Trauma in the Fire Service for Clinicians

In this webinar, learn about how trauma affects first responders, how trauma-related conditions are treated and where firefighters and other EMS professionals can find help.

Estimated watch time: 1 hr 54 minutes

Objectives and Summary:

This introductory webinar is intended for clinicians who are interested in working with fire service personnel that are coping with post-traumatic stress or PTSD. Fire service personnel may attend as well. 

Lauren Kosc, LCPC, CCTP, is a behavioral health specialist at the International Association of Fire Fighters. In this presentation, Lauren will cover topics and data on PTS and PTSD in the fire service, unique aspects of trauma among fire service personnel and the role of peer support in addressing trauma. The presentation will also include an introduction to evidence-based practices for PTSD, explain risks of PTSD and co-occurring behavioral health disorders and provide updates of PTSD presumptive legislation.

By the end of this presentation, the viewer will understand:

  1. Current data on trauma in the fire service
  2. Unique aspects of trauma among fire and EMS personnel
  3. Differences between PTS, PTSD and complex PTSD
  4. The role of peer support in addressing trauma
  5. Evidence-based treatments for PTSD 
  6. Next steps in the fire service


Welcome to our Community Education Series, hosted by the IAFF Center of Excellence for Behavioral Health Treatment and Recovery. Hello, everyone. It is 12 EST, so we are going to go ahead and get started. Welcome to today’s webinar: Trauma in the Fire Service. My name is Kelly Savage. I am one of the community outreach directors for the IAFF Center of Excellence for Behavioral Health Treatment and Recovery, and we are so excited to have you here. I think we have a record number of registrants, so I’m excited to see how many people will be joining us. Just for context, we’ve got people from what felt like every state in America, Croatia, Greece, people from all over. We are really excited for those that are joining us. We are looking forward to learning a little bit more about you during the presentation, but I’m going to take care of a few housekeeping items, and then I’m gonna go ahead and turn it over to our speakers. 

So, for those of you who have joined us in the past, this will be old hat, but we do have a lot of new registrants. So, if you check on the bottom of your screen, you’ll find our chat feature. I see a lot of you have already found that — we would love to know where you’re joining us from. If you want to chime in with who you are and where you’re from and if you’re a firefighter or clinician or whatever your professional role is, we’d love to see it in the chat as a very brief introduction. You’ll also see the Q&A box at the bottom. That is where we’d like for you to drop any questions you may have during the presentation. Lauren and Ray are gonna, I think, be doing a little Q&A throughout. And then save some questions for the end as well; if you put them in the chat, we will probably miss them because it runs really quickly. If you’ve got a question, we would love to answer it, but make sure you put it in that Q&A box. 

We’re also going to be doing a few polls as we go along. We’ll do that in just a minute. The first one, which will let us know what your professional role is, but keep a lookout for those polls. We’d love to get some insight as to your experience and some of the other questions we’ll be asking. I’ve got some exciting news to share for some of our clinicians who may be joining us today. We are currently in the process of obtaining accreditation through the NBCC, so the National Board for Certified Counselors. And this is a presentation that they will be evaluating to pursue credit. So, if you are someone who could utilize credit hours, CE credits from the NBCC — that would generally be professional counselors, but if you also are a member of a different board, like a National Association of Social Workers or another licensing body, and you know that they will accept NBCC credits — we are able to offer one of those for today’s presentation.

In just a little bit, when the chat slows down, I’m going to drop the link for the evaluation form. If you’re interested in getting continuing education credit as a counselor, all we need you to do is complete that evaluation after the training. That will be sent to our team; we will follow up with your certificate. It will be applied retroactively once our evaluation process is approved. We’re really excited about that. We’re also looking to expand some of our abilities to offer CE credits to different disciplines, but this is where we’re starting with the NBCC. I’m really excited to be able to offer that to some of you, and I hope you take advantage of it. Likewise, we’re going to drop that evaluation form, but if you have any questions about that — the CE credits or NBCC stuff — just follow up with an email after the training is over. I’ll put our email addresses in the chat as well. 

Those who’ve registered should have gotten mine in the registration confirmation. It’s [email protected], but we’ll share that in the chat during the training throughout. As a reminder, those credits are not for firefighters, so this is through the National Board for Certified Counselors. If you are a firefighter and need some sort of certificate of completion, we are able to issue you those. Myrrhanda will put her information to follow up on that, but what we’re talking about with the CE credits is just for counselors for now. 

Alright, Myrrhanda, do you want to take it away? This is my lovely counterpart. My fellow outreach director, Myrrhanda Jones, coming to us all the way from Anchorage, Alaska. Good morning from my side of time, good afternoon for everyone else, if I don’t enter your time zone. Well, we have two very exciting guests with us that I am looking forward to introducing to you. Then in the interest of time, we’re going to jump right in. Today we’ve got Lauren Costas, licensed certified professional counselor. Prior to joining the IAFF as their behavioral health specialist, Lauren worked as a psychotherapist and clinician in a variety of community-based treatment settings. For 10 years, Lauren is a licensed clinical professional counselor — glad I had that written out — over here in Maryland and a certified clinical trauma professional. Lauren is one of two behavioral health specialists at the International Association of Fire Fighters headquarters in Washington, D.C., where she oversees peer support training and helped create the IAFF resiliency training, provides technical assistance to IAFF affiliates and clinical oversight of the IAFF Center of Excellence, and we’ll be sharing a little bit more about that program later today. 

Also joining us, IAFF 9th District Vice President Ray Rahne. He’s a retired firefighter from Local 2086 South Metro in Littleton, Colorado. Ray Rahne is the IAFF 9th district vice president, proudly representing Colorado, Nevada, Oregon, Utah and Wyoming. Ray is a member of IAFF Local 2086 South Metro Fire Rescue and a retired battalion chief from Littleton, Colorado, where he served as incident commander for the Columbine High School mass shooting. Ray is a passionate behavioral health champion for the fire service, as well as a Vietnam veteran, a husband and a father and a friend to all of us. With that, I’m going to turn it over to our speakers today. We are going to be sharing some links and things that they are referencing in the chat, so people — look out for that. But as a reminder, if you’ve got any questions, drop those in the Q&A and we’ll hit them as we go along.

Thanks so much for those introductions, Kelly, and good morning or good afternoon to all of you. We’re really excited that you’re here. This clinician webinar, really, is going to be an introductory webinar for clinicians who are interested in working with fire service personnel. If we have, also, firefighters or family members or chaplains that are joining us today, we’re definitely excited that you’re here and do believe that you’re going to be able to take away a lot from our discussion as well. Kelly’s going to go ahead and bring up a poll, and we would just like to get an idea of what your role is. So, are you a clinician that’s already working with fire service personnel? Are you interested in this population? Are you a firefighter EMS professional? Whatever your role is, go ahead and take a minute to answer that poll, and we’ll just leave that open for a couple more seconds. Then Kelly, whenever you’re ready, if you’re able to close out the poll and share those results.

It looks like we have a good variety and some breakdowns — certainly a lot of firefighters and EMS professionals that are joining us today. We’re excited that you’re here. We also have some clinicians that are interested in learning more about this population, as well as some that are already working with firefighters. We have a decent mix here. I’m going to go ahead and close out the poll on my screen. And I would say for advanced trauma clinicians or for those of you that are already working with fire service personnel, this will be a lot of review and reinforcement for you. But hopefully, you’ll still be able to take away something useful, as well as for the rest of you that are joining us for today.

I’m going to get started by just sharing a little bit of background on the IAFF since we are speaking with a general audience today, I don’t want to make any assumptions. IAFF members, please bear with me if I’m sharing content that is known to you. The IAFF was formed in 1918 to address the working rights, safety pay and other conditions of professional firefighters and paramedics in the U.S. and Canada. Today we are the largest labor organization, representing over 320,000 professional firefighters and paramedics and EMS professionals in North America in the U.S. and Canada. Certainly, the behavioral health component of our organization has really taken off and exploded in recent years — we will touch on some of those initiatives today before we wrap up — especially our treatment center, the Center of Excellence. I would just say that, as a clinician, whether you’re going to be working with professional firefighters or volunteer firefighters, union, non-union, it is a good role to have some understanding of the role of the union of the IAFF. Not only in terms of occupational health policy, but also just an understanding — kind of how all of the different pieces of the fire service fit together. If you’re interested, as a clinician, in learning more just about the fire service in general — the history of the labor movement in the fire service — there’s a nice 200minute video on our YouTube channel that Kelly’s going to share in the chat. That might be something that you want to check out after today, just if you’re interested in learning more. 

