Articles:

• (PDF) Post-Traumatic Stress, Acute Stress Disorder
  & Post-Traumatic Stress Disorder
• 4 Most Overlooked Signs of PTSD
• Why You Shouldn’t Put Off PTSD Treatment
• The PTSD Pressure Cooker

Welcome to our Community Education Series, hosted by the IAFF Center of Excellence for Behavioral Health Treatment and Recovery.

Kelly:

Hello everyone, welcome. My name is Kelly Savage. I am one of the outreach directors for the IAFF Center of Excellence for Behavioral Health Treatment and Recovery. Thank you so much for joining us this afternoon, or maybe not afternoon, depending on where you’re tuning in from. I have the distinct pleasure of introducing our presentation today. We’re very excited about our guests and what we’re doing with this webinar initiative. So for those of you who might not be familiar, The Center of Excellence is an IAFF initiative — one-of-a-kind behavioral health treatment and recovery center, exclusively for fire service personnel. We are the only treatment center in the world that treats fire fighters, paramedics and dispatchers only, and this is exclusive to past and present IAFF members. We have learned a ton in the three years that we’ve been opened. This partnership between the IAFF and Advanced Recovery Systems is to truly deliver one-of-a-kind services to the people who deserve it most, ensuring that help is there for the people who are so willing to help others in their time of need.

In the last few months — as we’ve been homebound, if you will — we have endeavored to create opportunities to educate membership and beyond to do a few things: to further the conversation about behavioral health and reduce stigma. That’s going to be one of the things we talk about a little bit today, but there is a stigma within the fire service about behavioral health issues and seeking help for these things, and our goal is to challenge that and to create conversations, provide this type of education, so that hopefully we make a real change in how these issues are perceived. One of our other initiatives has been building our clinical network. 

I expect that a lot of our attendees today are fire service members themselves, but we definitely have a number of clinicians and treating health care professionals that have registered. So I’m really excited to have those individuals become a part of the fold because our goal is not only to provide treatment on an inpatient basis, but to be able to connect members across the U.S. and Canada with clinical resources in their community. Both for aftercare for those who have come to The Center of Excellence and are looking for resources when returning home, but also those who reach out to us simply looking for things in their community. So if you are a clinical provider and haven’t had the chance yet, we are excited to connect with you — that’s part of Molly’s role. I’ll introduce her, and we appreciate you being here. 

So, a few housekeeping items before we get started. Firstly, thank you so much — the Colorado Professional fire fighters Association for hosting, Molly and DVP Rahne and your studio today. We are so appreciative of the work that you guys have put in to make this a success, both Mike, Kent — and I know some other team members there, so thank you guys. We appreciate it, and we appreciate what you’re doing for your fellow members. I see a lot of people have already found our chat feature. Awesome. We’d love to know where you’re coming from, so please drop in the chat your name and where you’re tuning in from, and if you’re a fire fighter or a clinician or what your role is. We’d love to know who’s joining us. 

You will also find, on the bottom of your screen, a Q&A button. We’re going to be doing some Q&A throughout. Molly and Ray are going to be having their discussion, and then we have some opportunities for questions and answers throughout the presentation, as well as at the end. So if you will please use the Q&A box if you have any questions about what’s being covered or things that come to mind, we will be able to cover those as we go. So please try to put your questions in the Q&A box, not the chat, because sometimes chat moves quickly and we don’t want to lose anything. So, I hope to see a lot of great questions. I know we’ve got prepared speakers who are ready and willing to answer them. 

Without further ado, I’m going to introduce my colleague, Molly Jones. She’s a licensed social worker and our clinical outreach coordinator at the IAFF Center of Excellence. She wears a lot of hats, but she does a lot of work in our discharge planning and connecting IAFF members to community resources, but also continuing education such as this. We’re really proud to have her on board, and all the great work she’s been doing over the last several months to further the conversation within the fire service. I will let her introduce our esteemed guests. 

Molly:

Thanks, Kelly. Hi, everyone; thank you so much for joining us today. As Kelly mentioned, I’m Molly Jones, and I’m the clinical outreach coordinator for the IAFF Center of Excellence. As Kelly stated, I am joined today by the one-and-only 9th District Vice President Mr. Ray Rahne. Ray and I are going to be discussing trauma and trauma exposure in the fire service and how these members’ mental health and overall wellbeing can be impacted by the nature of their job. Ray is going to share his personal experience with trauma, PTSD and treatment. He is a retired battalion chief from the Littleton, Colorado, fire department, so he’s going to be sharing his experience — both on the job and pre-fire service — as well. We’re going to talk all about stigmas too and what we can do to combat those, and whether you are a fire service member or clinician, a spouse, whatever your role may be, there are certain things that Ray and I both believe that we can all do to reduce stigmas and normalize that. It’s okay to talk about how you’re feeling, talk about your stressors and be vulnerable. 

With that being said, we are going to jump right in and start talking about trauma. Trauma exposure is actual or threatened death, serious injury or sexual violence. Trauma can be experienced firsthand, or a person could witness something traumatic happen to someone else or hear stories, see pictures, listen to recordings and have some sort of reaction or be affected by the exposure to that traumatic incident. When someone is exposed to a traumatic incident or event, having a reaction to that — whether it’s a big reaction, or some may call it an overreaction, or maybe just something simple, like some disruptive thinking or sleeping patterns — it’s all normal, and these reactions exist on a continuum or spectrum of sorts.

I really want to hit hard about these reactions being normal, whether it’s that you end up being diagnosed with post-traumatic stress disorder or you’re able to work something out on your own or in outpatient treatment. Whatever it is, it’s all normal, and that’s kind of what Ray and I — our main goal today is to just normalize that for everyone, and we’re going to talk a little bit about the spectrum. So on one end of the spectrum, you have kind of this lower level reaction, which could include some symptoms like poor sleep, changes in appetite, feeling stressed, anxious, depressed. It really could look different for everyone because these reactions, whatever it is, are normal. They’re also all unique to the person, but basically for this lower level — a reaction, if you will — it’s manageable. It doesn’t persist for longer than maybe a couple of weeks, and day-to-day functioning is not impaired either. Then in the middle of that spectrum, you have maybe more of an acute reaction to trauma exposure. Maybe these symptoms persist for a little bit longer than a couple of weeks, and maybe there’s some slight impairment in functioning, but for the most part, there’s not this kind of all-encompassing, complete deterioration in functioning and a lot of distress from the person. That’s PTSD. 

We’re going to put up a slide right now that outlines the symptoms of PTSD. Kind of the hallmark with post-traumatic stress disorder — to be clinically diagnosed with that, you have to have symptoms in all four categories. So, if you have symptoms and all four of these categories and that persists for longer than a month, and there is significant distress or impairment in daily functioning, and a major disturbance to that person, that would be the PTSD. I hit hard there because I think that there are some misconceptions or misinformation out there about what PTSD is, and I think it’s really important that everyone knows that to be clinically diagnosed with it, you must have symptoms in all four categories for longer than a month, and there must be significant deterioration in functioning and or distress. 

Now that we kind of have a good understanding of what that clinical piece of trauma looks like, Ray is just going to move on to talk about something that we have decided to do throughout this presentation. Even though we know that — by clinical standards — there is a post-traumatic stress disorder, we have chosen to call it an injury. So throughout this presentation, we are going to say “post-traumatic stress injury.” And Ray is going to elaborate a little bit on why we decided to use that verbiage. 

Ray:

Thanks, Molly. First of all, Kelly, Molly and I would like to thank everybody for taking time out of their busy day today and be with us and hopefully get a better understanding of PTSI and signs and symptoms. We really appreciate it, and as Kelly already said, I just really want to thank Local 858 for letting us use their studio here in the day and have this look like we really know what we’re doing. So the question that Molly is talking about is PTSD and PTSI, and we’ve all known PTSD as like a disorder, and as I explain my story in a minute, it was really hard for me to believe that I had a mental disorder. Would that allow me to get professional help and then still go back to work, or would I have to take a retirement or do something like that? 

As we moved forward with this and the IAFF and talking with the general president and the rest of the board, I really thought that the idea that came up was with PTSI entry. The reason I talk about that is that it’s so important that, you know, if you have a fire fighter fall off a roof, break an ankle, hurt your back or anything like that, they’re going to take you to the hospital. You’re gonna go there, do your recovery, that department’s going to give you the time off and you’re going to recover — you have to go through some type of rehab, and doing all that. We talked about that as an injury, and PTSD is really no different than that. So PTSI in my mind, and something that you’ll hear me use the majority of the time unless we’ve gotta be technically talking about it for presumptive legislation or something.

So, it’s the same thing; it’s exactly the same thing. You have an injury. You received it at work, then — if in fact, clinically — they say that you need to get professional help and move forward. Whether it be from a clinician at home, or if it needs to be where we actually go to The Center of Excellence and that’s available and then you come home, you go to rehab — we’ll talk about that a little bit later — and then you’ll be able to come back to work. Then, in my story, what happened is that I came back and was protecting a person on the job for another 13 years, so that’s really important. 

Molly:

So you kind of felt like, based on your own experience, that that disorder had the connotation of unfixable, maybe, and an injury is a little bit easier to digest and kind of say, “Okay, there’s a problem. What’s the solution? What can I put into action and move through this?”

Ray:

Right. So when you try to explain to your peers that you’ve got a disorder instead of an injury, everybody’s looking at you like, “Oh, you know, so what really happened?” But when you explain to your peers and to your chief and to whomever that you have an injury and you need help with that injury, everything seems to be a lot smoother for the fire service and for us in the field. Much more digestible in some ways. 

Molly:

Okay. Why don’t we get into your story a little bit, if you just kind of want to talk us through, Ray. I mean, I know why we chose to interview you and have you talk about your experience, but if you can just share with everyone a little bit about what you’ve been through or experienced pre-fire service and then kind of just bring us all the way up to now.

Ray:

Okay. At first, Molly, I just want to say to everybody out there that my story is really not any more unique than stories out there. There’s a lot of good stories out there. What helped, I believe, was when I got elected as the 9th District vice president, I was able to bring this forward to the general president to board, and we were able to move this whole situation forward. As we know now about The Center of Excellence, it’s just not my unique story — there’s many out there. So my story really started — I went to Vietnam. I was in 1st Recon at the time, and what you did there is that you have six-man teams at that time in our group. So, we went; they would take us by helicopter and insert us into where they thought the enemy was, and for us to find out what they were doing and then report back. 

Sometimes, we were successful in getting in and out without them knowing it, but many times, we weren’t. So it was very stressful times for me. Very. I did numerous combat patrols and was able to move forward from that. When I left and came home — I was there in ‘68, ‘69. Very high area for very high time of combat in Vietnam — when I left and came home nobody knew about PTSD. World War II, they talked about shellshock; they knew that there were some mental issues with recon, people that are members that came back, so they tried to help us a little bit with that. Then come home, and then you’re done. You’re there, you’re back home and now you gotta function. So I came home and I didn’t know what I wanted to do, I was a ski bum for a year, and then a good friend of mine worked for the fire department. He said, “Man, you gotta get on.” He explained everything about the fire service, and I said, “Yeah, I’ll try.” It wasn’t as hard then to get up as it is now, and, and I was able to get onto the fire department. And it was really a true fit for me because, as I was explaining in Vietnam, I was an adrenaline junkie, a team player, a six-person team. So getting in the fire service was the same thing — around the team, adrenaline junkie. Plus, it was like military structure. That really worked for me, and I was able to move forward from there.

There was a lot of different calls that affected me over the time. It was more of, as we’ll get into a little bit, unloading the pack. I was able to unload some of those things, talk to some other people about it, but not really professionally. And as we all know, back in those days, those were the time when they said, “Come on, cowboy up,” or, “You’re here, we’ve all gone to this, you’re no different than the rest of us. If you can’t do it, leave.” That was a difficult time, and with that, I just kept going and making things work as best as I could and have different emotions — different ideas. 

