a start, but we can try to identify those providers in your area.

So back to you, do you find it hard to go into a new firehouse and have the guys or gals open up to you to talk about their mental health on a tough call. I’m a shrink, you know, and I’m female. I show up and they’re all on their best behavior. They’ll go into their bedroom, go workout. So I go in and I play a round of ping pong and hang out and eat dinner. I often try when I go, I don’t necessarily go on a formal basis.

When I travel, I go to conferences, I will just hang out for a 12-hour shift or I go cause I’m bored or I go ‘cause I want to know where the best place to eat is, and I hang out. I don’t necessarily go, I don’t do a lot of schism. I don’t do any schism actually, I go and I go to hang out. I go to spend time with people to learn from them.

If they want to talk great, and if they don’t, we don’t. We sit and we watch sports. I sit in my recliner and we watch Jeopardy together. I’m on my local fire board in my County, and so I go before our wait, well, we would meet the entire board. I would go before the fire board and hang out and bring cookies and eat dinner with them and watch Jeopardy before our fire board meeting. For me, it’s just a matter of just kind of hanging out. I think that’s the problem with EAP in some ways, not all of the problems with EAP, but like they just aren’t there to just get to know people, to just be in existence in a firehouse, it’s not a crisis.

I think that’s the way you get to know people and when you recognize what a calm fire house looks like. So then if you know what a calm fire house looks like, you know, when it’s not calm, I think what I would recommend to anyone who wants to work with fire fighters is start spending time in a firehouse, start off with like three hours, spend a dinner and watch Jeopardy.

Then go back for a weekend for a 12-hour shift or an overnight shift every quarter and just hang out different shifts, different times, different people, meet the newbies. That’s the way to understand the culture, the language, you know, see how people interact with each other. See how fire fighters get called on a call, hear a tone. I mean, if you haven’t heard a tone in the middle of the night, it’s jarring. You really do get a sense of what it might feel like to go in a fire truck and see what it’s like to have somebody not follow the lights and go through a light and almost hit them; see what it’s like to be out in the cold in the rain and the snow and stand there while other people are being ignorant around you or hear how people speak to you or the fire fighters.

It’s just fully worthwhile to just exist in the life of a fire fighter for periods of time, at different periods of time, in different parts of the country. That’s my best advice I could give to anyone who wants to work with fire fighters.

People don’t just open up to you because you show up and they shouldn’t because why the hell should they trust me until I have proven that I’m a decent human being who truly cares about them, who’s not there with any other agenda other than this is who I am and I’m interested? So I don’t know if I went around that question, but I tried. No, I think that was, that was great advice, especially for clinicians that are looking to learn more or become involved. Obviously times have changed a little bit with COVID, we’ve talked about that in past webinars but hopefully we’ll be back to normal-ish soon and, and those opportunities will be more accessible.

Okay. So we have two more that hopefully we can answer pretty quickly. The first being, how helpful have 12-step programs been at the Center? Any suggestions on what has worked at the center in promoting 12-step involvement, particularly in continuing care after they may leave? I think that 12 step programs are fabulous for the right person.

We do have 12-step programs at the Center. They’re not run by us, obviously that would make no sense to have a 12-step program run by the Center, but we have 12-step programs that come in and well, at this point they don’t come in, but they’re, they’re zoomed in or tele-health in or whatever.

So we invite 12-step programs and SMART Recovery. We have SMART Recovery and AA and NA. It’s been very highly encouraged since the beginning. We went round and round about whether or not it should be, for people in our substance abuse, part of the program, whether or not it should be required, or whether or not it should be encouraged, and we went with the highly encouraged. We don’t track it. We don’t make people sign in and prove to us that they go, but we really, really want them to be able to go.

We think it’s important. but if we shove it down your throat, you’re not necessarily going to get something out of it just because we made you go. I think it’s always an important part of an aftercare plan for someone who is in substance abuse because it’s a community. It’s a way of connecting people outside to sober peers, but some people don’t really like the structure of a 12-step program. So we, again, we’ve introduced 12 steps, we’ve introduced Smart Recovery, and other options along those lines, but it’s always given as a resource.

When somebody says that they go to 12-step programs, my first question is, do you have a home group? My second question is, do you do the steps? My third question is, do you have a sponsor? If they’ve been in it for a long time, I might ask them, do you sponsor? Because I think that that helps me to gauge whether or not they just sort of know where the groups are, where they might show up or, you know, how invested somebody might be at that time in that program.

It’s evidence-based, there’s enough research over enough years to show that 12 steps do work if somebody is invested in it. If somebody in the right stage of change for the 12 steps. I mean, if you make somebody go to a 12-step program who really doesn’t want to be sober then it probably isn’t gonna work.

I’m going to ask you this one. If you know the acronym, 10 extra pervasive developmental disorders. Yes. I have to read the question aloud because our other attendees can’t see this. So I’m going to ask it for the group. I’m glad, glad you knew because I didn’t. Dr. Morris, are you seeing symptoms of pervasive developmental disorders amongst fire fighters?