So, for clinicians that are joining us today to go, we’re really excited that you’re here. Before we move on, we just want to take a look at why might you be interested in working with this population. We are living in really unprecedented, crazy times right now, and there’s a lot of vulnerable clinical populations out there. Why might you be interested in working specifically with fire and EMS personnel? Certainly, we know that firefighters are a very resilient population; at the same time, they do struggle with higher rates of some behavioral health disorders. They do struggle with problems that definitely warrant clinical attention and support and need services. We also just are in need of more culturally competent and aware clinicians that are comfortable and interested in working with this population. Certainly, working with fire and EMS personnel is an opportunity to give back to your community. These are the men and women that are going to be there, no matter what, in a matter of minutes if you are ever in need or have an emergency. The opportunity to work with these folks is definitely an honor and a privilege, and this is just also a very clinically diverse population. It’s not only trauma that you’re going to be dealing with, but this is certainly a population that’s gonna keep your skills sharp, and there’s going to be lots of transferable skills that you can use that certainly are going to be relevant for lots of other clinical populations.

Then I would also just emphasize that because this is such a tight-knit, socially connected group, often if you have a good experience treating a firefighter, that is going to lead to other referrals, whether it’s for a crew member or a spouse or an adolescent of a firefighter. That might be something that you’re interested in, and then there are also just certainly some qualities that I think are desirable for the treatment provider in working with this population. So, this was definitely a very high-functioning population. They are very goal-directed. They’re very task-oriented and truly are capable of engaging in treatment — of doing homework therapy assignments and really following through. Certainly, this is a population that also has daytime flexibility in their schedule, so that might be something you’re interested in. Then of course, this is an insured population. These are just some ideas that we’d like clinicians to keep in mind. 

This is a look at our objectives for today. We are going to be cramming a lot into this hour together, so I’m going to move quickly. If there’s something that you’d like me to come back to later, please put that in the Q&A, or feel free to follow up with me after today. We will be looking at rates of death, of trauma in the fire service, and certainly going to look at some of the trauma spectrum disorders, as well as the role of peer support in the fire service and some evidence-based practices that can be used to treat trauma. Then we’re going to wrap up with some next steps of what’s happening in the fire service, as well as touching on our treatment center, the Center of Excellence. 

Let’s go ahead and get started. I would like to start by just sharing some results up here on the screen from a survey that the IAFF conducted in collaboration with NBC. The purpose of this survey was to better understand behavioral health issues and help-seeking behaviors and occupational trauma among our membership. There’s a short video clip and the raw survey results of the survey that is publicly available. I can ask Kelly to share that link in the chat if you want to check it out after today. I do want to mention that the survey was not a scientific research study, so representative sampling was not used. Nonetheless, about 7,000 IAFF members responded to the survey about mental health issues. We definitely want to take that feedback very seriously. As you can see, about 65% reported coping with unwanted and intrusive symptoms, as well as some of the other symptoms that are listed there. 

When we’re talking about trauma in the fire service and we’re referring to bad calls or potentially traumatic calls, these are some of the scenes and images that our firefighters are exposed to on a regular basis. These are not stock photo images, but certainly real images and scenes that our members and the affiliates have responded to. We just wanted to share a little bit of that. We knew, of course, that fire and EMS personnel do experience a much higher rate of traumatic stress when compared to civilians, and of course, that’s to be expected. But we would like to take a look at how much higher that rate is. So, the literature does tell us that about 90% of Americans will have at least one traumatic event in their lifetime, while the most common number of traumatic events experienced is about three. When I say traumatic event, for clinicians, I mean an event that meets criteria in the DSM. 

In contrast, firefighters will routinely experience as many as four unique and potentially traumatic events in just one year of service. This is data from an NIH-funded study that was done by one of our behavioral health partners, Dr. Suzy Gulliver, in which they looked at about 322 firefighter recruits from seven different urban U.S. fire departments, followed them during their first three years of service, and that’s what they found. When we think about the majority of professional firefighters working for about 20 years in the fire service, if you do the math, the rate of annual occupational exposure does really add up quickly. While, of course, that rate can vary widely for each firefighter based on certainly the call volume of their health and other factors. It is safe to say that most fire and EMS personnel will experience more trauma in just one year of service than civilians will in our entire lifetime.

Considering the available research that we have, the consensus is that somewhere around 22% of fire and EMS personnel will experience PTSD at some point in their career, and many more suffer symptoms of post-traumatic stress. This isn’t to say that 22% of firefighters have PTSD; we’re saying that 22% will meet criteria for the disorder at some point in their career. This was compared to about 9% of Americans that will be diagnosed with PTSD during their lifetime. We know that individuals like that — that have PTSD — are more likely to experience major depression and substance use and suicidal thinking. Certainly, firefighters are no exception to that. We know that alcohol use is a serious problem in the fire service. A lot of the celebrations and rituals and memorial services that are common in the fire service often do include alcohol. We know that alcohol use and dependence is a problem for not most, not all, but many firefighters.

In one study that was done of over 2,700 urban male firefighters, they found that about 30% met criteria for alcohol dependence. That’s definitely something that we’re concerned about. We also know that people with PTSD are more likely to attempt suicide, a this is the case for everyone — not just for firefighters. At the same time, we do know that suicide is a problem in the fire service. There was a study that was done in 2015 by Florida State University, in which they looked at rates of suicidal ideation, attempts and nonsuicidal behaviors among firefighters and did find that about 15% had made a suicide attempt since starting their career in the fire service. These are just some of the main clinical issues that we are very concerned about with this population. 

While we do focus a lot on trauma and PTSD, the fire service are definitely less comfortable talking about clinical depression. While someone with PTSD is six times more likely to attempt suicide, by comparison, we know that someone with major depressive disorder or clinical depression is 20 times more likely to attempt suicide. Given the fact that we know suicide is a problem in the fire service, this is just something that we really need to keep in mind. And certainly, as clinicians, we have an opportunity to broaden the conversation a little bit beyond only trauma and PTSD.

While we’re more focused, in the fire service, on looking at trauma and PTSD, it can sometimes have this unintended impact of kind of further stigmatizing those firefighters who might be coping with a primary depressive disorder but just feel less comfortable speaking up about that. Maybe they feel they haven’t earned it in quite the same way, or their symptoms do not go along with the primary traumatic event. In fact, there’s a misconception sometimes about our treatment center — that firefighters have to have a PTSD diagnosis to receive treatment there, and that’s definitely not the case. We know, as clinicians, PTSD does bring about negative changes in mood and thinking. At the same time, suicide attempts and suicidal thinking are not part of the symptom criteria for PTSD. The DSM was really clear about that. If we have a firefighter that is presenting with PTSD but also is having suicidal thinking, there’s definitely something else going on there that we need to address. The research does tell us that: For those individuals that are diagnosed with PTSD, about 50% of them also meet full criteria for major depressive disorder. So, this might be no surprise to clinicians, but less known to some of the fire service personnel that are joining us today.

There are definitely some important treatment implications here. As clinicians working with this population, we definitely need to be thinking about and screening for and doing treatment planning around depression, if that’s at all an issue for this population. And certainly, of course, if we have a client who is presenting for PTSD treatment but is also having more severe depressive symptoms, such as not eating, not sleeping, not functioning, having suicidal thoughts — of course, we want to stabilize those symptoms first before we can expect that client to benefit from any kind of trauma-focused therapy. This is just some of the references for some of the research that I just shared. I’m happy to share this list with anyone if you reach out to me after today.

We’re going to look more now at, really, what do we mean by traumatic events in the fire service, and what is unique about this experience of trauma? The traumatic events we’re referring to in the fire service are so much more than responding to structural fires or wildland fires, but a broad range of different kinds of events that can be traumatic. So, this includes a line of duty death of another crew member. It might be a natural disaster or a manmade disaster, such as a mass shooting or a school shooting. It could be an automobile accident, a terrorist incident, a drowning — certainly responding to the suicide of a known civilian or a crew member even could be very traumatic. We also know that in today’s era of synthetic drug use or opioid use, it’s not uncommon for a firefighter or EMS professional to be assaulted by an agitated patient, which is not something that we saw 15 years ago as much. Of course, in today’s COVID era, there’s just a tremendous rate of occupational fatigue that can be caused by this chronic exposure to such a high rate of death. While we know firefighters will witness and experience these events throughout their career and some will go on to develop PTSD, the vast majority will not, and they will continue to work, live and function just fine. This really is a resilient population, and we really believe that that has a lot to do with just the very socially connected, cohesive group that these men and women are. So, we know that that can definitely serve as a buffer against trauma. 

How can people talk a little bit about different examples of occupational trauma in the fire service? I just want to explore a little bit more about what’s unique about this experience of trauma. Whether you’re a clinician that’s joining us today or a firefighter, you’re probably aware that the fire service has traditionally not placed a lot of emphasis on the mental health of its workforce. “Suck it up, buttercup,” is the phrase that we hear frequently. Basically, this just means if you can’t handle what you’ve seen on the job, you’re weak and you shouldn’t be doing this kind of work. For decades, really, this was how we thought about our first responders, and we really expected them to suppress very real and human natural reactions to the trauma they were experiencing while giving them essentially no tools or education to do so. We’ve definitely come a long way in this regard, and yet in many fire departments, there’s still a long way to go. 