Molly:

So, let me ask you: Before, when you came back from Vietnam and you started in the fire service, did you feel like you had been impacted by your two tours? Did you feel like you were different? I mean, I hear you saying that they tried to offer some sort of help, but did you have any sort of trauma-related symptoms? Well, that you were aware of. 

Ray:

Yeah. I mean, I wasn’t really aware of them, but I had come back and I became a loner. In Vietnam, you start losing people on your team — you just don’t want to get too close to anybody. So when I came home, I was the loner, which, before I left, I totally wasn’t. So I knew that was happening in my life. I was very agitated, meaning any loud noise from a firetruck or a car backfiring, anything like that, I was down on the ground. I didn’t relate that to PTSI, but with that, yeah. 

Molly:

So there were certainly some things that you were dealing with throughout your time early on in the fire service, and then you start maybe running these calls and, like you said, the backpack analogy — you’re just kinda continuing to pick up some rocks along the way, and it’s maybe getting a little heavier but functioning, hasn’t been completely impacted necessarily. Do you agree with that? 

Ray: There was a couple of calls where people come back and ask me, “Are you alright,” after a call and everything, and I’d kind of wake up and go, “Yeah, I’m fine, I’m fine,” and go through that. So that was really happening — it also affected the relationships. I couldn’t have a long-term relationship, but was just ready to move on and do that and not get too close to me. So with all that — thinking of all that happened now — hindsight’s 20/20.

Now that we know about that, my career went on and yeah, I moved up through the ranks. I became a lieutenant and a captain and then, a battalion chief. I hadn’t been a battalion chief too long when a Columbine high school mass shooting happened. That was 1999. I was in on a staff meeting and then the call came in and was, “That? No, that don’t make any sense.” First, there was a bombing, and later on we found out there was the bombing away from the school, and that was a diversion to take fire fighters away from there and police officers. Then, they started at the school. With that, I was just driving out there and then it came in that we had a shooting and there was somebody wounded and that kind of stuff. All that went down, and I got to the scene and I set up a command right in front of the school. Not even thinking about — at that time in the Denver Metro area, we were having a lot of drive by shootings and everything, so we just kind of thought that’s what it was about. So with all that happening, it then escalated and we really found out that there was a lot more going on, and then they moved the command post about a quarter mile away. That’s where I spent the next 24 hours, you know, taking care of business there. 

Columbine ended up to be the straw that broke the camel’s back for me, and it’s not because I was actually going inside with the patients, the paramedics and retrieving patients all over. You’re getting more and more places where there were gunshot wounds and what was happening. I was doing that — what came to me was kids killing kids, and that really took me down, and then it was that it lasted for 24 hours. During that 24 hours, they had to bring in a bomb squad and they were detonating some of them, which had always put me on edge, and some of them didn’t quite make it to the bomb trailer and were exploded. I was just really, really on edge. 

Molly:

So you say that it’s the straw that broke the camel’s back and that it kind of set you over the edge, but you’ve made it through that 24-hour period. You completed the call, or the mission, so to speak. So what is it that happened afterwards that really kind of set the ball in motion for you to kind of start connecting all those dots, both pre-fire service, during the fire service? What kind of led you to realize, “I need some help.”

Ray:

Well, one of the big issues was that, at that time in 1999, we only had critical incident stress, debriefing, PTSD. It wasn’t a good fit for this call and for our members. 

Molly: Can you elaborate a little bit? 

Ray:

Well, what we did is we’d have meetings on critical stress to grieving — really looks at what happened at the call. What did you do right? What did you do wrong? What could you have done better? Whereas the peer system that is used now is more worrying about your mental health and not worrying about that actual “what you did at the call” and trauma, with us, we’d have the meetings. Then guys would be talking about something and say, “This is what I did,” and then somebody else goes, “Oh, you’re not telling the truth. I saw you hiding in the engine. You never did anything.” And then all this kind of stuff, so it just got to really be detrimental. 

Molly: A hostile environment. 

Ray: 

Hostile, yeah. The problem with this is that this went on for about a month. They kept trying to redo it and kept trying to make the members go to these. He says, “Yes, briefing,” and finally, one time I went to the station and they said, “You know, chief, that’s the way it’s going to be. Make us do one more of those meetings, we’re going out back.” And I said, “Okay, I get this loud and clear.” So what we really did, I said, “Well, what are you talking about?” Then we really sat down and started talking and really had a peer-type debriefing, and everybody started feeling we weren’t talking about the calls — we’re talking about how you felt.

Molly:

Do you feel like those peer-to-peer conversations helped you get into treatment or realize that you needed some help? Or was it your spouse or, you know, what kind of was the tipping point to treatment? 

Ray:

Well, it really was my wife that said, after say eight months for her, that, “You know, we’re really not working good together now and you fly off the handle so easy. Are you eight months post-Columbine?” Post-Columbine. It was like she said, you know, — you’re just so agitated. Can’t drop a fork or a knife without you being on the floor, and you gotta get some help. And I think she told me too, there were some strong, emotional reactions to minimal sort of events. Yes. For an example, one of my kids did really good in school, and instead of being happy — I was happy, but I was very emotional, tears and all that. And I’m going, “This isn’t right for what I’m going through,” and I was recognizing that, but I didn’t know what to do.

Molly:

So where did you go to get treatment? 

Ray:

Everybody’s got to remember, this was before The Center of Excellence, before peer teams, before all those types of things. We knew the signs and symptoms of PTSI and what was going on. I was lucky enough to be a veteran, so I read some information about PTSI through veterans so I was able to go to the VA and get help. 

Molly: And what did that look like? Like, did you go to residential treatment or was it outpatient every day? Kind of what was the structure? 

Ray:

Well, it was both. It was a residential treatment, and then, actually, I was able to be able to go home, work on my issues, work on my bulk homework. It was cognitive behavioral therapy. Most of you are probably saying, “What’s that?” That’s what I said, and I think the big issue here was, first, why it took so long and why I did it outside. I was still working, yet doing this was that I had to be able to trust in my therapist, and the therapist had to build trust in me that I was going to be honest with her. This took about three months of going three or four times a week on my days off to go there and sit down and talk about issues. Finally, we both came to that agreement that we trusted each other and we can move forward. Then that took a little bit of a different — how it looked after that. 

Molly:

So, what were your kind of big takeaways from treatment? 

Ray:

Well, I think the biggest thing is that after going through the treatment and working through my issues, let me tell you that it’s not easy. Again, my wife — all these different things I was going through and doing. It’s not easy, but it’s totally worth it. I’ll tell you that right now. What was able to happen was that I was able to become aware of — for an example, let’s just use a call. You get a fire call and you’re like, “Do I send the teams in? Do I send in your company and then do an interior attack or an exterior attack?” Do all that stuff, and you’re looking at the smoke and you’re getting information from your captains on the scene and doing nothing, then you have to make that decision. After a call there’s a lot of times you go, “Did I make the right decision?” 

And what’s CBT? What really helped me with that? Obviously, I wanted to sit down and say, “Okay, what would I have done different?” And then when I go through it and go, “Now, I made the right decision from that information,” sit down with the captains, be able to do that and talk about it. “Here, maybe we should have recognized that. We didn’t, but from the information that I got to move forward…” and I think that’s what everybody’s got to really go back and look at. What the call was, what you did, why you did, why are you feeling bad about that call? And would you have really changed anything, anything major, maybe a few little things, but major things that really would have totally been different than that you made? So I think that was important. 

Molly:

The other issue is that you’re able to know your trigger points, and that was a big one for you. 

Ray:

That was a huge one for me. What I’m talking about there is that the trigger points are different events in your life that maybe you don’t know about that are affecting you. Maybe it was coming up to April 20th, 1999, which is Columbine, and I didn’t want to associate, wanted to forget about that incident. And all of a sudden, two weeks before, I’m getting real irritable — I’m getting stressed, I’m doing all that. Once I started figuring out trigger points in my life, whether maybe it was another fire fighter had passed away or maybe it was something to do with Vietnam, then I was able to be aware of what triggers me on these and then be prepared. For example, fireworks just really set me off. So if I go to some place and I know there’s going to be fireworks, then I’m prepared for it. It’s not like it’s just happening, right? Like a car backfiring. 

Molly:

So, what do you feel like — just to kind of wrap up your story a little bit — because you got treatment and you kind of connected all of these dots for yourself and were able to kind of reinvest in yourself and get back to this level of functioning that you wanted to be at. I know that you shared with me that, had you not gone through that, you don’t think that you would have been the district vice president. And because you did all of that and put all of that work into your mental health, you’ve gotten this platform to talk about behavioral health. So, can you share with us what this platform has kind of lended itself to, as far as your work or becoming a behavioral health champion, so to speak?

Ray:

I was able to know that there really was a crisis. It wasn’t just me; there was a lot of us. And after Columbine, after I got my therapy, through that, I was able to sit down with some people that I thought were hurting and talk to them and really understand that there was a lot more out there. So with that one, that was kind of my goal when I got elected district vice president — to take this to the IAFF and talk about the issues that we are facing out there, and that really is a crisis. There’s really a lot of us that are suffering. Then, as you know, that magazine came out from the IAFF, talking about coming out of the shadows and doing all that and all the calls that IAFF had on that — myself with numerous calls and from people saying, “Yeah, that’s me, that’s me.” 

I think that was a great platform and brought it before the whole board. Then, the general president, general secretary of treasure — they really started understanding the out-of-the-box idea of The Center of Excellence. I wish I could say that was mine, but that wasn’t mine, but out came this phenomenal idea and here’s where we’re at now. Everything is available, so we want you to use all those resources. We’ll talk, I’m sure, a little bit more about that, but they weren’t available to me, but they are available now. I think that’s really important, and as you say, I’m a real champion for behavioral health, and I know that we’ve made great strides and we’re moving forward. 

Molly:

Well, that kind of concludes this first part of our presentation or webinar today — or discussion, I guess, is really what it is — and we’re going to take some questions. I think Kelly is gonna field those to us, then we’ll get into talking about stigmas. So, Kelly. 

Kelly:

Awesome. Thank you guys so much. We have been getting some questions, and anyone who’s watching, if you have questions, please drop them in the Q&A and we will cover them as we go. Firstly, we’ve gotten a few mentions, Ray, that say thank you so much for sharing your story and thank you for your service. It goes without saying, from our perspective, that you mean a lot to us and a lot to the IAFF, and I definitely can concur that you’re a brave guy but probably too humble to accept that compliment, but the people want you to know. More of a comment than a question. One question here that I’m going to answer, and it is that, “Will we be able to get a recording or notes?” Yes, we will have a recording available. This is being recorded, and we will be able to post that on our website. So we’ll share that link — where this will be posted later for everyone in the chat — in just a little bit.

So yes, it’s recorded, and we look forward to being able to share with people who may not have been able to attend today. Molly, maybe you can address, well, and Ray too: Is it possible to have or experience post-traumatic stress versus PTSD or PTSI? 

Molly:

Yes, so I think that that really is about the spectrum or goes back to the spectrum. There’s all varying reactions for exposure to a traumatic incident or event, and maybe clinically, those lower level kind of reactions might not exist in a diagnostic manual. But I think that they certainly are real when you experience anything out of the norm — anything that we expect to see on a daily basis, anything outside of that kind of warrants a reaction, right? Because it’s not expected, and I think really the difference in each of those spectrum categories is how long those symptoms persist for. If it’s just a couple of weeks, and maybe you do have some significant disruption in your life, maybe you don’t sleep for 48 hours or 72 hours, but then you’re able to regain some functioning and get back to your baseline — that’s just one of those kind of more normal or lower level reactions. Not more normal, ‘cause they’re all normal, but that’s one of those lower level ones.

And then there’s the acute stress disorder, which has more symptoms that may persist for a little bit longer than a couple of weeks, but not symptoms in all four of those categories. When it gets to be PTSD is when you have symptoms in all four categories for longer than a month, and there’s this significant amount of distress and impairment in functioning. So, I think Ray — he has shared that throughout post-Vietnam and throughout his career as a fire fighter, even though he was dealing with, and I’ll let you kind of elaborate on it, but even though he was dealing with some of these symptoms, not every day was a bad day, right?