So we’ve seen it some, but not a lot. I mean, certainly not as much as PTSD, depression, generalized anxiety, OCPD, social anxiety, binge drinking, you know, not the ones that didn’t make my list. We’ve seen some, but, I would say out of maybe the thousand plus patients we’ve seen maybe four or five that we’ve been able to diagnose with that or came in with a diagnosis of that. So not often I’m I I’m guessing it was more to that question than have you seen it? I mean, if the question is just, have you seen it, we’ve seen some, but not, not really as much as in the general population.

I think that diagnosis is much more common in the general population than we see in fire fighters. Probably because it’s you’re in a population where you’re kind of always out there and talking to people and doing things, and it’s such a social motherhood, you know, developed, occupation that I think it would be very difficult for somebody. I’ve seen, it’d be very difficult for people with PDD or, Asperger’s.

Okay, one last question, and then we’re gonna go ahead and wrap up. This, I think is more intended, for a first responder, but we don’t have one of those on our panel today, but how might you suggest a first responder or fire fighter deal with those who shoot down the talk of mental health or treatment in their department, making it difficult for anyone to speak up or get help in those situations?

So I use an analogy. You know I often talk about how we are in the 1970s of mental health in firefighting. The analogy I will use is in the 1970s, fire fighters didn’t wear gloves. You know, first responders didn’t wear gloves when they went to a call. Any fire fighter who would wear a glove would be looked down upon, be called names.

I mean, how stupid was it? You can’t feel a pulse if you’re wearing gloves. You know, in fact, the sign of a really good call was when you came back to the station and you were bloodied up to your elbow, you know, you went, you wore the blood with pride, you know, you got bloody at a call and it was ridiculous to fire fighters to think of wearing a glove to a call. Something happened in the eighties that changed that. It was, you know, science, it was, AIDS and hepatitis that changed that for all fire fighters or first responders, because we learned how you got AIDS and hepatitis. It was a bloodborne disease, and if you expose yourself to blood, you would get sick.

You could get sick and die and you could bring that home to your family. All of a sudden people began to consider wearing gloves, but it wasn’t a right away thing.

You know, now, you know, we’re in the 1970s, and mental health people are dying from suicide. People are dying from mental health issues and if we’re talking about it. We know how to prevent it. We know that we can, if we reduce stigma and we get treatment, we can stop people from dying, but we’re not really there yet. So for a while, people would, you know, maybe bring their gloves or start to wear gloves. Then it became, no, you have to wear your gloves when you go there, but it was still this old guard of people who would laugh about it and make fun of it.

It took a couple of generations of people to get it. I don’t know if that analogy would help when you’re talking to people about it. Like, you know, Hey, I know you don’t get that, but like you used to not get wearing gloves. Where would that get you? If we didn’t talk about AIDS and we didn’t talk about hepatitis, you would still not be wearing gloves today.

I think it’s just as serious of an issue and it changes, it changed the behavior of fire fighters quite significantly to learn that something so simple as wearing your gloves could stop people from dying. Well, something as simple as talking about mental health and talking about suicide and talking about PTSD could save lives. I don’t know. Maybe that could change things. I mean, you’re not the person, you know, either you hear the term thou doth protest too much.

The person who speaks most loudly against mental health is probably the person who’s suffering the most. Maybe taking a minute to step aside and trying to understand where that person’s resistance is might be the most helpful, but it’s going to be difficult. This is going to be an uphill battle, but I know what I see is that the people who leave the center go back and do the most talking. It’s not going to be me talking to you that’s going to make the change. It’s going to be people who go get help, who then go back and talk to their peers who are going to make all the difference, honestly.

Absolutely, and I think that was an awesome answer and very practical advice. So we appreciate that. That’s it for our questions, and I know you have a busy day ahead of you, so, Dr. Morris, thank you so much for your participation and everything that you’ve shared with our attendees today.

I’m sure there were a lot of great takeaways, for anyone interested in another event next week, we’re going to be hosting Dr. Brandy Benson, who works with the St. Petersburg fire fighters and some other groups down in Florida. She’s going to be talking about suicide prevention and intervention strategy.

Can I just there, my last slide, can you just also make sure that these people know how to get in touch with me? Can you share that slide again and we’ll leave it up when you go to, yeah, let me just put it back up there. There we go. Perfect. Okay. let’s see. We appreciate everyone’s participation.

There’s Dr. Morris contact information. She is very open as you can see, showing your cell phone number, to, you know, further this discussion and taking any types of questions you may have. I know there’s a few of you who will be following up on and with specific items. but yeah, Myrrhanda and Molly’s information is in the chat if you’re looking for clinical information in terms of providers, or certificates of completion will go to Myrrhanda.

If there’s anything we can do to assist you, a colleague, a friend, a fellow IAFF member, a client, please reach out. We’ll be happy to help connect you with resources either with us or in your local community. We really appreciate your time and willingness to learn more about this. Dr. Morris, thank you again, and we hope to see you all next week. Bye everyone.

Thank you for joining us, please visit our website, IAFFrecoverycenter.com, for future training opportunities and recorded webinars. Thank you for all you do.