The reactivation of childhood trauma is not something you might hear as much about with this population, but I do think it’s important, so I wanted to mention it. We really just need to be mindful that when our firefighters and EMS providers are responding to fires, medical calls, overdoses in the community, this inevitably brings them to families that are in crisis or communities that are broken or maybe families that are living in underserved communities. Certainly for a firefighter with their own childhood history of trauma, it could be very triggering for that individual to enter a home for a medical call where there’s a lot of family dysfunction present. Or maybe parents are fighting or there is clearly drug and alcohol use in the home or kids don’t appear well cared for, or maybe living conditions in the household are not great. Certainly, being exposed to these kinds of images can reactivate trauma that has been dormant for that firefighter for many years. Just something to be aware of.

The reactivation of military trauma is also not uncommon for this population. There are a large number of firefighters that have a military background. There’s a lot of transferable skills in both of these occupations. It’s not uncommon for a firefighter to start their career in the fire service already having a whole set of traumatic issues that stem from a previous career in the military. Unlike military personnel, however — who will have a nine-month tour and then, hopefully, have several months back on base to kind of rest and recuperate and have some more normalcy — a firefighter that has an occupational exposure is typically back on shift within 48 hours, continuing to work, sometimes live and certainly still operate in that same community where a traumatic incident occurred. Exposure to the trauma is not only reoccurring, but it can be chronic over several months or years if that firefighter remains in that house. 

We know that firefighters are often very hardworking and just a civic-minded group of men and women. Again, this kind of purpose-driven social activity is really what makes this population so resilient at the same time. This is definitely a population that can take the idea of being busy to an extreme — to a whole new level. So, I commented that the work schedule for a firefighter might be an average of 54 hours per week on the job, not including overtime. In addition to that, these individuals are often also working as volunteer firefighters or paramedics in the next county over. They might also be involved in peer support. They might serve on their member services committee or a fitness committee. They might hold a title within their local union, which is often very time-consuming and on-call work. They’re often a spouse or a parent or a partner. They might also be a homeowner. So, as clinicians, if we have a client — a firefighter with a trauma history that’s presenting for treatment and is literally keeping their schedule booked 24/7 — we do need to be prepared to look at that. Is there some form of avoidance going on there that’s serving to protect the firefighter in some way? We know a level of emotional attachment is certainly necessary for this population to function at work. 

As clinicians, we know that if we got attached to every client or patient that we saw, it would be very hard to do our jobs, and this is definitely the case for firefighters as well. When they come back home to the home environment after work, it can be hard for some to turn off that kind of emotional detachment and numbing, and this can get in the way of relationships — not only with intimacy, but also in interacting with kids and in children. Also something to be aware of. I know we just want to hit on the idea of administrative betrayal. This is the idea that my fire department doesn’t have my back in some way or is leaving me out to dry — leaving me kind of out on my own. One way this can play out in the context of trauma is if a firefighter has a traumatic exposure on the job and then, down the line, developed some kind of mental health or substance use disorder as a result of that. The fire department might be aware that this person is not in any condition to be working, but doesn’t really know what to do with them. Puts them on some kind of medical or administrative leave without connecting them to meaningful health services or treatment. When this happens — and it does happen sometimes — it really is an insult to injury for that individual. Because now, not only are they coping with whatever behavioral health problem that has developed, but they’re also isolated and alienated from their natural support system, which is being around other firefighters. These are just some themes that we want clinicians to keep in mind when working with this population.

We also want to hit on the idea of the survivor’s guilt. This occurs when a person, of course, feels a sense of guilt that they have survived a traumatic incident when someone else has not. Survivors often think, “I should have done more. I should have been able to change the outcome of what occurred in some way, and this is my fault.” There’s often a huge component of shame that goes along with this that can really fuel PTSD and also fuel substance use in many cases. So, in the fire service, this idea of survivor’s guilt really does take on a whole new meaning. As clinicians, we really need to be prepared to validate and honor that firefighter’s experience. For an individual whose job was literally to save innocent lives, or to save the life of a crew member — if that individual gets into a dangerous scenario, the inability to fulfill that mission can be deeply troubling for some firefighters and really cut at the core of their identity and how they see themselves as a protector and as someone who is trained to save lives. This can be kind of further complicated as well if the firefighter feels like they don’t agree with the tactical approach that was taken on the call, or maybe felt they didn’t have the right resources or equipment. There can be some anger and resentment there as well.

Whatever the response is of a firefighter, as clinicians, we need to be prepared to sit with that experience and allow that individual to sit with their pain and honor it a little bit before we’re moving on to any kind of cognitive restructuring or helping them rewrite their story. We need to sit with it for a bit and certainly maintain our own composure while doing so. To follow up on survivor’s guilt, I do want to mention the idea of the just-world theory. So, this is a theory that is central to cognitive processing therapy. That’s one of the main evidence-based treatments that we have for treating PTSD. This can help us understand it a little bit — how a firefighter might feel deserving of their PTSD — which can really then fuel the illness itself and really impede recovery and kind of prolong suffering. The idea here is that many of us are taught in our upbringing this very fundamental concept, which is that the world is inherently fair and good things happen to good people and bad things happen to bad people. Basically, people deserve what happens to them. When a bad thing happens, then, to a good person, the individual’s sense of how they fit into the world no longer fits. This bad thing could be a car accident, it could be a rape, it could be the inability to save someone in a fatal fire. To make sense of this bad thing that happened and create a sense of order, the survivor might compensate by developing one of two dysfunctional belief systems. 

One side of this is, “Well, since only bad things happen to bad people, then I must be bad.” Left unchecked, this can really fuel a sense of guilt, shame, helplessness and hopelessness because that firefighter doesn’t even feel worthy of their recovery. Then the flip side of this is, “Well, since I know I’m a good person and this was still able to happen to me, then the world must be inherently unfair and cruel and messed up. Therefore, I can’t really trust anyone. I can’t really plan for my future, and I don’t feel secure anymore.” If you’re working with a firefighter and they’re stopping in their treatment, if trauma is an issue, this might be one way to think about their experience.

I want to pause for a minute now and check in with our guest, District Vice President Ray Rahne. Ray, I’d like to ask you — we just explored some different themes and aspects of fire service trauma, and I want to ask you what you can personally relate to what we’ve discussed? 

Yeah, thanks Lauren. Thanks for everybody being on here today. I wouldn’t say good afternoon, but it’s still morning time here in Denver. Again, thanks. Personally, I think it goes back with me to the trauma in Vietnam. I was in Vietnam at age 20 and 21, saw a lot of action there and did bring that home. But as we all know, there was no even idea what PTSD was at that time. Then as you said earlier, I fell right into the fire service. I was an adrenaline junkie from Vietnam doing that with the fire service. So, I think it’s really important that if somebody is a veteran, they possibly could have seen a lot and carried that with them. I didn’t feel that I was carrying a lot with me. Did I change when I came home, now that I talk to family and friends? Yes, but I really didn’t feel that it was that much, but I think what you really talked about — it’s about the repetitive exposure to trauma. As I was with the fire service for 40 years on the job, and 20 of those years was as a paramedic, seeing all that repetitively, really, is what I think starts really eating at people. I had one friend that retired from the fire service, said he could not go on one more call with a child.

That type of stuff would eat at firefighters. I think the last thing for me that really was kind of the straw that broke the camel’s back is Columbine. Being the incident commander, I wasn’t inside seeing all the destruction, but just the idea of kids killing kids, and our firefighters having to deal with and see that was very, very difficult for me to ascertain and comprehend and move forward. I think that’s where it kind of put me over the line and with all the other stuff, the repetitive and the military service then. 

Thank you so much, Ray. We are going to touch a little bit more on that idea of cumulative trauma and what impact that has on firefighters before we wrap up today, so thank you. I want to move on now to get into more of a discussion of the trauma spectrum disorders. Of course, this will be a review for clinicians that are joining us, but I think still an important part of our discussion, and hopefully, firefighters can walk away with a bit of a better understanding about trauma and how we think about it clinically. Diagnostically, this is how we define a traumatic event. In the clinical sense, we say that for a PTSD diagnosis, you have to have one of these four scenarios going on. One is a direct personal experience of threatened death, injury or sexual violence. An example of this would be if I’m personally attacked or raped or maybe I’m injured as I see my home being destroyed in a natural disaster or a flood or something. 