Ray:

So, and I think following up on that a little bit and Kelly, our goal is to keep everybody at PTS; we don’t want them to go to PTSI. So our real goal with teams and clinicians and education and all of that — yeah, we’re all gonna have some PTSD in our career, no doubt about it. And it could be every day for a while, depending on the calls you get, and so I think that it’s really important that that’s our goal. That’s really what we’re trying to do, and it’s so those symptoms and what you’re doing — what you’re feeling is normal, and the fussiness doesn’t last, you said, for 30 days. The other thing is like, yeah, I had normal days. I really felt fine and functioned fine, and then — maybe a lot of different calls, different stress, different workings with the chief or whatever — that backpack got really heavy. It started getting heavy, and then maybe I would go in and have a meeting with the captains or something and unload some of that and then be okay for a minute. Be functioning as normal functioning, you know what I mean? 

Molly: 

I think what we’re getting at is it doesn’t have to be this total breakdown, rock bottom that someone has to hit in order for it to be characterized as a reaction to trauma or stress. 

Ray:

I also think what you have to understand — it doesn’t have to be Columbine. No, it doesn’t have to be a Pulse nightclub, it doesn’t have to be a Las Vegas, any of those types of things that it can be — just that one call for whatever reason, you know? I had a friend that it was calls with children, and that just finally was his straw, and he just couldn’t do that anymore. So it doesn’t have to be one of these major calls, and we got to look at that — every call we go on, for us, is major ‘cause we’re really feeling a lot of that stress and that pressure and what’s going on. And for us today, we’re dealing with everything, right? With COVID, with staying at home, our kids and everything else, and then we go to work. That’d be — you know what I mean? It’s tough. You have a lot of stressors, and maybe there’s not a rhyme or reason, or you can’t connect it to a call, but the reaction is there. Maybe it’s because of all those other life stressors that you have on your plate. It doesn’t have to make sense, and that’s normal. 

Kelly:

Thank you guys — a good segue. You hit a lot in this answer about the four criterias. Can you repeat — I think it was covered at the very beginning and then we were having some technical difficulties with the slide — those four criteria that is like, where that comes from and if it’s all only medical or if it’s legal, (which I think the answer is it’s medical, right Molly)? The four categories that you’re talking about, where does that come from? 

Molly: 

It comes from the diagnostic manual, so from the DSM-5. I think we’re going to pull up the slide. Yeah — the four categories, intrusion, and on the right there, those are some examples of that. Then after that, we have avoidance and the negative changes in cognition and mood, and then arousal and reactivity. So you must have symptoms in all four of those, and by no means is that a complete list of all of those types of symptoms that fall under those categories. Those are just some basic examples listed in the DSM. 

Kelly:

And Molly, can you elaborate for those that aren’t familiar with the DSM and what it’s used for?

Molly:

It is the diagnostic manual that a psychiatrist or a clinician that can diagnose would use. It’s the clinical criteria for a disorder. So if you’re going to be diagnosed with major depressive disorder or generalized anxiety disorder or post-traumatic stress disorder, there is certain criteria that someone has to meet, based on symptoms and functioning, to be diagnosed with those. You could go online, you could look up DSM-5 and read through all sorts of different clinical criteria for every disorder out there. Were you gonna elaborate a little bit? 

Ray:

No, what I was just gonna say is I think that the part on the right and when I was diagnosed with it, I had just about every one of them, you know what I mean? You have to have one in each category, but not have to have every one. I think the other thing is, we as fire fighters have our own language, and if you kind of think of those on the right, you’ll know what that really means to us as fire fighters. But it’s important to know those. 

Kelly:

And part of that question was, are these legal definitions? I can speak a little bit to helping some of our locals and states with workers compensation cases, and Ray can certainly attest that the qualifications for coverage for PTSD are different in every state, and are different in Canada. So, when you look at, are these qualifying factors for legal coverage of post-traumatic stress? Maybe if the law is written in such a way that it acknowledges the criteria as outlined in the DSM, maybe not if the state has written their laws in another way. So, it varies greatly. It’s kind of hard to give a direct answer to that question because it’s just different, a lot of places. But one would hope that in a legal situation, you would be referencing the medical qualifications for any disorder.

Is there anything you guys want to add to that? I’ve gotten more questions, let’s see. Actually, Ray, I’m gonna give this one to you. It’s kind of in the same vein of what we’re discussing. Do you know if PTSD is covered under the heart and lung law? 

Ray:

No, I think they’re speaking here in Colorado and no, that’s not covered under that. Although that law we’re looking at — to include PTSD — is like we expanded it for cancer, and now we’re looking to expand it for PTSD. Well, we’re talking about that there has to be legally called that and again for PTSI. So no, it’s not covered under heart and lung.

Kelly:

Thanks, Ray. There’s a mention that this slide we were showing with the DSM criteria references an event, and the comment is made that maybe we should consider several events or no one singular event. It just seems like we’re looking at it from a standpoint of one incident when it generally is from multiple over a span of time, which I think this question came in as you guys were saying that, and I think we can all agree that that’s probably true. But the DSM criteria, and often what is written for state laws for coverage, does refer to specific events that fire fighters would need to qualify for, for coverage for this issue.

Molly:

Quick clarification there. I had made the point that maybe sometimes you can’t tie it back to a call, and there’s life stressors, but I just don’t think — I agree with this person — that you can’t call it an event. Sometimes, it’s a lot harder to pinpoint, but I think that that’s where treatment can come into play. Working with, whether it’s an individual outpatient therapist or in a long-term residential treatment setting, a therapist or a clinician can help you uncover what some of those trigger points or what some of those major calls or incidences may have been for you. We do that at the center. We sit in on — I’ve sat in on — groups and heard people talk about just that. It’s really hard to say because I’ve had a 20-year career, “Where would you like me to start?” So I think therapy can be a huge advantage in that regard. 

Ray:

Yeah, and I think as you heard me say, “Columbine, it was the straw that broke the camel’s back,” really when I went through therapy, Columbine wasn’t really the big incident we were talking about. It was everything that happened before that and all the other calls I went on and all the other stressors and obviously Vietnam and that type of stuff. So, no, it doesn’t have to be one event and usually isn’t; it’s over multiple events, but you finally have that one event that you go, “Oh, I’m overloaded.” 

Kelly:

Would you be able to touch on secondary traumatic stress, and differentiate between primary and secondary stress? 

Molly:

Well, I think Ray kind of gave a very good example of that. You know, you said that as the incident commander, you weren’t at Columbine, you weren’t necessarily in there helping out on the scene, you were kind of calling the shots, right? I would consider that more of a secondary kind of level of trauma, even though you were there. I would also kind of say that dispatchers, to me, have a secondhand level of trauma because they’re hearing the calls, but they don’t see the images and maybe they don’t have the follow-through. So to me, that’s secondary. 

Ray:

I think that’s a great example with the dispatchers — they dispatch, they hear everything was going on, but maybe when we get back from a call or whatever, they don’t get to follow up. You know, how did that patient do, what went on with everything?

Molly:

So, or maybe even a paramedic, you know, taking a patient to the hospital? Well, I guess that would be more firsthand, but not getting that follow-through or that closure can sometimes be impactful. 

Ray:

Yeah. Maybe you don’t get to be able to talk to the doc and how it really went and how you did on the call. Sure.

Kelly:

I’m going to do a few more and then we’ll move on and we’ll, we’ll hold the rest as we go along, cause we’re getting some great questions. Is sleep deprivation, a common symptom of post-traumatic stress? 

Molly:

I would say in this world with this one population, that one might be a harder symptom to kind of pinpoint to post-traumatic stress because there’s so many other kinds of contextual factors at play. Being that you’re on shift work that causes sleep deprivations, interrupted sleep when you’re on shifts can impact that, but certainly exposure to trauma and the very nature of this job causes changes in the nervous system, which can make it much more difficult for someone to get to levels of relaxation. So that would definitely impact your sleep as well, but in my mind, sleep is one of those ones that we have maybe more control over, and it might not be sleep — taking a nap, getting eight hours — but there are stress reduction techniques, stress management techniques that people can use. Mindfulness meditation, and that can help you to reach relaxation easier. It’s kind of like a muscle — the more you work it, the easier it is to access. So to me, sleep deprivation is kind of an issue across the board. Would you agree? 

Ray:

Yeah, I know for me it was an issue. Not because of the fire service, but because of every time I went to sleep, I had flashbacks, I had dreams, I had all this that went on. So if I got three or four hours of sleep at night, whether it’s at work or home or any place that it was, that was an issue. But once I got through the therapy, I was really able to start then at home and start getting eight hours of sleep, and I wasn’t going to those flashbacks all the time and dreams and doing all that. There’s trigger points that continued to make me do that, but yeah. 

Molly:

So you would say then that your sleep deprivation was caused by the flashbacks and nightmares, versus just not being able to fall asleep. So those are two major differences, I think. 

Kelly:

Thank you for that, that was very helpful. Can you touch a bit on compassion fatigue? And this question actually was compassion fatigue and secondary traumatic stress, which you’ve covered a little bit. Compassion fatigue is something we hear about often and maybe it doesn’t really get talked about enough. Ray, you may have some insight on that.

Molly:

I think compassion fatigue could be its own webinar, and to me, that kind of goes in line with the backpack analogy. When you are stressed because of all your other roles in life, and then you have your work stress, that’s kind of just another rock, I think. Then it gets more difficult to take care of yourself and kind of be emotionally aware or even have the energy to be introspective. What are your thoughts on compassion fatigue? 

Ray:

I just think it’s that we, as fire fighters, don’t allow us to go to that because we’re there to help other people not help ourselves, and that becomes very detrimental to us. Whenever you get to that loaded backpack and haven’t unloaded the rocks that you get, you’re going on calls and you got to do that, but you can’t come back and take care of yourself because that’s not my role. And we got to change. That, to me, is one of the stigmas we’ve got to change now. 

Molly:

And we’re going to kind of get into that — ways to take care of yourself and ways to combat the stigmas too, to give fire service members maybe some more time to decompress. 

Kelly:

And we have a number of questions about that, so why don’t we continue on and then we’ll get to the rest of these questions as well as anything else you all may have as we go along. 

Molly:

Okay, perfect. So that leads us right into stigmas, and Ray, you just kind of touched on one already — that there’s that stigma in place that it’s maybe not okay to talk about your feelings or to be upset. To emote, I guess, but what else do you think? 

Ray:

Well, I think we now know it is okay and that that’s the culture that we’ve got to change — is saying it’s okay. When you talk about the stigma for me, it was, “Will I be fired, how do I want my peers to look at me, will I be accepted when I come back to work?” Because they look at it as a disorder instead of an injury. That’s why I think it’s really important to look at it as an injury. So all those are stigmas that I had to work through, and again, I didn’t have a Center of Excellence doing all that. I had to keep it quiet and go to the VA, but now we don’t have to do that, and that’s what’s so important about why we’re doing this. 

So I think there’s many, many different ways that we can do that. Education of officers — the officers can get an education on the signs and symptoms, what to look for. I think most of us know that, but that is: One, the officer is okay taking me aside and talked to me about, “You’ve been really hyper lately, or you’ve been real moody and we’re all noticing that with what’s going on.” So, an officer to get that education and then have the thought process that, “I need to call the peer team and have a member of the peer team come out and talk to Ray.”

Molly:

That’s kind of this next level of normalizing PTSI, right? Just kind of talking about it, studying it. I always say this, but setting out that welcome mat and going up to someone, pulling them aside like you said, and asking a direct question about what you’re observing in them versus saying, “How are you doing?” Because everyone’s going to just say, “I’m okay,” ‘cause it’s hard to talk about that. But I think even if they’re not ready to hear your concerns or are ready to talk about it, you’re at least saying, “Talk to me when you’re ready.” They know that you’re a safe person. 