A second scenario would be the direct observation of such an event occurring to someone else in real-time. This would be if I witnessed someone getting hit and struck by a car, or maybe I see someone being attacked or something like that. A third scenario would be learning of such an event occurring to someone else that is a close friend or a family member. This would be if I receive a phone call that my best friend has been killed in a car accident, or maybe I’m notified that my best friend or member has been killed in a fire. Then lastly, we have repeated or extreme exposure to aversive details of actual or threatened death, injury or sexual violence. The inclusion of this kind of trauma in the current PTSD diagnosis that we have in the last revision of the DSM really was a huge step forward for the first responder community, because it really acknowledged and recognized occupational trauma as true trauma. Examples of this for a fire EMS professional would be recovering a body after a fire or a building collapse, or maybe responding to a bad car accident and encountering maybe a child’s crushed car seat or other related debris, or maybe a dismembered body part or something like that. We know from the research that being exposed to these kinds of images, especially repetitively, is as traumatic as having one’s own life threatened.

Another important distinction that we saw in the DSM-5 revision of the PTSD diagnosis was that the diagnosis no longer hinged upon them having to identify a single traumatic event; it could be one or more traumatic events, which is really more consistent with the experience of fire and EMS personnel, as well as other first responders. Many firefighters can recall their most horrific scene or scenario, and at the same time, many others cannot. The trauma just begins to kind of blend together over the years, and they cannot identify a single traumatic event. That’s how we think about a traumatic event when we’re talking about PTSD.

What is post-traumatic stress? After a traumatic event occurs, as we just defined it, we know that often, post-traumatic stress symptoms do emerge. At the IAFF, we’ve worked really hard to normalize the symptoms as a normal and common reaction — a non-pathological reaction to trauma, to an abnormal event. We educate firefighters on a really important distinction between post-traumatic stress and post-traumatic stress disorder, whereas we would often refer to it in the fire service as post-traumatic stress injury. And since we have many firefighters joining us today, I will comment just briefly on what we mean by each of these symptom categories.

Category B, intrusion symptoms: These are intrusive thoughts, flashbacks, dreams, nightmares of the traumatic event itself. Then we have category C, which is avoidance. This is behavioral avoidance of people, places, things or experiences that might trigger or remind that individual of the traumatic event. Then we have D, altered mood or cognition, and these are negative changes and feelings or thinking that emerge after the event. It might be a lot of self-blame about the event, or feelings of numbness or feeling detached from others. Or, it might be an inability to recall certain aspects of what occurred during the event. Then lastly, we have symptoms of arousal and reactivity. These are symptoms that emerge because the firefighter is remaining in a physiologically activated and hypervigilant state. This leads to feelings of jumpiness, might be outbursts, agitation, inability to sleep, unable to concentrate, those kinds of symptoms. Experiencing one or more of any of these symptoms — really, for any duration of time — is considered a normal reaction to trauma. It’s not PTSD, again, unless it’s really interfering with one’s daily functioning. It’s really important to keep that in mind. 

Then we have acute stress disorder, which is really the precursor to PTSD. Again, if someone experiences a traumatic event, as we’ve defined it, and has nine or more of these symptoms — not just one or two symptoms, but nine symptoms of post-traumatic stress, and these symptoms last for three days to one month — if they cause major problems to a person’s functioning or major distress, that’s what we would call acute stress disorder. This one would be a problem that warrants some clinical attention and support. Then lastly, we have PTSD. After a traumatic event occurs as we’ve defined it, sometimes individuals experience symptoms of post-traumatic stress in all four of these categories. If someone has one or more symptoms of intrusion, one or more symptoms of avoidance, two or more symptoms of negative changes in mood or thinking and two or more symptoms of arousal or reactivity, and these symptoms last for longer than one month and they really interfere with daily functioning, that’s what we would call post-traumatic stress disorder or PTSI, as we often refer to it in the fire service. 

I do want to touch on the idea of complex PTSD. And for those clinicians that are already working with trauma clients who might be using the ICD-10 code for chronic PTSD for reimbursement — the next edition of the International Classification of Diseases, or ICD-11, which is a system of codes that we as clinicians use for billing and reimbursement, we will see a new diagnosis called complex PTSD, or C-PTSD. The difference between regular PTSD and this complex PTSD is, really, the frequency of the traumatic event. We also found changes that develop in a person’s self-view and how they see themselves and how they regulate emotion. Proponents of this diagnosis would argue that there really is a different flavor of PTSD that emerges when the exposure to the trauma is really persistent and reoccurring and does not have a clear resolution.

Examples of this kind of trauma would be things like child abuse, neglect, abandonment, surviving genocide, torture, war, slavery or early domestic violence situations. Again, the hallmark of those kinds of trauma is often a physical inability to escape, as well as major changes that develop in how the person sees themselves. There’s often a sense of, “I’m damaged goods, I’m forever changed, I’m worthless,” things like that. Someone argued that this is an appropriate way to think about fire service trauma, specifically for those individuals that have been exposed to one traumatic incident after another after another. As of today, the American Psychiatric Association does not accept complex PTSD or recognize complex PTSD as a distinct diagnosis from regular PTSD, so that’s something to be aware of. I think for clinicians that are joining us, rather than getting in a diagnostic debate, there’s just a couple of takeaways that we can keep in mind for our clients.

No. 1, of course, for a firefighter that has an early history of childhood trauma or just previous trauma, certainly it is going to be more difficult for that individual to overcome occupational trauma as an adult. Then two: For the firefighters that have that cumulative trauma history, there might be lasting changes that occur in not only how that individual sees themselves, but how they regulate emotion and their capacity to form secure and trusting attachments with other people in their life. I want to check back in with Ray now. Ray, I’d like to ask you — we just went through a lot of different symptoms of PTSD — I’m curious what symptoms you most relate to and what eventually drove you to seek help. 

Thanks again, Lauren. The symptoms, really, were everything that you just talked about. One of the big ones was that I’m really hypersensitive to any type of noise, whatever, and I always just associated that with war. If a balloon would pop or anything like that, then I would be on the ground. I would be looking around, and I’ll tell you the one incident that happened to me. Not too long into the fire service, there was a suicide. I went inside, there was a media helicopter flying above, and all of a sudden, I just reverted back to Vietnam. I could smell the blood, the gunshot, the smell of everything. That should have been a real issue for me at that time, but everybody talked me down. I went forward with that, but I really got short-fused. I would become really irritable at anybody if they ask the wrong question, or didn’t do the right thing or what I thought should be the right thing. I was really short-fused. Then what really struck home to me is I became very emotional about anything. Say my kids did something good or my grandkids did something good, I would be, like, really emotional. I would cry, or not cry — I would just, it was it. That was the part that really hit home for me that there was something wrong with me — that I have all this going on. Then obviously, the dreams and the night sweats were just bad for me. Getting two to four hours’ sleep a night was good for me at that time, but obviously, I wasn’t functioning at the top for getting that little bit of sleep. So, a lot of different symptoms for me that you were just talking about were there.

Thanks, Ray. Now, we are going to have some opportunity to ask some additional questions as we wrap up. Again, if there’s anything that’s coming up for you, feel free to put them in the Q&A. We are going to transition a little bit now to look at the role of peer support and addressing fire service trauma. Just want to share a little bit of background again from that IAFF membership survey that I mentioned earlier. We know that fire service personnel do experience higher rates of trauma, so some behavioral health problems when compared to the general population. At the same time, EAP services are widely underutilized in the fire service, at least among many of our IAFF affiliates. Firefighters have different reasons for not wanting to seek help through traditional means. Sometimes, that’s about stigma. Eighty-one percent of our members, as you can see indicated there, reported they would feel fear of being seen as weak or unfit for duty if they were to seek help, while others reported a perception that EAP services are unhelpful. So, one positive takeaway that we did get from this feedback was the report that for those members that have utilized the peer support intervention, they did find that to be a helpful and affirming experience.

We just want to build on that a little bit when you think about peer support. So, what is peer support? Peer support is used in many different ways throughout health care today. I’m just gonna look at the model of peer support in the fire service and how the IAFF uses peer support. So, as I mentioned, firefighters can be weary of talking to a clinician, but they will often talk to each other. We define peer support as one trained member of the fire service helping another. Peers are trained to recognize the common behavioral health problems that impact firefighters, such as active listening, crisis intervention. We actually trained firefighters how to ask another firefighter, “Are you thinking of killing yourself?” Then connecting that individual to the next level of support — whatever they’re willing to do. So, they are not trained to be clinicians or therapists, nor can they replace them, but they are equipped with some basic knowledge to identify common behavioral health problems and then link that individual to a next level of getting help, whatever that’s going to be. Peer support is not meant to replace a functioning EAP program or a CISM team — we want to be clear about that — but just, really, is one more tool in the toolbox to connect a distressed firefighter or EMS professional to help. 

Here are some of the psychological benefits of peer support that we know to be true, according to the research that we have. As you can see, these are definitely some promising results and outcomes that we would want for any kind of intervention, whether it’s professionally delivered or peer-led. Just a very quick update on the IAFF peer support training program — you can see in there, the program was launched in 2016. If you’d like to learn more about the peer support training program or request the training for your local or department, Kelly is going to post the program link in the chat there, I believe. And that’s definitely something you can check out to learn more about the peer support training program.

Alright, I’m gonna kick it back to Ray now. Ray, I’d like to ask you: I know you’re familiar with the peer support training model, and I’d just like to get your sense of how you’ve seen peer support impact firefighters that are coping with trauma or other behavioral health problems, either in your district or just nationally.

Okay, Lauren. Yeah, the peer support has been a huge success in the 9th district. I feel throughout the IAFF, as I travel around the country talking to different people about how the peer support system is working — at the time that happened to me, we didn’t have peer support; we didn’t really understand it. How we dealt with Columbine was extremely bad for our individuals on the job, and really put us into a worse spot than we understood. Peer support, as you were saying, came about 2016 but was pretty much used at the 9/11 situation in New York, and the IAFF went in and learned from them and helped them. I think that’s what’s really moved. As you said, we’re willing to talk to other firefighters and we’re willing to talk to somebody that understands our culture and our thought processes. As I often say, firefighters have a kind of dark sense of humor, and if other people hear that, they probably think that we’re really pretty strange. How we relieve ourselves, after coming back from Columbine — try to cope with it.

I think peer support really brought that about, and then you really had somebody, as you said, that’s trained in active listening, which is really important. With that came the peer support education and the education for firefighters. What I mean by that is that we then started training officers in the fire service so they knew the signs and symptoms of a PTSI or PTSD. I call it “I” because of injury, and we can go into that, but with that, we started educating those officers so they understood. Then now, we’re doing a phenomenal job about educating the recruits — they come on the job and are understanding that it’s okay to ask for help. It’s okay to sit down and talk about it. That is a huge success for firefighters to know that. I would say in another five to 10 years that this will really be helpful for everybody in the fire service. Now, we have a whole generation growing up understanding how it works and why it works and how you can help your brothers and sisters that are also dealing with that. For an example, in the shooting in Las Vegas, Clark County, that was unbelievable how it affected the fire service. If it hadn’t been for peer support dealing with the firefighter scene and what they did there, then it could have been really difficult for those firefighters to come back to work and be able to work at a good level. 

I’ve just seen so much positive from peer support. Looking forward, I’ll tell you that the last big thing is through this peer support. If we do send somebody to the Center of Excellence — if a department sends somebody to the Center of Excellence, they come home and tell them about their great experience and how well they’ve done and what’s going on. Then I’ve had numerous locals that will send two or three or four more people from that local when they come home. Then the guy who’s, “That’s what I need. I need help.” That peer support is there to help guide them and say, “This isn’t bad. You’ll make it through and go to this.” I think that’s really important. 

Thanks so much, Ray. We definitely are going to touch on some of those trends that we’re seeing in the fire service, starting with education at a very early level. We’re going to get to that in a minute, but next, I just want to touch on a high-level review of some of the evidence-based treatments that we have for treating PTSD. Just to save a couple seconds, I’m actually just going to ask if — clinicians that are joining us today, you could go ahead and type in the chat what, if any, of these evidence-based approaches are being frequently used for treating PTSD. If any firefighters that are joining us today have participated in trauma-focused therapy and you want to share, you can do that as well. Go ahead, if anyone wants to put in the chat. I just like to get a sense of what approaches folks that are joining us today are familiar with.

I’m thinking of some EMDR and DBT, CBT CPT — a good variety of approaches. Today we’re just gonna take a look at three of these approaches. Of course, when it comes to behavioral treatments for PTSD, it’s important that we keep in mind that there is no single best approach that we know works the best for everyone. It really is an individual-tailored approach. The National Center for PTSD has recognized, however, these three main treatment approaches that we know are effective in treating PTSD. These are cognitive processing therapy, prolonged exposure, and then eye movement desensitization and reprocessing therapy. I do want to point out that this list is definitely not exhaustive; while these are the three approaches that seem to have the most evidence at this time for being able to successfully treat PTSD, there are definitely other approaches that can be used to treat PTSD, but maybe we don’t have as much research on them yet. So, again, there are other approaches that can be used, and we’re just going to take a look at these three today. 

Cognitive processing therapy, or CPT, is a highly structured form of cognitive therapy, meaning it’s very focused on the thoughts. And in this approach, the belief is that traumatic events that occur disrupt very core beliefs that the person previously held about themselves and how they relate to the world. For example, if a person previously went through life believing that I am basically safe or people are generally good and trustworthy, or I am in control of my body, when the traumatic event occurs, these core belief systems are really disrupted and kind of turned upside down. Then the client is unable to make sense of how they fit into the world. They develop what are called these stuck points. A lot of this is rooted in that idea of the just-world theory that we explored earlier. 

The primary goal of this approach is to identify the client’s stuck points, and through cognitive restructuring, literally help the client arrive at more accurate and balanced interpretations of the event, as well as themselves — how they relate to it. So, this is an approach that was developed as a 12-session protocol, and there is some evidence to suggest that it can be delivered in less or more time than that. So, there is some flexibility there. One possible drawback of this approach that I would share — and this is just my personal opinion — is that this is an approach that’s really heavily focused on talking and not so much on doing. We know that PTSD is often a condition of behavioral avoidance, and this isn’t an approach that’s going to directly address the behavioral avoidance that someone might be experiencing. That’s just something to keep in mind.

Now, we’re going to just look at prolonged exposure therapy. This is another highly structured form of behavior therapy, and it’s really focused on modifying a stress response that develops after the traumatic event occurs. These are sometimes called fear structures, and the idea here is that when someone experiences a trauma, certain benign stimuli experienced during the trauma get paired with a specific stress response, which can be physical, emotional or cognitive. For example, a specific stimuli such as the smell or odor of gas, or maybe a specific color or a street sign that the person saw when the trauma was occurring, somehow gets paired in the brain with a certain stress response. The response might be physical, like heart’s racing, sweating. It might be emotional — an intense feeling or sensitive despair or terror or fear — or it could be cognitive. Thoughts like, “Oh my God, I’m going crazy. I gotta get out of here. I’m going to die.” The stress response leads to really persistent avoidance for the client or firefighter because they attempt to avoid any and everything that might activate this fear response. Their world becomes very small very quickly, so the goal of this therapy is really to modify — first through an imagined setting and then a real-life, safe setting — the client’s response to this feared stressor and to experiencing this response. 

For example, if someone has developed a fear of using public transit, they are first encouraged to really think about being on the subway — to talk about being on the subway. They might be asked to look at photos or images of a subway train, and then eventually, they build up through this gradual exposure the experience of actually going and sitting on a subway train, assisted by the clinician. This is prolonged exposure therapy. Again, the idea here is to really teach the client that, while their distress is certainly uncomfortable, they can learn to manage it. Often, what happens is the stress response is really habituated over time and just becomes less intense and more tolerable. That is prolonged exposure.

Then I want to hit on EMDR. So, EMDR: In this approach, the idea is that PTSD symptoms are thought to result from the activation of inadequately processed memories. One belief is that trauma can overwhelm the capacity of the left rational brain to create a coherent story about what is happening, rather than the brain integrating the traumatic event into the memory as something that occurred in the conscious past. That was then, this is now. The person is left with these kinds of sensory, emotional fragments that keep getting triggered as they go about trying to live their life. Prior to getting into the meat of the sessions, the client is taught some emotional or stress management skills, regulation skills to help manage what they’re experiencing during the event. And then bilateral stimulation is applied to the person as they recall the traumatic event. The bilateral stimulation could be visually following a finger back and forth. It could be a clicking sound or a tapping sound. The client is forced to focus on the stimuli while also processing their traumatic event. 

This kind of dual attention allows the event to begin processing and get stored into the brain in a different way. There’s a lot of debate about how this approach works exactly — we just know that it does work and seems to be quite effective for many people. This is just one idea of how it works that I shared here today. I do want to mention, in his book, psychiatrist and researcher Dr. Bessel van der Kolk — the book is called “The Body Keeps the Score.” You might want to check it out if you’re interested in trauma. He would argue that EMDR is a superior treatment approach for treating trauma because, one, it can allow the individual to process and resolve their trauma without having to actually remember every detail of what occurred. And then two, someone can resolve their trauma without having to actually talk about every single thing that happened. Certainly for some clients, that could be very appealing. 