Ray:

Right, and one thing that I would do is I would say, “Hey, how’s your family doing? What’s going on in your family? And I’ve noticed…” you know. Then, they’re not like talking about me. Then, they’re saying, “There’s that feeling — not just talking about me, the kids really been sick,” or these types of things. So that really kind of brings it out — try it rather than, “How are you doing?” I think that’s really important. And I think another one of those ways we’re changing the culture is academy, so the fire fighter academy. When I first got into this, we talked a little bit — maybe an hour, maybe two hours — and now we’re seeing academies really devoting two or three days to it and explaining to fire fighters that it’s okay and it’s alright to talk to your officer. It’s all right for an officer to say, “I’m going to put a rig out of service. He got back from a call and we all just need to sit down and talk, debrief a little bit — not about what we did at the call, but how do we handle it on the call for what that was?” 

So I think that’s really important — the academy training. We’re going to change the culture. As you know, I look at it as different things. For an example, we used to always put our bunker gear right next to our beds, and that’s why we call them bunker gear — ‘cause we got in our bunker, and as soon as we roll out, we got in our bunker gear. And as we all know, now you can’t even take them into the kitchen, you can’t take them into the bedroom, you can’t do any of that. Which is a great thing because we know of all the cancer agents, everything, but that didn’t just happen overnight. We had to educate and we had to work with officers and we had to work with fire fighters to say, “Okay, now I’m getting it.” That’s the same with this — that as education goes along, you get more and more academies through the process. Then later on down the road, it’s going to be a normal culture. That we have to do this. 

Molly:

So what about for everybody in between? What do you think we do there for everybody in between — the captains and then between probies — about just general education? I know I’ll talk to peer support teams and kind of help them refine skills or talk about certain topics, but on a day-to-day basis, do you think it’s true that you just got to start bringing it to surface and bringing it to light? 

Ray:

Yeah, I think you hit the point there with the peer teams, and once the peer teams go out and educate, explain what they’re there for, the peer team is not going to be your — as I call them — “shrink” there. They’re going to be out there and listen to you and understand, and if they really think it’s time that you get some help by a clinician, then they’ll move you forward to that. The big thing about a peer team is confidentiality, and I just want to stress that to everybody and every peer team that that’s what it’s all about. When I go to talk to Sam about, “I’m having some issues at home, we’re having financial issues, we’re having this,” not everybody in the department has got to know that. They can help me get therapy or get me to the right resource for financial issues and that. 

Molly:

So to me, that kind of goes in mind with the culture too. We’ve already kind of hit on that there used to be the culture and maybe not so much anymore of this “pull yourself up by your bootstraps, you’re going to be fine.” I think that the peer support teams definitely have changed the culture for the better and just kind of general awareness about certain things, but it seems like for you — and you shared with me when we’ve been talking, practicing for our webinar — that on a higher sort of level, there’s been some cultural shifts. Like the Oklahoma City Murrah bomb incident commander reaching out to you, and then you reaching out to Parkland, kind of bringing people together, or was it Vegas? 

Can you kind of talk about how you have this leadership position, what you can do to change their culture? But then also just on a smaller scale, because we’ve talked about that — not everyone’s going to have a Columbine, not everyone’s going to have a Pulse nightclub. But even if in the next town over, there’s a big house fire, what can be done to support those people and kind of change the culture of supporting each other in maybe the out-of-the-box sort of ways?

Ray:

I think there’s many ways of that, and I think we’re really talking about the stigma here. I feel there’s three stigmas. There’s one that we’re just been talking about — that we, as fire fighters, have of ourselves. How are we going to handle it? Two is the stigma of the officers and the chief administration — do they believe in mental health and do they support the mental health of fire fighters? And three is the administration, that they understand from the chief that this can be handled. There may be some time off involved or whatever, but in the long run, it’s going to save them money — that they’re putting money into behavioral health now and able to help them down the road with all of this. So getting through all three of those stigmas, it’s like we as fire fighters really have been talking about everything, but then again, if your chief doesn’t believe in it, now we’re going to have to educate them. And so, great job that Molly and Kelly and they do; they can come out and talk to the administration, talk to the chief, explain how it really works. So that that’s a huge educational part.

Molly:

Yeah. I’ve done, you know, sit-downs with the city and talked about our program. I’ve hosted presentations about behavioral health, and chiefs have come in and had really good discussions about that. So, I mean, I’m right there with you that education is key, and it sounds like, too, that it’s a bunch of moving parts that we have to kind of get working in tandem right. 

Ray:

Right. That, and I think that’s a great example here in the Denver Metro area that, with me being here and being a real champion of this, there’s a lot of chiefs that have accepted it and supported it. Matter of fact, we have one department that, after the end of the negotiations last year, the administration came in and said, “Well, we got one more thing.” Usually, you know, have you ever negotiated a contract you got in an hour? And the chief is going, “You know what? I’m going to give each and every member on our department two days of mental health leave.” So a person can just call in sick and go fishing or be with the kids, or take a night off, go for a hike or whatever. Unload the backpack, unload the backpack. And that chief realized how important that is. And so that says that the strides we’ve made over the last say five, six, eight years, that we’re really making great strides with that type of a culture change, clear up to the administration.

One more thing that I want to touch on here is that we’re kind of getting to using our resources, whether it’s a peer support team, us at The Center of Excellence or at the state level. And we kind of talked a little bit about reach. If you don’t have a peer support team reaching out to your state association and trying to get connected with one in the state that does exist, I think that everybody can or should have a peer team. It’s time-consuming to put together, it takes a while, but we have the framework for it. We can really help you understand and have your administration understand that. So that that’s one thing, and if you don’t have one, maybe one of your neighboring departments has one and you could tie into that. But many states have a state team that can come out and help, say we need some help. And then the other one is the IAFF has their team that can come out and help. But to get that, you have to call me or call your DVP and say, “Hey, we need some help here.”

And I really want to stress to the teams out there that when we come in — the IAFF team comes in — it’s not to take over. It’s to help you through it. And what I’ve found many times is that the department team is just too close to the issue. Let’s say we have a shooting in a department and one of the fire fighters has been wounded or killed and everybody there is really close to that, and it’s hard for them to function as that peer team and to be able to separate from. Being able to bring in the IAFF or your state team to help you work or both, we can do that. But there is a process for obtaining this, and I think that everybody needs to know that. And for the IAFF, it’s contact your DVP and they’ll be able to help you work through that. 

Molly:

Well, there are a lot of different kinds of resources out there, whether it’s officially with the IAFF or a partnership like the center. I know here in Colorado — building warriors — there’s lots of organizations like that out there that freely have the purpose and the mission to serve fire fighters or first responders, and it’s all about being vulnerable and saying, “Hey, we need some help.” It’s kind of that higher level of asking for help. 

Ray:

Yeah. And I think that’s really important — is that every team has a clinician, and that clinician is so important to the team. They’re able to set up training, they’re able to understand the fire service, all that is happening and especially your department. Or you may share a clinician with three or four different departments, but that clinician is going to be aware of all the different issues that are going on. And that is so important to have in the fire service and for each team. 

Molly:

Next month, actually, we’re having two webinars on the IAFF peer support team model. That will definitely answer, I think, a lot of questions that anyone has about peer support teams or what they can do to get those off and running. But certainly, if you have questions for Ray that are specific to his kind of involvement with peer support or personal beliefs on it, definitely ask us those. But just know that we’re going to do a deep dive next month, too, on peer support stuff.

One more thing that I just want to talk about here — I’m going to put you on the spot, Ray — is how do you, since we’re all about culture and changing the culture and modeling vulnerability, how do you do that on a daily basis? Or how do you show others what you’ve learned and that it’s okay? 

Ray:

Yeah. Well, I think the big thing for me is that you got to know, after you go through therapy, that that’s not the magic pill. I mean, it gets you to where you can come back and be functional with The Center of Excellence. I’ve never gone to it besides going out and looking at it, but I’ve been involved with it for forever — since the beginning, But the thing for when you come home, you have to continue with your therapy. You have to continue unloading that backpack. And so when I was done with my 30-day therapy, then I start out having at least three times a week I continued to see my therapist, and the work goes on and on and on. The Center of Excellence has that too, where you’re supposed to do that. 

We got to do a better job of when our members come home to make sure they’re doing that clinician work. So here it is many, many years later for me, and I still go see my clinician or my shrink every three months. I call it a tune-up, and it’s great. There’s times in between, I may have to call her and say, “Hey, I’m really confused about what’s happening right here,” but at least every three months. I think people got to understand that this is a continuous thing. You’re going to have your triggers. You’re going to have that. Maybe you have new triggers, maybe different ones, but that’s how I continue to know my triggers down — what’s going forward. Or having my wife again say, “Hey, you’re getting pretty grumpy here, what’s going on?” And I go, “Yeah, you’re right.” I think that’s important. It’s a piece we’re missing in the fire service, when our members come back or get help and making sure they continue on their therapy. 

Molly:

What about retirees? Do you have any advice for retirees? 

Ray:

That’s a great point. In my own department, I had a retiree that was really suffering and he was able to go back to The Center of Excellence and get help. I think that a lot of the retirees don’t understand this culture change, and we need to let them know that we’re there to help them, whether it’s just through a peer team or just as a friend or if, in fact, they really need to go back to The Center of Excellence.

Molly:

Alright, well, I think that pretty much covers what we wanted to talk about stigmas. Did you have anything you wanted to add? 

Ray:

No, I’m sure there’ll be questions. 

Kelly:

We’ve got questions, and we have a lot of questions and we don’t have a lot of time. I want to try to cover as many as we can and get to the next part. So just keep that in mind, okay? Thoughts on a peer support team being established out here aside or private from within the fire department, and I’m sure Ray has a lot to share about this. I know that I know of several locals that have their own peer team that are not specific to the department, which could be an example of how that works. Do you want to share anything about that or your thoughts? 

Ray:

Well, as you’re saying, you know about that. I’m not really aware of outside peer teams. I am aware of what we were talking about — warriors and different places like that can really help outside. But most of them are really involved through a peer team and are able to bring forth that help to us through a peer team, and we’ve even assessed some of that, meaning that we’ve been able to get somebody some help. Maybe they need to be able to get a ride someplace or they need to go to therapy, but they have a family issue and they need help with that. So we’re able to be able to help with that if the peer team isn’t being able. 

Molly:

So the one I know of is northern Nevada, and I think that they include all types of first responders in their peer support team, but I’m pretty sure it evolved out of the fire service peer support team. I could be mistaken there, but that’s really my only thought on outside peer support teams. I don’t know too much. 

Kelly:

Well, you guys touched on state peer teams. They’re not specifically associated with the department in many cases, so they could provide a higher level of confidentiality — that you’re not having to go to someone within the department or whatnot. So, it just depends on the region, the locals or departments in play, but I think there’s probably a few ways to be successful there. 

Ray:

Yeah. I see what you’re saying now. Correct. 

Kelly:

Ray, you had mentioned that your recovery helped you become aware of your triggers, one example being fireworks. You said that this helped you prepare for that event. How do you prepare for those things? What, if any, coping skills do you use? For example, outreach calls, meditation, journaling, etcetera. 

Ray:

Well, it’s really, for me, to know those types of events are gonna start coming up. Or, say a significant call in Vietnam where I lost a few members, that’s had nothing to do with the fire service, but it affected my work — as in the fire service that affected my life at home. With knowing that I’m starting to get a little grumpy, I’m starting to feel that I go, “What is the event?” And if I can’t put it together, I call them — my shrink — and away we go, and we started talking about all these events. And I go, “Oh, I get it now.” So those are the triggers that I do. I know a lot of people are doing yoga and really enjoying that as a stress release. I find my time to work out and really not think about my workout. I get off into other ideas and thoughts going on and try to unload my backpack while I’m working out, so that’s really helpful for me. 