This is just a quick overview. As a licensed clinician, if you’re interested in getting trained or certified in any of these three treatments, this is some organizations that do the training and kind of what’s involved. Then for firefighters, if you’re interested in finding a clinician that is certified in one of these treatments, these are also organizations you can check out. For clinicians, I’d say if you’re not ready to commit to everything that’s involved with these certifications, you might check out the continuing-ed section of the National Center for PTSD, which is listed there. They have a lot of good one-hour introductory trainings where you can explore more of, “Is this something that I’m interested in and want to invest my time?” 

I think for clinicians, regardless of what treatment approach you’re going to use — or for firefighters, if you’re seeking treatment — regardless of what kind of treatment you want to explore, there are some basic things that we can keep in mind. Again, there’s no one-size-fits-all approach. It really does need to be individually tailored to the client’s strengths, as well as their most debilitating symptoms. For clinicians, I think one way you can think about treatment selection, again, is thinking about what is making this person’s life so difficult. What are the symptoms that are making this person’s life so challenging? Then if we think about the score categories of post-traumatic stress that I shared earlier — if you have a client, for example, whose primary issue is a lot of self-blame and a negative worldview, then CPT might be a good approach for that client. Or if you have a client whose main issue is a lot of behavioral avoidance and hiding out in their own life and feeling very paralyzed to do much of anything, then prolonged exposure might be a really good fit for that person. Or if you have someone whose main issue is a lot of dissociation and feeling fragmented and really hypervigilant, then EMDR might be a better fit.

Again, that’s one way to think about treatment selection. I think we just always need to keep in mind that talking alone is rarely enough to resolve and work through trauma. Effective treatment really does need to address that behavioral avoidance that we mentioned earlier and really support the client to go out and behave differently and encounter new things or people, places, things, experiences that they’ve been avoiding since the traumatic event occurred — when they’re ready, of course. Then we also want to remember to incorporate any kind of body-based skills that help the client regulate their own physiology and help address that state of hypervigilance. So, it might be yoga, it might be breathing meditation, biofeedback — any of these kinds of body-based skills are going to be really important for treatment.

Then lastly, we just want to always keep it in mind when possible to connect that firefighter to any available peer support networks that are available. It might be at the peer support team of your local fire department, it might be IAFF online recovery meetings. It might be a first responder group that meets in your community. If you have access to any of these kinds of resources, definitely keep those in mind. I do just want to very quickly mention — during the pandemic, of course, we’ve seen really an explosion in tele-mental health services, and there is definitely good evidence to suggest that video-delivered therapy can be as or more effective than traditional in-office therapy. If this is something you’re at all interested in as a client, definitely check out the IAFF guide. Kelly can post that in the chat. This is just a good guide that explains what telehealth is, what you can expect and also some specific questions that you can use as a firefighter to really screen a clinician to determine if this person is a good fit for someone in the fire service.

I’m going to check in with Ray one more time, and Ray, I’d like to ask you — could you share with us a little bit about what kind of treatment you received and what was really helpful to you in your treatment journey? 

The treatment I received was CPT and, again, this was before the Center of Excellence. I went through the VA. I really didn’t know how to go find a clinician — never thought that I would ever need a clinician or anything like that. I went to the VA and I did a 12-week therapy class there. I’ll tell you that the therapy was very intense, and I was really thinking, “Man, is this really going to help me?” But when I came out the other end and the skills that I learned and the coping skills — really, what I’ve learned is when a situation came up, I was able to relate back to what I learned from the therapy and help move through the issues that I was dealing with. So, I think that you’re right. There’s so many different ways that can help you, and I’ve never done the EMDR. I know people that have, and I also know that people have tried it and haven’t been successful. I guess that’s what you’re saying — whatever works. I think that’s where the clinician really needs to be aware of, “Will this work for this individual?” So, I think it’s so important that they understand that this therapy is going to be not easy. You just don’t walk in and walk out, but the end results is what really count. So here I am, many years down the road, and I still use the coping skills that I learned. 

I also believe that one thing we need to continue to work on is that when you do leave the center or when you do leave getting therapy, you need to continue on with this therapy when you come home.  I think that’s where, as you’re talking to these clinicians today, that’s where they are so important — because if you just go and then forget all about it, I don’t believe it’s going to be as helpful. Like I say, I still go every three months — as I call it, a check-in tune-up — and see a clinician that still really works with me through the VA. I think that’s really important. 

Thank you so much for sharing that, Ray. We are going to wrap up a little bit here. I just want to share some next steps and some trends that are happening in the fire service to really promote behavioral health among firefighters and EMS personnel. There’s a lot happening in this field right now. It’s really exciting. I don’t have time to get into all of it, but we’re gonna try to summarize some of these trends. As Ray mentioned earlier, for firefighters that are joining us today — if there’s any takeaway here, it is really the importance of behavioral health awareness, education and training for all levels of rank within a fire department. That’s really where we need to start. Of course, firefighters spend hours upon hours in training and tactical drills and learning how to use equipment. But often, they are given no training or education about what to expect from a mental or a psychological perspective in this line of work, so that’s definitely something that needs to change. We really do believe, at the IAFF, that behavioral health education does need to be standardized into a department’s regular training schedule, starting and looking at school even. 

I just wanna touch a little bit on some of the initiatives and training programs available through the IAFF. I’ll mention a few of these now — again, I know I’m going really quickly. If there’s specific questions, please ask them or reach out to me after today; we’re happy to get back to you. A good place to start for anyone interested in learning about firefighter behavioral health issues is our two-hour online awareness course, which is free and open to the public and just a good place to start kind of as an introduction. Then we also have our two main in-person training programs — the IAFF peer support training program as well as the IAFF resiliency training program. We have worked quickly over the past six months or so to get these programs fully online in the COVID era that we’re all in. We are currently accepting requests to deliver this training online to IAFF affiliates and departments, so we can do the training as early as February of 2021. Again, we are accepting requests for that now. We also have two advanced training programs that are available to anyone that’s attended the two-day peer support training program, and both of those training programs are fully online and free. Our website is listed there at the bottom if you want to check out anything about any of these resources up there on the screen. 

Beyond simply offering training, we really believe that fire departments need to build a robust behavioral health program into the fabric of their department to be able to recognize behavioral health issues and intervene before they turn into really debilitating and costly behavioral health disorders. The IAFF has worked collaboratively with the International Association of Fire Chiefs to develop what we really believe is a gold standard for what fire departments should work towards in terms of their own behavioral health programming. That model is listed here. If you would like to learn more about that, definitely check out our wellness fitness initiative — I believe it’s chapter seven. That’s all about behavioral health program standards. And Kelly, if you could post that link in the chat, that would be great.

We also just want to mention behavioral health screening. Given the rate of behavioral health problems in the fire service, it might come as no surprise that there are no state or federal guidelines designed to encourage firefighters to have routine screening for behavioral health conditions. This is a problem because it means that members who are coping with very mild and treatable behavioral health problems are not identified and referred for evaluation, but instead keep working. And of course, these issues can progress into more debilitating conditions. In the NFPA 1582, which is the standard on fire service occupational health programs, the IAFF has developed a very clear guidance on annual behavioral health screening, which would require departments to screen on an annual basis for depression, PTSD, active suicidality and substance use disorder if the department wanted to be compliant with the standard. That is just an update that I wanted to share. Then when we’re talking about screening, again, we’re not talking about a full diagnostic evaluation. A screening is a specific set of maybe three to five questions that are designed to identify a behavioral health problem that may warrant further evaluation. This was a list of some of those validated screening instruments I’m referring to. These are free in the public domain and already widely used by lots of clinicians. These tools are effective in identifying conditions that may be an issue for firefighters that we’ve discussed today. These can easily be added to a weekly therapy session or to an annual physical. 

Lastly, I just want to touch really quickly on PTSD presumption laws in the U.S. and Canada. I saw we had a question about this, so anywhere in green on this map — if you’re in that state and you are a professional firefighter and you’re diagnosed with PTSD, it is presumed that the PTSD is occupational-related and, therefore, workers’ compensation will cover some of the costs of treatment and lost wages that that firefighter might incur because they are unable to work for a period of time. As you can see, Canada is way ahead of the game compared to the U.S. in securing this legislation. I will mention that the states listed there in yellow — firefighters diagnosed with PTSD in those states are eligible to receive workers’ compensation, but the benefit is not presumed, which means that the burden is on the firefighter to demonstrate that the PTSD was, in fact, occupationally related, which often involves a lot of legal resources and a lot of red tape that that firefighter has to work. Then in the remaining states, there’s no legislation related to this issue. Those are just some of the trends I wanted to summarize. 

I am going to transition briefly to Kelly, who’s going to share a little bit about our treatment center, or the Center of Excellence. And I think we’ll have time to take a couple of questions. I know Ray and I are available to hang on for an additional 15 minutes today. So, I’m going to turn it over to Kelly now. 