Molly:

I think, too, that the more awareness that you have to your triggers, the more mentally prepared you can be for them, and I think that can reduce anxiety. Any time that we expect something, we’re less inclined to be fearful of the unknown, right? Because we know we expect that this is coming. That’s not to say to get in the weeds about your triggers and completely avoid anything and everything where this one trigger could happen, but it’s more so that you can mentally prepare yourself and mentally say whatever your personal mantra may be. Or maybe it’s you gotta go run before you go to this event where this trigger could exist. I think it’s just to prepare yourself. And the more insight you have, just like we’re saying education is key on stigmas and all of that, I think education on yourself is really important too. So that way, you can be aware and prepared for whatever may happen. 

Ray:

And I’ve heard many different, you know —whatever that you find relaxing to you. It could be reading, it could be anything. Maybe just being in a quiet place for a while. But whatever works for you where I find exercise works for me. 

Molly:

Hosting webinars like this is mine. That’s how I relax. 

Kelly:

What have you found is the best way, or maybe some strategies, to rebuild resiliency?

Molly:

I mean, that’s a loaded question. I think that, first and foremost, is unique to the individual. Just like Ray is saying that not every coping skill is going to work for everyone, the things that I would choose to do to build my resiliency is going to be much different than the next person. And I know that the IAFF is actually looking at putting out a course, or they have put out a course, on resiliency, so that could certainly be a resource for this person. But in terms of my own personal opinion, I think that it’s using all of your resources.

When we’re talking about injuries and we’re saying that you gotta go to a doctor and then maybe you have to go to a specialist and then maybe you have to go to physical therapy and then you have to do some at-home stretching, things like that. It’s this buildup. And I think that resiliency is similar to a muscle too. That the more you work at it and the more you keep that at the forefront of your mind and as your goal, I think you’ll get there easier. There are things like therapy — going to individual therapy, going to treatment — I think certainly builds resiliency. It can X the dots that answers that “why” question for you. I think involving your family, doing your coping skills, unloading that backpack, just kind of reinvesting in yourself is, to me, how you build resiliency. Do you have any thoughts on that one? 

Ray:

I think you’ve really covered it — that’s, you know, that’s individual.

Molly:

Kelly — just wanted to let you know that we’ve pretty much covered the rest of our talk. I’m just kind of looking at our outline. So I think we can maybe continue with questions here, or Ray does have a letter that he definitely wants to read from a spouse. It’s our parting words in some regard or kind of — we feel like it really sums up this topic. So I don’t know if we’re going to — we’ll just pause here and read this letter and then we can resume questions if that’ll work. 

Kelly:

Yep. That works. We have a lot more questions, but let’s do that and then we’ll come back to them. Just for time purposes. 

Ray:

Okay so I think this was really important. This brings us all together, understanding that we as fire fighters have to be open to get help. This is from a wife of a fire fighter. Her name is Emily and her husband was named Kurt and he, within the last month, has committed suicide. So Emily wanted to talk about this and gave us permission. As I read it, at the end, you understand that this is her goal now — to make sure that her husband’s life wasn’t in vain. So, Emily puts this.

“Kurt always wanted to be a fire fighter. He wanted to be just like his Pa, Craig, who he looked up to for so many years. He always talked about how strong and tough his grandfather was and how he admired him for that strength. As a fire fighter, you automatically have strength built into you. You are courageous, brave and strong. The mentality behind being strong is often thought as holding in your feelings and struggles. That mentality has to change. Being mentally strong means sharing your struggles and your feelings. You cannot let those thoughts and feelings eat you alive. You cannot hold your struggles in. The strongest thing you can do for yourself, your wife, your husband, your children, your brothers, your sisters, your mothers and fathers, is open up. Get the help you need, whether that be medication to control anxiety and depression or counseling to talk through what you have seen. Get to help, save your life. 

“Save your family from the grief and sorrow, save your family from the guilt. If Kurt had just opened up and talked to one person, it would have saved his life. If he told one person he was struggling, it would have saved his life. If Kurt had done the strongest thing he could for me and his children, it would have saved his life. If Kurt had opened up to one person, I could still have my husband. I have to go to sleep every night without my husband, I have to wake up every day without my husband. I have to raise our children without my husband. My life will never be the same. I will live with guilt, grief, heartache for the rest of my life. So when you are struggling, open up. If you need to talk, call someone, anyone. If there’s one thing that should change from Kurt’s death, this is it. Change the stigma. Do it for Kurt, do it for your wife and children, do it for your brothers and sisters that you work beside every day. You are on the front line of our community. You have to be mentally strong, emotionally strong and physically strong. I’m so proud to be Kurt’s wife. I’m so proud of the department that he was a part of for so many years.

We have to change this. We have to honor Kurt’s memory. Kurt’s death will not be in vain.” 

I think that’s very powerful and really brings us all together. 

Molly:

Yep, yep. Do it for Kurt. There you go. For Kurt, no one else. Yep. 

Kelly:

Thank you for sharing that, Ray. I know that that’s heartbreaking, but it’s motivation to do better. And I hope that we can be a part of that with what we’re talking about today.

So, revisiting some of these questions, which do actually hit a lot of the points made in that letter and some of the things you’ve said so far — how can union leaders support members best when they come back from treatment? Specifically, how can we support them in their continuing care plans that you have mentioned? 

Ray:

I think there’s a lot of ways that can be done, and I think you have to do it up front. I’ve had discussions with The Center of Excellence and with the — what do you call the clinical team? We all talked together about issues that go on. The advisory board — yeah, that’s the one I was looking for, and we’re going to have a meeting on that. So we bring up these different issues that I feel maybe needs to be worked on and tweaked as we move on forward, and this is one of them. So we’ve talked about The Center of Excellence and, again, I’m just talking one thing here in Colorado that I know of that we’ve done, is to get the state team involved. I’m sure other state teams have done the same thing — that is, get a clinician available for this person that they have before they need The Center of Excellence saying, “Here’s the clinician you need to see.”

And one point I want to really make sure about that is that they’ll see that clinician, and if it doesn’t work out, that’s okay — we’ll get you another clinician. We’ll get you another person to go see. I could tell you about myself — I went through like four different people before I really found the right one over many years, but before I really found the one I trusted and felt comfortable with. I’ve talked to other members that have come home and said the same thing. So don’t be saying I have to go to this one, or this is the one, but don’t give up on that. We can help you — there’s numerous clinicians that have been vetted for the fire service. And those are the ones we want you to get so you don’t have to go in and explain all the stuff that you’ve already been through. 

Molly:

Just to kind of piggyback on that, I think it’s a sticky situation because to release someone’s records, even if it is just an appointment for a therapist, we have to have permission from that person — from that patient. They would have to sign the release of information for us to give that information. So in theory, yes, it would be awesome if we had a designated person on each peer support team that we knew we can send them these appointments to, and they aren’t going to ask them questions other than, “Did you go just to be a continued support for them?” Again, that’s in theory and it solely relies on that person being willing to share that information. 

I think it’s twofold that, maybe on the treatment side of things while they’re in treatment, having a therapeutic conversation about why it’s important to have supports could be beneficial. And then like you’re saying, on the front end, just kind of making it more of a common place to involve your peer support teams to know that those are your trusted resources. But you’ve got to have confidentiality. First and foremost, you have to have a team and you have to have that clinician. I think that’s a really important piece of all of that because fire fighters are busy, and to expect them to keep up with everyone’s appointments I think is a big undertaking. But if you have that clinician that you already have a good relationship with, that might make it a little bit easier.

Ray:

Yeah, and I think it’s so important. And also, there is information that we can get you that talks about how to prepare for when a member comes home. That should be done two or three weeks to a month before they come in back saying, “Hey, Ray’s coming back. He’s coming home from therapy,” and it tells you how to handle it in the station. You know how the chief can handle it, how the dining chief can handle it, on down. And so I think that’s really important — that you’re able to prepare the whole department for when Ray comes home. 

Kelly:

There is an IAFF guide to supporting a crew member after treatment; I just shared the link in the chat. So if anyone’s interested in that, please check that out. That references what Ray was just discussing. And as Molly said, being able to share details of someone’s treatment or appointments is contingent upon a release of information. But I have successfully worked with some peer team leaders who were the person that referred someone to us or to treatment, and they had a conversation with that member before going that said, “Hey, I really just want to support you in the best way that I can and help you be accountable on the backend.”

And that kind of set the stage for that person agreeing to release that information. Once they got to treatment, knowing why that person was trying to be involved and using them more as an accountability partner rather than someone prying into their privacy or whatnot. So I think as Molly highlighted, kind of prefacing the benefit of an RLI, where appropriate, can help do what Ray was explaining in terms of making sure that we have someone in your corner that’s only there to help you — from the department or the local or the peer team or wherever else — that can help you follow through when you do get home. But check out that PDF that I just shared too.

Ray:

The other thing I think that that Center of Excellence does and IAFF can work on is being able to contact a spouse before they come home, what to expect, how to handle all that. I’ve heard some real different stories about that. And so I think that’s another very important part — that the spouse is involved and understanding what to expect when they come home. 

Molly:

And we have guides similar to that — I think Kelly can drop the link — for spouses and for talking to your kids about treatment. I am the designated family resource coordinator for the center. That doesn’t mean that I’m only available to patients or spouses of current patients. I feel very strongly about involving the spouse and family and kind of rebuilding that supportive network because I feel that it’s undoubtedly impacted by the fire service member’s trauma. So I think that the family probably needs work too, and at the very least, some education. So if you have questions, if you’re a spouse and you need treatment or your kids need treatment, definitely reach out to us and we can still help facilitate that. 

Kelly:

Absolutely. And I did just drop in the family resource page. That is something that we prioritize at the center — involving in treatment, but also providing information that they may need to bridge the gap from having their spouse in our care for a period of time. Please do check those out, and let us know if you have any specific questions related to family resources. And Lauren from the IAFF just also included a guide on how to tell your kids you’re going to treatment that I encourage anyone to check out as well. We have numerous guides covering all sorts of topics on our resources page. If you visit IAFFRecoveryCenter.com/resources, we’ve got about 20 different guides covering an assortment of topics that I think would be helpful for this matter, but also a continuum of different beneficial topics.

Molly:

And as timely as COVID, so certainly lots of print resources. 

Kelly:

Yes, we are churning them out with much thanks to Lauren and her team at the IAFF. It is 3:30. We’re going to continue on with the questions, if that works for you, and try to cover as many as we can. So if you’re able to hang on with us, please do. If you have to go, we understand everyone’s busy. There will be a recording of this later on, so you’ll be able to catch it later if you need to as well. 

So this one will probably be for you, Ray. Is there a way to get employers to see past the stigma and believe that this is a real issue? They say one thing but may behave or treat their fire fighters in other ways. 

Ray:

Yeah, and that’s very difficult but it happens a lot. It happens a lot that we get the fire fighters educated, but then trying to educate the higher administration. There’s a couple of different ways to do it. One is that we can come in and really do a sit-down and have a program with them and explain. It even goes as far as financially, how instead of sending somebody to another facility that they have a high rate of coming back, the low rate from The Center of Excellence or any of that saves them money for sick leave for any of this. So we can talk all that kind of issues with them, and I’ve just found that to be really, helpful — to find the chief that is a champion for this and get them involved. Have the chief call them and sit down and just try to explain to them why this is so important — how it can really help their department.

Kelly:

Thank you, Ray. What are some tools to use to prevent an increase in burnout that is now trending earlier and earlier in member careers? 

Molly:

To me, that brings us back to the backpack, and it’s being proactive. A clinician uses an analogy that I really like about a cut. If you get some sort of flesh wound, you don’t just let it fester and wait to get infected, right? You’re going to take care of it. You’re going to clean it. You’re going to make sure that you’re not gonna get gangrene and die, right? And have your leg cut off. To me, that’s what you have to do with burnout. That’s what you have to do in this job. I think starting in the academy and putting it in the forefront of someone’s mind is really how you get that ball rolling. Talking about it, bringing light to it, giving people some practical tools. I think in terms of burnout, what I would suggest is if you’re burnt out on the fire service, maybe try to find some other outlets. Like if you have a close friend or group of friends who aren’t involved in the fire service, maybe hang out with them for a little bit and kind of get your mind off of that.