Thank you so much, Lauren. We are going to talk a little bit about the Center of Excellence as a resource for many of the things you’ve discussed today. Myself and my colleague Myrrhanda, we have actually been navigating ourselves through several workers’ compensation cases. I can tell you that, with PTSD presumptive legislation evolving and certainly having made some significant strides recently, we have gotten many members approved for treatment at the Center of Excellence through workers’ compensation. We will always be honest that it might not be easy or quick, but it is always worth a try, especially if you’re in a state where the law is on your side. So, we’ll go ahead and move along to cover some highlights and services from the Center of Excellence for those of you who might not be as familiar with our treatment program.

We opened in March of 2017. We’ve been open about three-and-a-half years now, and we are exclusive for IAFF current and retired members. This is an initiative that was spearheaded by the leadership of the IAFF specifically to address the needs of their members and professional firefighters, paramedics and dispatchers across the U.S. and Canada who, for so long, weren’t having their needs met in a specialized fashion with culturally competent providers who had experience treating firefighters. Now that we’ve treated almost 1,500 firefighters in three years, I can very confidently say that our staff is one of a kind and has an extreme amount of unique experience with this population. We have 64 beds at our residential treatment center across a 15-acre campus. So, we have a virtual tour — I’m hopeful Myrrhanda might be able to share that in the chat, if you haven’t seen the center. It was very intentionally designed not to look like a health care facility. We know that firefighters and paramedics spend a lot of time running calls to medical facilities, and in many cases, that’s not necessarily a therapeutic environment for them. It doesn’t look like one, and I really think that that fosters a very serene and therapeutic environment for our population to thrive. 

We are in-network with most major insurers — that’s Cigna, Aetna, Humana, Blue Cross, United, MultiPlan, First Choice, First Health, the list goes on. And we’ve had great success in even being able to get single-case agreements approved for HMO plans, given the unique specialty nature of our services. We have a program of 18 months of aftercare monitoring. This is fairly unique for a residential treatment center. Most do not follow their clients after discharge, but it was really important to the IAFF to have a research component to this center, given that we’re doing something that has never been done before and treating one occupational group under one roof. I think that the research we are developing is going to help greatly to maybe turn some more of those states green on that map over many years to come. We’re grateful for the participation of our clients because it really does show the efficacy of the program and what we’ve been able to capture from those who’ve participated, and it’s also providing more research around firefighter behavioral health.

You can see, there, our staff ratio and our facility and amenities resemble the firehouse. We talked about not necessarily being something that feels like a medical center in every way possible. We try to make it as easy a transition as possible for our firefighters, whether that’s the kitchen table being just one — we learned pretty quick that we were not going to have multiple kitchen tables. Everybody sits around one, and the station houses that our clients reside in look as close as possible to where they’d be living and working back at home. Most of our clients are coming to us from the job and are planning to return to that. We try to make this as transitional an environment as possible. Maybe not necessarily a highlight, but one feature there. You know, I get a lot of concern that members are not going to be able to talk to their family or stay in touch with their union representative or otherwise be cut off from society, and that’s not true. Our members do have access to their cell phones at designated times, the internet to pay their bills, take care of their businesses that they might have at home, and that’s just one aspect that makes the center very unique. We understand this population. We know you guys have obligations, careers, families to return to, and we want you to stay as connected to those things as possible.

Total members treated to date, as of last week: 1,436. We’re inching near to that 1,500 mark. Currently in treatment, we have 68 clients: 38 at the inpatient level and 30 outpatient telehealth clients in Maryland, D.C. and Virginia. Common admission diagnoses, as we’ve kind of touched on during today’s presentation, post-traumatic stress disorder — but as Lauren said, that’s not a requirement for admission and not necessarily something that all of our clients experience. Major depressive disorder is very common, as well as alcohol use disorder and other substance misuse diagnoses as well. If you’re interested in learning more about the Center of Excellence — I know we’ve kind of hit it pretty quick — for those of you who are maybe new to our organization and haven’t joined us in the past where we’ve covered a little bit more of this in depth, we do have some great YouTube resources. 

One of which you’ll see — that virtual tour is that first result. If you Google or YouTube IAFF Center of Excellence, you’ll come up with our virtual tour/what to expect video, which walks members, local officers, anyone who’s interested through the admissions process, and you do get a look at our campus. You can see there are a few different features that the IAFF has done. And our medical director, Dr. Abby Morris, has a very enlightening presentation that she gave at the Redmond Health and Safety Symposium back in August of 2019 that I encourage clinicians, fire service members alike to check out. She shares some great wisdom that she’s come away with in the three-and-a-half years treating firefighters that I think really speaks to what we do on campus, and makes sense to everybody who might have the opportunity to listen to her.

Then our clinical program overview — Myrrhanda can probably share this resource in the chat as well. Particularly for clinicians who may be interested in learning a little bit more about our modalities of care, we do have a full continuum on campus — all-in-one facility grounds. From detox all the way down to outpatient, we use a holistic approach and evidence-based modalities. Lauren touched on many of them today, and all of that can be found in our clinical guide. Myrrhanda will share that, but if you have any questions, please do drop them in the Q&A and we’ll be happy to answer them. 

We’re going to take some questions; I know I’ve got a few bubbling up there in the Q&A. Lauren and Ray, I think they’re mostly for you guys. I’ll kind of volley them to you if that works. You can see here our contact information. That is actually not me — that is my colleague Molly, who is giving another presentation today, but Myrrhanda and I will share our contact information in the chat. You can see here, you can also get in touch with Lauren and Ray if you’re interested in doing so, and we encourage you to join us in the coming weeks for our other webinars that will be covering different topics, but let’s get to some questions. I know we’ve still got quite a number of people on here with us, and we still have one minute for our official time frame, but we’ll stay on just a little longer to see what we can cover. 

Lauren and Ray, if you could discuss maybe some ideas or thoughts on how departments who might be a little bit slower to the curve of embracing mental illness — how can we get them to take that more seriously and potentially find some resources for their employees? 

Sure, I can take that. Just as a start, the IAFF does have a lot of short video resources and data about our membership and rates of behavioral health problems, in general, that we certainly can share with anyone. These are open, certainly in the public domain. I think it starts with just creating awareness around these specific behavioral health issues and that these are real and this is a problem. Ray, I don’t know if you have any other specific ideas about how to get the conversation going from your perspective, as a firefighter and within the department. 

Yeah. It’s hard to do and I understand that, but I think that the big issue is back to what you’re saying. Awareness or education, and being able to hopefully have some type of a health committee that you can sit down and present to your chiefs. I also think that if you can bring in anybody that has been to the Center of Excellence or have a clinician that’s worked with firefighters and sit down with a new department, a new chief, and sit and talk about how it’s helped is very helpful also. Because I think they don’t really understand what the whole process is and peer support and all that that’s going on. I think that’s really important — that we can educate the administration about why peer support is so important for behavioral health. 

One thing I’ll add that’s been very effective for peer support programs to get off the ground is demonstrating utilization data. If you are able to obtain utilization data of your EAP program that your department has, it is likely low. Demonstrating that peer support — once it’s up and running — is often utilized and members do often report good levels of satisfaction with utilizing that service, which then in turn can also be connected to other data, such as absenteeism, sick days and that kind of thing. There’s a lot of directions you could go there. Definitely reach out to me after today, and I’m happy to share some resources that might be helpful. 

One other quick thing for clinicians is to understand that most peer teams are associated with a clinician. Once you learn about the fire service firefighters, that’s really important that you can help continue education for that peer team. Clinicians have such a big role in this whole process that I think is really important to mention.

That reminds me, Ray: Clinicians that are interested in peer support and in fire service personnel, we did a webinar several weeks ago specifically for clinicians. All about peer support, how to work with peer support teams and how to really be a champion for behavioral health issues in the community and in your local fire service community. Definitely check out the community education webpage that’s posted up there for that past recording. 

Thanks, Lauren. I’m going to hit a few logistical questions that we’ve got. One is regarding Canadian access to the Center of Excellence, and potentially adding an equivalent center in Canada. I can tell you that that is not on the immediate horizon; however, we are a partner or rather an approved provider with the WSIB, which is the Work Safety Insurance Board of Ontario, essentially allowing access with the WSIB claim to the Center of Excellence. We’ve also had a member from British Columbia and their municipality pay for treatment. So, I can tell you that in about the last year, I’ve not had anyone reach out trying to access the Center of Excellence from Canada. If that is something that you’re familiar with someone needing, let me know. I will try to blaze every trail we possibly can to get that member in the door and that access to be granted. It is a possibility — we’ve had it done several times. We’ve done the work to become WSIB approved, and we’re looking forward to helping those in Canada immediately. As soon as you need the help, please reach out. We’ll try to do everything we can to assist those members.

One more and then we’ll bounce back to peer support. Someone — they are interested in setting up a tour of the Center of Excellence. They feel as if it would be helpful in their position as health and wellness coordinator. We would love to have you tour the Center of Excellence. It’s one of my favorite parts of this job. Right now with coronavirus, we are limiting guests on campus to reduce potential exposure. We’re hopeful we can resume in 2021. So, we will absolutely be in touch with you about that possibility. As a potential for right now, we have that virtual tour video — Myrrhanda, if you could share that in the chat for access — that does give a great picture of campus for those who might not be able to travel to the Center of Excellence prior to potentially admitting, or local officers looking for a way to check it out. But I’m hopeful that we’ll be able to have you on campus for an official tour in the future.

How does someone — I think this is from a clinician, and Ray had just said something about this right before you guys wrapped up. How does someone — I think a clinician — connect with a peer group? How would you recommend doing that if they’re interested? 

Well, if that’s for me, I think that the big issue there is to get in touch with the fire department, or if you know the IAFF local in that area, get in touch with them and talk to them about getting in touch with their peer group. I think that’s really important, and also, there’s a lot out there that are trying to develop more teams. If we have a clinician that’s really interested in that area, then we would have peer teams reach out to you, and I think that’s what we’re trying to develop as we have been continuing to develop our, what we call, “vetted clinicians.” Therefore, if somebody said in Grand Junction, Colorado, they wanted to start a peer team, then we could hook them up with a clinician that is vetted in that area and move forward. 

Just to add to that, Ray — and I know Lauren probably has great information on this too. I’m just looking at Molly’s picture here. That’s a large role that our clinical coordinator, Molly, is playing. She’s vetting clinicians to be able to connect them to our IAFF locals and vice versa, and we have a database of sorts of all the IAFF locals that would be relevant to your particular area, if that is something you’re interested in having a conversation with us about and wanting to get connected to your IAFF local. If you don’t know where to start in terms of doing that, please reach out to Molly at the email address listed there. We’d love to have a conversation with you to get your information for potential clients looking for resources in your area, if you’re interested in connecting you with the right players in your community. I apologize, Molly — I should have thought of that. She does a great job, so thanks. 

You said Grand Junction. We literally were just doing this in Grand Junction, like, two weeks ago. I would just add to that — again, for any clinicians that are interested in connecting with their local peer support team or their local fire department, definitely check out the webinar. Just referenced the peer support for clinicians that we did — it’s on that community education page. We do talk specifically, not only around best practices and working with a peer support team, but really how to initially make that reach out. One idea there is offering free education. As the fire service becomes more behavioral health savvy, they really are interested in an accessible education on behavioral health issues, specifically, that impact the fire service. If you’re able to provide a short in-person training, or maybe now it will be something virtually that’s free, that’s some education that fire service personnel and peer team members are going to want. That also allows them to get to know you better as a clinician and as a potential referral source because they know, “Hey, this is someone that has shown some interest in us and wants to connect with our clientele.” So, definitely check out the webinar I mentioned for more ideas. I think Myrrhanda is probably gonna help us out and share that link in the chat too. 

We’re getting a little close in time, but I do want to try to hit a few more of these. Last session, it was discussed that the preferred method for treatment at the Center of Excellence is group therapy. How do we bring that model to departments and unions at the local level? Can it be a productive tool? What would that look like? Who would be qualified to facilitate, and what would be the right number of participants? I’m going to add a second question in this because I think they kind of go hand in hand — does peer support help in a small group setting? Maybe, Lauren, you could talk about that — maybe being a little less clinically driven, but group peer support. 

Important to distinguish peer support from conducting group therapy. Two different approaches here; support is often delivered by a trained fire service member to one or more firefighters. It’s an informal interaction between two firefighters to have a basic kind of awareness-level discussion about, “Hey, how are you doing,” and connecting that firefighter to another support service or clinician. It can also be done with one tree. You’re working with a small group of firefighters. This is definitely an approach we use in peer support deployments when there’s been some kind of major critical event disaster or incident. We will send in teams of trained peers to go into the fire station and conduct a kind of small group — not debriefings, but it really provides some light psychoeducation. 

To just have a discussion — we definitely know that that’s a helpful model in terms of providing group therapy in a fire department. That would, of course, need to be a voluntary service for the firefighters, but it would need to be provided through a licensed clinician that is in some way connected to that fire department, so certainly, there’s an end. There’s just a lot of opportunities for clinicians to collaborate with fire departments; it doesn’t necessarily have to be a specific billable service like group therapy. It can instead be maybe an evening of some light psychoeducation conducted as a support group, which then really kind of opens it up a little bit. Or whoever was actually able to provide that service — often, support groups can be led by either a clinician or a trained peer with lived experience or the combination of those two. Of course, that can be done for free, and it might be more appealing to prior service members to join or check out rather than signing up for group therapy, which is certainly another level of service. 

Lauren, I would just like to add to that. Just keep in mind that when we’re doing — I don’t want to call it therapy — but when we’re doing peer support, we’re not talking about the call. We’re talking about the behavioral health of the firefighters. Great examples Lauren was just talking about — we just had those huge fires in Oregon, and many of these firefighters had never been on a wildland firefighter and seen how it moved through a town, or in this case, a lot of mobile home parks were completely destroyed. These firefighters were dealing with that whole issue of trying to save the people at the mobile home parks. When it was over, it was more of the therapy — going in and just talking about, again, how you’re doing and not how you did it, to recall what you didn’t do, whatever. I think that’s really important to keep in mind because we’re not concerned about what happened — what they did at the call. We’re concerned about how they are doing after the call, mentally and emotionally. I think that’s important when you start talking about group therapy — you’re not talking about the call. You’re not dealing with that issue. That’ll come up and be done with later. 

Thanks, Ray. I’ve got about two more minutes and then we’re being kicked off. There’s another event happening, I’ve been told. Let’s see, I’m going to hit a few quick ones. I think I can do it here. One says, “Why hasn’t workers’ comp caught up with allowing cumulative PTSD or PTSI rather than linking it with a physical injury in all states?” This could probably be an hour-long discussion itself. My understanding is that that’s not necessarily true in Florida. That’s where I live. I don’t believe that there has to be an association with a physical injury, but it does differ in every single state. So, why hasn’t workers’ comp caught up? It’s generally pretty slow to evolve in such a way, but we’re hopeful, especially with the work that the IAFF is doing daily to advocate for members in different states. 

Another question in that regard — is the IAFF expanding a Center of Excellence into other regions? We are going to be opening up a West Coast location, and that will be in California, we’re hoping, in the next year. That’s lofty, but we work hard. I will say there’s some discussion that everyone wants a Center of Excellence near them, right? Sometimes, we hear that from everyone but the firefighters in Maryland. It’s not about calling it a Center of Excellence: Truly, it’s having members from all over the country and North America be under one roof with perhaps different experiences yet so much in common that I think makes the program so special. The unique experience at this point that our staff has lends itself to our success. So, I would encourage anyone who might be concerned about geography to prioritize where the best care may be for you. If that is something that you’re seeking and will not let geographical barriers stand in your way, we will help you cut them down as much as we possibly can, especially if it’s regarding insurance coverage or anything like that. But we are looking forward to that second location for our West coast members. Certainly, it will be easier to travel to. 

We do have a few more questions that are coming in. We might have to follow up, Lauren and Ray, via email. One that we might be able to cover — you mentioned the online peer support program. Is that only available to IAFF members? 

Peer support training programs only available to IAFF members? No. Anyone. It’s at the department’s discretion or the local’s discretion that hosts the training, so they can invite anyone that they want. Not only IAFF members — sometimes, they choose to have clinicians, chaplains or non-IAFF members within the department. It’s really at the department’s discretion that hosts it. If you’re a clinician or otherwise not affiliated with an IAFF local, reach out to your department, as Lauren encouraged, to see if you may be able to join a training that they may be hosting.

I’ll just add to that. Once the peer support training program is fully online, we will be hosting a limited number of trainings that are just open to the public as well. You wouldn’t have to register with a department or local. You can register and pay as an individual. So, feel free to reach out to me after today. I’ll send you the sign-up form to be notified when those dates are posted.

Thanks, Lauren. We do have many more questions that we’re not going to be able to answer today; if we did not get to your question, please shoot us an email. We would love to make sure we get that address for you or connect you to the right resources. I’m going to post — again, for any counselors that are still with us — submit that evaluation form for NBCC credit. Ray, Lauren, thank you guys so much for your insight and your time. We’re so grateful for you and all that you do for the fire service community. We hope to see everyone again next week and potentially the week after that. Stay safe, have a great day. Hopefully you stay away from the TV ‘cause it’s getting a little crazy over there, but we are very grateful to all of our attendees and hope everyone has an awesome day. Thanks so much.

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