I know for me, when I hang out with a bunch of social workers, it’s really hard to not talk about all the crazy stories, and that just can kind of fuel some things sometimes. So I think getting outside of the fire service, maybe connecting with your family a little bit more. Nature, I think, is really important. I may be biased ‘cause we live in this beautiful state, but those to me are my suggestions. I don’t think that there’s enough credit to get into and having support outside of the fire service, but what are your thoughts? 

Ray:

This is probably my union hat on here, but I have to just say that I think a lot of the burnout is because our departments want to do more with less than they should. They keep us so busy, especially in the medical side of the calls. It’s, again, talking to administration. I mean, everybody’s having a hard time getting their paramedics now — they really are. It’s just one of those side things, because we haven’t touched burnout. So I think that if we can put on more stations or we can put on maybe an even set of stations and more medic units that can distribute the load more. We don’t have this very much and not very many departments, but if you have a slower station — maybe the chief is aware of the burnout — put them to a slower station. They tried that with me once, and I have this dark cloud hanging on me as a paramedic for 20 years now. Wherever I went, nobody wanted to work with me. I still got the cloud. I had the slow station. So it may not be the total answer, but you’re seeing what I’m trying to get at — that we really need to talk with administration and talk about these issues of burnout and come up with a way that will work for your department.

Molly:

Something you shared with me from your position — a leader within the department — when there was a tough call and you called and said, “Why are you guys off service?” They said, “Hey, we just need some time to decompress.” And that kind of became more of the norm. So from a leadership perspective, if you have the ability to do small things like that, maybe that’s one way. 

Ray:

Oh, that’s a great example. And I forgot about that — if an officer noticed or even if the other said maybe you’re out, maybe you’re noticing your officer. “That was a tough call and everything,” you’d say, “I think we just need to go over this call a little bit. Again, not about what we did on the call, but our feelings about the call and emotions about the call and how that affected you or me or whatever.” You know, again, as battalion chief, that I really supported it — that I was able to. Like the captain called me up and said, “Hey, we need to go out of service after this call for about a half hour to talk about it.” I go, “Yeah, take what you need.” And do it kind of like that chief, then take a day off for mental health. And so I think that’s really important, that the officers and the members know about that. That’s a good point. 

Kelly:

Thank you. I’m kind of going to jump around just to make sure we get different things covered. We got a question from a clinician regarding Ray’s comment about trying to find the right clinician. It might not always happen the first time, but it’s really important to find that match. They’ve asked, is there a network of clinicians with specialties in trauma treatment? Or fire service, cultural sensitivity. So, Molly, can you maybe explain the work you’ve been doing to cultivate our database a little bit in that regard? 

Molly:

Sure. That encompasses a large part of my job. I will reach out to clinicians and vet them in a sense and just make sure, ask questions about their understanding of the fire service, just to ensure that they are culturally aware of some of the differences that exist for these folks versus just your average, general population client. That’s one really important piece because we hear all too often that someone worked through those stigmas, worked through whatever the barriers were and eventually got into treatment. Then they found that it wasn’t a good fit with the clinician because they were asking too many questions about the job, or the client ended up feeling like they traumatized the clinician because they weren’t a trauma specialist. 

So I think it’s twofold in that it’s really important for us to know who those clinicians are, but I also think that it’s really important for the fire service members to be aware of those different specialties and know what they’re looking for in someone. That definitely comes with education that comes with calling on your sources. We will give you all names of clinicians for outpatient purposes, so if a local calls and says, “Hey, I have someone who needs a therapist. They don’t necessarily need to go to the center. They’re not at that point, or the severity hasn’t reached that level, well, yet. Do you have someone that we could recommend?” And I’ll give those names to the people that we’re aware of — I’ll give those names to that local. 

So we are just really trying to figure out who’s who so that way we have a list of those people, so that we can be more proactive too. I’ll send out those lists to locals just in my own sort of vetting with clinicians, I’ll say, “Hey, I talked to this person and I think that they would be a really great resource for you all in the future,” and what they do with that and what they do with that. But the hope is that they pass it on to their members.

There are various trainings out there. The IAFF is putting out an official training on cultural competency in the fire service. We have a building cultural competency webinar each month that I host and just kind of skim the surface of some cultural issues with them and this population, but I think that it’s a never-ending process. Even once you go through an official course or a credential, just like you have to take CEU classes or get CEU credits for your license, I think it’s important to stay up to date with this group too. So while I don’t know that there’s an official database anywhere, we are trying to definitely create a good network of people.

So if you’re one of those clinicians, whether you’re breaking into this population and you want to know more or you’re super experienced or somewhere in between, please let us know because we want to know who you are for sure. 

Ray:

This is a real big issue for the fire service as my logistics plan there. We’re looking for clinicians and what we’re finding — President Tidrow out of Utah has done a great job. He’s put together a couple of seminars on talking to clinicians, talking to fire fighters, and have talked to each other about what would it take to have a person vetted for the fire service? We have, in the fire service, a very dark sense of humor — how we handle stress at the end of a call at the end of a shift. And that works for me many times, but if you told that to a clinician, it’d be going, “Oh, you’re all sick.” So for a clinician to understand all that and to vet a clinician, we talk about, “Do they need to go and ride a firehouse for 24 hours, 48 hours, be around the crew, see the calls that go on now, understand the culture and the humor of whatever we’re talking about.” So I think we’re looking for clinicians. What we’ve also found is that clinicians don’t really know that there is a need in the fire service.

So we’re trying, any way we can, to contact colleges — anything to say, “Hey, if you might want to get into this type, which is very different as you would know.” I think that’s important that we get clinicians on board, and we’re trying to find that right criteria — what they need to do to become vetted. And again, I think it’d be good for them, that maybe they go, “No, this isn’t for me,” or, “Maybe this is really where I want to be at, and I really want to help.“

Molly:

Ray, can I ask you — because I have definitely said many times on these webinars before, if you want to do a ride-along, if you want to go meet your local fire fighters, let us know and we’ll put you in touch with the local — would you say that it is just that simple? I know now that we’re in corona times, it might look a little different, but do you feel like it is just that easy? 

Ray:

Yeah, I totally feel that it’s that easy. And even just to get involved with a peer team and learn a little bit more through it that way, and then think, “Well, I really need to know more about the team or more about the culture and all that,” and then get to ride along. But yeah, it’s not difficult to get that. I think you just have to know, be prepared, and you need to talk to somebody first that is involved, and there are a lot of great connections out there. I mean, phenomenal clinicians. I think that’s what’s important, but we don’t have enough. I’ll give you a great example: While in Vegas, there was so much for the general public and the fire service, and you would think there’d be a lot of clinicians in Las Vegas. And we found out that it was very hard for just our own members, but with vetted clinicians. So that’s a big issue right now in the fire service. 

Kelly:

In terms of vetting, that can mean something different for everyone and different agencies, right? So “vetted” is truly about who is doing that, what their criteria is, what those standards are. We have our own at The Center of Excellence, and Molly runs point on that to ensure that those are qualified people that we trust our clients and other IAFF members in the hands of. But that might look different for every particular agency, and that’s just about kind of setting your standard.

One thing — I’m hoping our clinicians are still here — we have another presentation on July 30th. It’s open to anyone but it is intended for clinical professionals. It’s a bit of a deep dive on trauma, and Ray is going to be joining that one. It’s going to be led by Lauren Kosc, who is the behavioral health specialist at the IAFF. So we will be sending information to all attendees about that, so hopefully see you there. But please be on the lookout for that. Also check out our website. The information is there already, but we do hope any clinical professionals here still will join us on the 30th for a little bit more narrow discussion of treating trauma and how trauma impacts fire fighters, and what you as a clinical professional can do to improve those circumstances.

Okay. We still have more questions, guys. We’re going to be here till like six o’clock. Is PTSD ever cured or does it stay for life? Is it remission like cancer? 

Molly:

I believe now — there’s probably a big debate around this — but I believe it is an injury and we are classifying it as an injury. Just like if you were to injure your arm and break it, you would get over that. You would not be in remission from that broken arm. I certainly believe it’s something that can be resolved. That’s not to say that there might not be something down the road that might cause another reaction or injury, but I definitely think that it’s something that can be resolved. I mean, I know the picture of health.

Ray:

I’m totally in agreement with that — that it’s an injury that can be resolved. Going back to the fire service or continuing on with my fire service shows that can be done. Do I have times when I need help? Yeah, and that’s what I talk about having to have my shrink that I can call and talk to and do all that. It’s very important to me.

Molly:

But I’d be willing to argue — not to cut you off — that that is the commonplace for all human beings. It’s my belief that there is not one person on this earth that has it totally figured out and wouldn’t benefit from an objective third-party view at some point in their life, though I think that you need this ongoing maintenance. Probably not because you’re still struggling with post-traumatic stress, but maybe just because you’re a human being that is living life and experiencing stress in general. 

Ray:

I don’t want to go back to that, right. And there’s another great example — my wife and I go see a marriage counselor every year, not because we’re having problems again, but we call it a tune-up. Let me just go in and talk about issues and do that. But that’s something that I think everybody needs to do.

Kelly:

Question regarding a volunteer or combination departments that may not be IAFF. I will start this out to say that if you are a representative or work with a volunteer or combo department and are looking for resources, please contact us regardless. We will help you with that, no questions asked. Obviously, we are an affiliate of the IAFF. We’re also committed to finding anyone care who needs it. So while those individuals may not specifically be eligible to attend treatment at the IAFF Center of Excellence, we have thousands of community partners that have other programming that may fit the bill, or we can connect you to someone in your community. So please reach out to us. 

I also know that the IAFF peer support program is not necessarily exclusive to IAFF members. I attend a lot of those trainings and give presentations, and there’s often non-union members that are members of the department, or volunteers in the area. So I know that depends on the availability of spots in those trainings, but many of the programs and guides and resources that the IAFF makes available are available to members of the public as well. Is there anything you’d like to add, Ray or Molly, on that? Awesome. 

This is one I don’t have a prepared answer for — what about faith-based resources for chaplains? Molly, do you have any suggestions in that regard? 

Molly:

I think that chaplains could certainly benefit from any sort of behavioral health training. I do think that spirituality can be a very important part of recovery, whether it’s from substance abuse or post-traumatic stress or any sort of behavioral health issue. Finding that purpose and what you value in life is really important. In terms of specific resources, I haven’t ever looked, but that is definitely a rabbit hole that I’m willing to go down. So if we could just jot that person’s name down, I will reach out to you and we can kind of talk a little bit more about what the specific need is. I don’t know if you’re aware of any chaplain resources. 

Ray:

When I went down to Parkland, and we had talked a little about earlier, is where the instruct commander from the Oklahoma bombing called me and said, “Hey brother, if you need any help, we can really help you. I can help you because not many other people have been through what you’ve been through.” So I’ve moved that far, and calling other people at instant command, and it’s really been helpful in a lot of ways. Now, I see them moving it forward. But with that — going back to the actual question — down in Parkland, there was a chaplain there. He was really interested in becoming educated by a peer system and that, so I think if they want to ask and get to become part of the peer system, then it would be available for them. 

Kelly:

Yeah. I see a lot of chaplains at our peer support trainings. So if that isn’t something that you already may be involved with and you’re in a chaplain-type position, please inquire as to how you can become involved. Because it is a great resource for chaplains to have training on and be invested in.

Molly:

To go along with your point about how you have communicated about Oklahoma city and then you’ve passed that onto Parkland — similarly to chaplains, I hope that there is a network that all of the chaplains are a part of, where they can call on each other and be supportive to one another. That’s really a kind of niche in this population that I haven’t quite explored yet, but I certainly think that they have a huge place in this.

Kelly:

Absolutely. Thank you guys. Okay, so how do you know this? This could be another webinar by itself, but we’ll try to hit it and see what we can answer here. How do you navigate the health care system for members? This seems like it could be a barrier. For example, it takes time to develop a trusting relationship with the therapist, yet an EAP may only give a member a handful of sessions, and then they have to switch to a different counselor who’s in their network. This person may or may not have experience with fire fighters and, at least I can certainly say, absolutely that’s a problem. Do we have a solution for it? Not really, but maybe you guys can elaborate.

Molly:

I definitely hear this person. I think that even, as someone who has been a social worker for almost eight years, sometimes I get lost trying to navigate mental health systems and figure out insurance and all of that. I mean, it can be a huge undertaking. So I think it’s not as simple as that, saying we’ll have your peer support team — these people. Because we’re also telling that peer support team — those members that have lives outside of the fire service — care for themselves too. The more we pile on them, that’s probably not so great. 

To me, the answer is use your resources. People like myself that get paid to do that job essentially. I spent the better part of a year really vetting people and kind of figuring out who’s who, and I think that even if you can get networked with the clinician from like a business standpoint or just kind of creating some sort of relationship between that clinician and your department as a whole, they might be able to help you figure out who else is experienced in the area. So I think it goes back to using those resources and calling upon your state leadership, or myself, or just other clinics that you may be aware of on kind of a superficial level that you don’t have any clinical experience with. But it’s definitely a process, and I don’t think that there’s an easy solution necessarily.

Ray:

As you said, Kelly, this is a huge question when it comes to health care. What IAFF preaches over and over is that somebody from that behavioral health team — the local president or whomever — contacts The Center of Excellence and sees if they’re okay. Insurance will cover The Center of Excellence, and if it doesn’t, then we can start looking for ways around that. Kelly and I have dealt with this numerous times — more than we’d want to think of — but we’ve had some success. Again, I think if you’re being proactive and finding out what your insurance does cover, and if it doesn’t, how can we change that? Maybe it’s just talking to the insurance company. Maybe it’s the chief talking to the insurance company about, “You’re going to save me money, you’re gonna save lives. You’re going to do all this kind of stuff.” So I think that’s really important — that you gotta be proactive and be looking at the health care

Molly:

Along those same lines, it’s my understanding that you can choose your EAP sometimes.

And there are EAPs out there that specialize or have designated clinicians that specialize in treating first responders. I have talked to many EAPs who are super progressive and very helpful in their treatment and their efforts with first responders, and they don’t limit those sessions. Or maybe there is a limited number of sessions, but on the front end, they’re going to make sure that they pair somebody with a clinician who does take their insurance so they can continue to see them.

So, being proactive, knowing what your EAP structure is, is really important. Not all EAPs are bad, and I think that that’s a common misconception. If you have some leeway there and are trying your ability to choose those EAP partners, talk to us because we know, or at least some of the ones, who specializes in this population.

Kelly:

Thank you. To highlight Ray’s point about our contracting, we’re very lucky at this point to be in-network with almost every major insurer in the country, as well as numerous regional providers and health trusts. One of our priorities is connecting members with similarly contracted outpatient providers. We know that fire fighters are generally not made of money and that anyone really is going to be more likely to continue their care if it is affordable. So, when we’re looking at who we’re going to connect members with, it generally is always someone that’s in-network. But we also recognize that many specialty providers are not paneled with insurance because it is a headache of paperwork.

It definitely doesn’t always happen because, especially in rural areas, those people just may not exist. But we have this database that we are building upon literally every day, and so we’re always willing to check that out for anyone who may be seeking a specific resource with a specific insurer that we can help connect you with.

Can you talk about any factors that may be correlated to someone being more susceptible to post-traumatic stress? Especially in ways to be proactive and proactively identifying PTSD in someone or someone who might be more susceptible than others to having it. 

Molly:

To me, the first thing that comes to mind is Ray and his experience in the Vietnam war. I think that we don’t talk enough about what you bring to the fire service with you. If you have been in the military or if you have been a victim of some other traumatic events — sexual violence, physical violence, anything like that, anything in childhood — I think is definitely important. Especially if you’re going to be constantly seeing trauma, you have to treat that. The best analogy I can kind of give there is, as a social worker, as a clinician, we are encouraged to go to therapy before we start being therapists. Because we know that there may be triggers that someone brings up in the session that could then impact my ability to be a therapist.

So I think that, similarly to this population, you have to be aware of everything that you bring with you to the job because later down the road, that may impact your ability to kind of unravel that thinking like you’ve talked a lot about today — you know, going through that tough call and figuring out what you did right and what you did wrong. Basically, meeting your emotions with logic and not letting it consume you. To me, that’s what you’re saying, but that is the big hallmark for me. Do you have any?

Ray:

I think that that definitely is a hallmark on the other side of that equation. I think veterans are just a really good population for the IAFF and for the fire service. I think that they, again, understand the concept of stuff — structure, and the paramilitary type of structure that we are. They also are hard workers and they’ve been through it. Good fit. I just don’t want anybody to ration that we shouldn’t hire a veteran because they could have this baggage with them, as you just pointed out. They can have baggage anywhere from childhood to something else that went on in their life. I think that you have to be aware of that, and it’d be great for that veteran to know his or her triggers and doing all that. But I think veterans are a tremendous fit for the fire service. 

Molly:

And that’s a valid plan. By no means was I saying that veterans shouldn’t be fire fighters. It goes back, I think, to some points that we’ve made earlier — that there is this personal initiative in all of this that can feel really frustrating for outsiders because that person has to be cognizant of the fact that they may be struggling, that there may be something that they need to address. While we wish that there was an easy answer of A, B and C, if you’ve experienced these things, you’re more susceptible. It’s just not always that clear cut, so it again goes back to that education and awareness. Everyone’s got to know themselves, I think, to be able to be proactive. 

Ray:

I think that’s the big part of education.

Kelly:

Well, on that note, how do we ensure that peer support and CISM teams maintain their skills? 

Molly:

Education and training. 

Ray:

What I just said earlier — that if you don’t have a clinician as part of your team, then you need to really look into that. I understand, again, the expense of that, and that’s why I say we have many departments — that four or five use the same clinician but that they can really continue knowing what they need to hit on for education. I think that the teams really think that they’re only really needed before the big call or a few little calls in, and it’s the everyday things that start filling up that backpack.

As we talked earlier about financial issues or home issues or kids issues or anything that you can think of, that team’s gotta be able to just sit and listen. And they gotta be able to continue to do that. Some of them take the training and they go, “We’re waiting for the big Columbine.”

Nothing happens. No, you gotta be available all the time, and it’s how you’re going to keep up your training. But the clinician has really got to help them in understanding where does that team need more help and what type of training and what’s beneficial. 

Molly:

Yeah, filling in the gaps is really important. I’ll see all the time, on different agencies or nonprofits that specialize in treating first response, they always have like a financial education class. And I think that’s because money is such a big stressor. So to me, the more you can kind of think outside the box and educate yourself on maybe those — not the big cost, maybe more prepared — you’ll notice that people are struggling a little bit more. Again, going around to stations or being involved with a training department to set up training for the whole department, maybe once a year or however, and remind people of that behavioral health team and their resources.

Kelly:

That’s one of our goals with these webinars — The Center of Excellence as an inpatient treatment center — but we’re trying to do more than that. Part of that is equipping peer support team members, CISM team members, the general fire fighter at the station, about the resources that exist and ongoing educational opportunities such as these that we’re offering on a weekly basis. We’re trying to play a small part in furthering that education and providing those opportunities, especially for free, because we know that costs can be a barrier to pursued education, especially within rural or small departments that don’t necessarily have a budget for these things. How will a member of a peer team know when it is time to recommend more professional support?

Molly:

I think anytime someone starts talking about something that — I think anytime you have the gut feeling that this person might need help — you need to tune into that. But as far as obvious signs that one’s okay, it’s a little bit more tough. I think you just have to explore that with the person. Maybe if you’re in a peer support relationship with them, ask, “What are your feelings about professional help?”

Ray:

It is so important, as Molly just said, that gut feeling that this person is really crying out for it. I don’t really need more than what you can do. And being able to suggest that, “I really think we can get you some help and a professional,” and doing that. The hardest thing I had to do, when I took my peer training, was to say — and they made us do it three or four different times — “Do you have a plan to kill yourself?” That’s not an easy question to ask, and as a peer team member, you have to be able to ask that question and not kind of, “Well, what are you thinking about the…” If you really think a person is to that level, then you need to be able to ask that question and you need to practice that, because I’m telling you — that was the hardest question for me to deal with. Really getting to that. So I just think that gut feeling that Molly talked about is when.

Molly:

Being direct — that’s another really important thing here to take away. You know, even if you’re not asking, “Do you have a plan for suicide,” being drafted and asking questions about, “Do you feel depressed? How much are you drinking?” Things like that with that person. I think you have to be empathetic obviously in your delivery, but if that person gets angry with you, you just have to know that you’re doing your part. And if you see something, you’re saying something, and I think if the intention is there, you’re well-intended, then that’s the best that you can do.

Ray:

Yeah. And this may sound a little crazy, but The Center of Excellence is its own best advertiser that people should go there or could go there. It’s that every time that I have a department, a new department that needs to send somebody, and we get that person in The Center of Excellence, it’ll be like four or five more people will go within the next year. From that same department, these guys or girls are coming back and going, “Man, that’s really saved my life. This really helped me.” Maybe there’s some issues that need to be tweaked at The Center of Excellence — we’re talking about that — but the big thing is their wives are kind of saying, “You saved our marriage.” They’re their best advocate, The Center of Excellence, and a great job they do. So when somebody is talking about that, if they need to talk to me or Molly or Kelly or whatever, we can have them talk to somebody.

Molly:

It helped prepare you for that conversation, if that’s what you feel like you need. 

Kelly:

Ray, you’re spot on in that. I’ve been really impressed and honestly surprised — not so much anymore, but in the beginning — of how willing members are to share their experience, seeking treatment, being successful in recovery and what led them to that point. And you’re doing it right now. But fire fighters, what I’ve learned or rather been enlightened to is, you guys are helpers, and when it means that, you have the opportunity to help each other in this moment. Being afraid of talking about these things or revealing that they had a problem or talking about a sensitive topic like going to treatment goes out the window because they have the opportunity to help somebody else or help a brother or sister who needs it. What is more impressive than that? I don’t really think there is anything. That’s my soapbox on that, but okay, we’re wrapping it up. We’ve got two, three more. As a clinician, our connection to peer support is vital. From your perspective, what other steps can clinicians take to work with fire professionals on the stigma around mental health and trauma?

Molly:

I think if you can get in with the peer support teams and do some education with them, a lot of them have to have quarterly training. If you can talk about stigmas and make yourself available, I think that that goes a long ways. I’ve been willing to get into debates with people about post-traumatic stress and if it’s real or not, and I think that that’s one way that we helped too — just having these constructive conversations with the nonbelievers, so to speak. Other than that, I think encouraging your clients once they’ve kind of gone through the treatment process. Work through their treatment plan, encouraging them to take it back to the station house and talk about it is really important. I really believe in post-traumatic growth, and I think that that’s exactly what you’re doing here is sharing your story and being altruistic in a way, and showing others it’s okay to talk about it. So to me, that’s something that clinicians could do. 

Ray:

Yeah. And — as I call them, disciples — once you find the disciples that will talk about the stigma, and hopefully your department never has to go through a curtain issue there, but once you find the disciples and then they can start talking about it and educating other members and then they become disciples, it starts happening and it can be very time consuming. It can be very tough, but if somebody goes to The Center of Excellence, they come back and the stigma is pretty much starting to take care of itself then.

Kelly:

Okay, this is also a kind of big question. Are there written or recorded resources or trainings that can be distributed to chiefs and municipalities to help educate departments about the variability in severity among individuals diagnosed with PTSD? It is important for departments to know that just because someone has been diagnosed with a mental health condition, this does not mean that they are unable to meet the expectations of their job.

Molly:

I think that that’s really important. If you have a psychologist that’s doing your fit-for-duty evals, I think it’s really, really important that that person is very aware of the culture and very aware of trauma and has a very good understanding of what that means. I don’t know that process for departments, as far as choosing who does the fit-for-duty evaluations, but if you have a hand in that, I think that it would be really important to do some solid vetting around that person. Asking them, “How do you consider post-traumatic stress? Is it a disorder or an injury?” Kind of fielding that conversation with them and figuring out their philosophy on it. Because if you have someone who thinks it’s PTSD and it’s a disorder that can never be fixed and this person has to get off the job ‘cause they’re never going to get better, that’s probably not the best person to be doing these evals, right? 

Ray:

Totally, totally important, and there’s great resources through the IAFF about how we can talk to the chiefs and explain to them why it is so important to have information and a behavioral health team and doing all that and working through that. I’ll tell you, there’s so many success stories out there that we would be able to — I’m sure Lauren probably talked to them about this — next week, it’s about those success stories. If like my Local 2086 needs Local 1309 and says, “How did you get your chief to where he’s at and doing that kind of stuff?” But then they’re out there and it’s going to be okay.

Different process for each department because the political process and the issues are with the chief or with the administration or whatever. So you’re going to have to, but there’s success stories out there that can help you say, “This is what we did. This was the process that we use,” and be able to help you start developing your program to present to the chief or the city council.

Molly:

To be mindful of your audience. You don’t know what their points are — what’s important to them. And then it sounds like, and it’s my understanding, that the purpose of IAFF is that your local leadership helps you advocate for the best interest of your members. So, I think calling on those folks as much as you can and letting us come and talk. Miranda, our other director, and I have gone and sat down with the city and talked through our program — talked through those success stories and kind of what it looks like on the other side of things when someone gets home, to help them have a solid understanding of what we’re doing. I know that Miranda has testified in like presumptive legislation cases, I’m pretty sure — Kelly’s nodding her head. So we will go above and beyond as well to help you guys gain understanding from those administrators.

Ray:

You said it much more elegantly than I did, but yes. 

Kelly:

Yeah, absolutely. There’s been a lot of situations where we get calls about things that are maybe outside of our scope of getting people into treatment. And I can say with confidence that our entire team is willing to do whatever it is to provide education, to provide information related to the center or something else based on who we connect you with. That’s where we lean on our DVPs on the IAFF staff just to be resources for members because sometimes it can feel like an uphill battle in these situations. We always want to make sure that we’re providing as much support as we can.

I’ve got one more question for you guys, and then I want to just hit a few questions that I’ve answered so that those that are on the recording might be able to hear them — the answers to those things. So, how do we prepare new fire fighters — I think this is a good place to wrap up — to help them prevent acute stress injury, as opposed to reactive coping and recognition after the injuries have occurred?

Ray:

That’s what I think I was discussing earlier about. It is so important for the academy to really get with your training division. I’m not, again, talking about an hour or two — I’m talking about maybe two or three, maybe a week’s time to really bring in people to really understand how important it is from clinicians coming in and talking about that and what we just talked about. How we understand you’re going to get PTS, we don’t want you to go to PTSI and how can you prevent yourself and other members from doing that. So it’s educating the new rookies, and two is then when they go to the state that — the peer team is out there — the officers have been trained and shown that there is that support and are willing to shut down the station if it comes to that to work through our issues.

All that has to be through that education. Again, the conditions are worked for the peer team educating and being part of that. I know Lauren has a lot of good ideas about the information and a program for the rookies to help them move forward and for the training division to do that. You don’t have to invent the wheel. That’s already been invented — what we need to be doing at that level. 

Molly:

Just to get on my soapbox real quick, I think too that if you can involve family in that kind of initial exposure to the behavioral health stuff in the academy and bringing them in for a set period of time or a day or an evening or whatever, making them aware. Because Darlene was kind of your — she was kind of the catalyst. I think for whatever reason she was clued in — I don’t know how she phrased it to you — but I think that the spouses really see things first. At home, they see those changes. They know their fire fighter better than anyone probably, so I think the more education they have so they can connect those dots in the background and really help people be proactive is important.

Ray:

Well, that was a point that I missed. I’m glad you brought that up. That is so important in a lot of the academies. What they’ll do is have a night when — so it’d be in the evening — they bring in the spouses and kids. They’re working and they can talk about it, and they can even have a class for kids. And I know they’ve done classes for spouses. That’s just for them, you know? fire fighters go away and play with the kids or go play basketball or something — we’re going to talk with the spouses. And so that’s really important; that’s a great point. 

Kelly:

This actually might be something you guys weigh in on too. I gave you a false alarm that we were going on two-and-a-half hours. Why not just keep on chugging through, right? Coming from a rural area where treatment options are limited, do you have any further resources for peer support groups? This person is a member of two social media groups but was curious if there was more.

One of the things I provided a link to was the IAFF’s online recovery meetings. These are not specific to substance abuse. Anyone is welcome to join, and I think they are specifically for those with behavioral health issues that are not necessarily as applicable to someone who might be seeking AA meetings online or otherwise in person. So those which are found at iaff.org/behavioral-health, I think those are a great resource. But finding opportunities in rural areas is hard. That it is a pain point, whether that be support groups, clinicians, specialists, this isn’t just for behavioral health. This is for anything. But do you have any other suggestions for my friends in Colorado — that is, in many places, a rural state? 

Ray:

Yeah, I think it goes back to that training again and being able to go to the training officer to talk about it. We don’t have very much training on behavioral health, and then help them say, “We got some contacts. We can bring in some people and help you do classes and do those type of things.” With that, we’ll bring these vetted clinicians that we know are in the area that maybe you don’t know about. Swe can talk to those vetted clinicians. Let’s say if it’s in northern Colorado — we know clinicians there that work with fire service. Maybe talk to them and, “Can you come up once a month or once every quarter,” or something like that. 

Molly:

I’ve dealt with this exact situation here in Colorado. There is an agency that’s very reputable here and has contracts or relationships with many of the urban departments. And because Colorado — out in the mountains — there aren’t a whole lot of clinicians. These bigger practices have contracted with these departments to come out on a set day and see their clients that are contracted through that agency. So yeah, leaning on your supports.

I’ve also heard of clinicians who are super into fire fighter treatment and treating first responders. They are more than willing to travel, sometimes hours — that’s something that I hear all of the time. So I think knowing those clinicians who are willing to go to those rural areas is important. I’ve been saying that I think the silver lining with the coronavirus is telehealth, but again, that’s really dependent upon that person’s receptiveness to virtual treatment. If that’s something that someone can get on board with, then you have to open yourself up to a large number of clinics.

Ray:

Yeah, and I totally agree with you about telehealth. The only issue that I think is that it’s very hard to get that credibility and that trust — that connection — through telehealth. Maybe if they’re willing to come out of here or you’re willing to go someplace and figure it out. If it’s a good connection for you, then telehealth is. 

Molly:

Yeah, that’s certainly what I have seen from clinicians who travel. It’s that they want to meet the person the first couple of times and build that relationship and build that rapport. And then they’ll start doing some telehealth services and then maybe every quarter or every three months, whatever it looks like, they’ll go and they’ll meet again in person. So maybe some sort of hybrid situation could be a potential solution, right? 

Kelly:

Thank you. I think that was really helpful, and you’re right. Telehealth is kind of the new frontier, especially for members in rural areas, and being able to connect with clinical professionals that would otherwise have not been within their reach. One question was regarding the resiliency course. I have that resiliency course that you mentioned — where to find that. I am pretty sure it is on the iaff.org behavioral health website that Miranda just shared in the chat. I bet she can probably share a link to the actual resiliency course information. But if you have specific questions regarding that, you can email Lauren Kosc, [email protected]. Or if you have email from the attendee registration, you can shoot me an email and I will get you over to Lauren. But Miranda just dropped the link to the resiliency training, which probably won’t be helpful in the recording, but, if you are listening to this later and want that information, just shoot us an email and we’ll get it over to you.

Okay, this is it. This is the finale, I think. And it’s going to be a nice wrap-up, I think. A clinician asked what treatment modalities we use at The Center of Excellence to treat post-traumatic stress. Whether, as a clinician, I can refer clients directly to The Center of Excellence, or if referrals are required to come from a fire or paramedic department. The answer I gave — and Molly, you can probably elaborate a bit — is that clinicians can absolutely make direct referrals. These do not need to come from the department. They do not need to come from the local. It can help in certain cases if there are people involved from the department or the local because then, that way, we can assist maybe more easily with time off or paid leave or FMLA paperwork or those types of things.

But in terms of making a referral, you do not need to go through the department. You can call us directly, and we encourage you to do so. We really appreciate those relationships and look forward to working with our clinical partners. In regards to, treatment modalities, I went down the list. I’m gonna name ’em off, Molly, and then if you have anything to add, please do. We utilize cognitive behavioral therapy, cognitive processing therapy, EMDR (which is eye movement, desensitization and reprocessing therapy), biofeedback, yoga therapy, recreational therapy, and we have a heavy focus on group therapy. It’s extremely impactful with this population. And especially given that all of our members on campus are coming from a similar professional background, it really, really goes a long way. Molly, anything you want to add that is specific to the center to kind of wrap it all up?

Molly:

Sure. In terms of treatment modalities, I think you hit all the main ones. I do just want to mention that certain clinicians on site have different skill sets, so they may be able to offer different types of treatment when appropriate. That’s kind of dependent upon that therapist, and in the past, we’ve had DBT therapists, dialectical behavioral therapists, and I believe right now we have an RRT therapist. I could be misspeaking there, but I’m pretty sure we do. So again, just kind of reiterating that it depends on the skill set of the clinicians, but EMDR is a big one that we use and we don’t use that with every client. It’s always dependent upon their treatment plan and readiness for that. 

Most importantly, we offer a variety of different treatments, and I think that that’s really, really, really important. To go back to the rural question, being that we have the ability to offer all of these different treatments because we have all these different clinicians, that might not be the reality when someone goes home. So we try to just offer all different types of treatment, give people tools and psychoeducation to understand themselves a little bit more. To understand their needs a little bit more and to continue this process. We’ve said it many times — The Center of Excellence is not the end all be all. People have to continue to maintain and seek out support and help when necessary. That’s really all I have to say. I’m talked out at this point. I don’t know if I answered that question.

Kelly:

Yeah, I think you did. That’s it; we’ve hit everything. We’ve answered all the questions. Thank you all for joining us, especially those of you who are still with us, how patient you are. But I think it has been a terrific discussion, incredibly enlightening. Ray, thank you for sharing everything that you’ve been through and that you’re continuing to champion as a leader in the IAFF. Is there anything else you guys want to share before parting? 

Ray:

I just want to say thanks to the ARS for all the great work that they’re doing with the IAFF on this. That’s a great partnership, and we’re moving this forward and I see great, great strides. And talking to people out there and saving lives or saving families. I think that it’s why we’re all here, so thank you. 

Kelly:

Thank you. Okay, we have one more question but it’s pretty cut and dry. Someone has asked what the average length of stay at the facility is, and I wanted to address it. It fluctuates because it’s not necessarily a 28-day program or a 36-day program. It’s truly based on the client’s needs, their progress, and in many cases, what their insurance company is willing to authorize. So our average length of stay I think, right now, is about 34 days, which is a little bit longer than a typical substance abuse program might be. But it speaks to the willingness of our clients to do the work and to stay in treatment — to see it through. Our rate of completion is extremely high as compared to a traditional civilian program. And it speaks to, like I said, the motivation to go back to work. To get back to their families to recover. And that length of stay does fluctuate based on who we have on campus at any given time. That’s what we see on an average basis. 

Ray, you had given a beautiful wrap-up and I just had to get one more in there, but you know me. Thank you all so much for joining us. In regards to rewatching this training, you’ll be able to find it on the community education page on our website. Molly highlighted some of our upcoming trainings. We have a trauma for clinicians on July 30th and then two deep dives of sorts into the IAFF peer support program — one a bit more for clinicians and one for fire service members. Those are going to be in August. Those will be on that community education page as well, along with the recordings of our past webinars.

So, thank you so much, Ray, Molly. Thank you. You guys are awesome, and we’re so grateful for all of your contributions and work that you’re doing in this field. Enjoy the Colorado weather — I’m sweating over here in Florida — and we will see everyone in two weeks, hopefully. Alright, thank you.

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