Treating Fire Service Professionals: Cultural Competency for Clinicians

• Breaking Down Barriers to Treatment
• Benefits of a Treatment Center Designed for Fire Fighters
• Treating Invisible Wounds
• The Surprising Number of Fire Fighters Struggling with Alcohol Use

Addiction in the Fire Service: Training for Clinicians

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

Welcome everyone to the IAFF Center of Excellence training and introduction on cultural competency for clinicians. My name is Kelly Savage. I am the community outreach director for the IAFF Center of Excellence. Somewhere on this call, my counterpart Myrrhanda Jones is also here. She’s the community outreach director as well and is based in the west coast. I’m based in Florida. We are so excited to have you all here. We have a lot of participants. The number keeps creeping up, but we’re at 160 so far, so we are just thrilled with the participation and thank you all so much for being here.

Without further ado, I introduce to you Molly Jones. She’s our clinical coordinator at the IAFF Center of Excellence. She oversees a lot of our case management in regards to connecting our clients on campus with clinical professionals in their local communities, as well as connecting IAFF members across the country and in Canada with clinicians in their local communities for outpatient services, behavioral health seminars, all sorts of things. So, we’re super excited to connect everyone who’s a part of this call and be able to work with you in the future. So, Molly, I will let you take it away.

Everyone, hello! Thank you for joining me today for this first ever fire service cultural competency webinar. Like Kelly said, my name is Molly. I’m a licensed social worker and the clinical outreach coordinator for the center. Kelly did a pretty good job of explaining my role, but it’s a lot of continuing education and networking and outreach. I’m really grateful to have this job and really excited to present this information to you all today. So, with that being said, we’ll just go ahead and get started.

So there’s my contact information, my phone number. That’s a super easy way to reach me; you can text me. There’s also my email address there. That’s another good way to get a hold of me. I also listed the website for the Center. There is a lot of information listed there. There’s information about our program. There’s some statistical information on this population as well as some additional continuing education videos. There’s one from our medical director, Dr. Abby Morris, who I have learned so much from, and highly recommend people checking that out, so be sure to go there. You can also find this video posted there once we finish up.

Okay. First step, I’m going to get some background information on the Center of Excellence. Throughout the presentation, I’m going to be weaving in some data and little tidbits from our experiences at the center. I figured it made the most sense to start here. First things first, the Center is over, or, excuse me, a little bit over three years old, and we are located in upper Marlboro, Maryland, which isn’t too far from DC and Baltimore, about 45 minutes to an hour from all of those local airports.

The Center was developed out of a partnership between the International Association of Fire Fighters and Advanced Recovery Systems, which is who I work for. ARS has multiple civilian treatment centers across the country that specialize in substance abuse, eating disorders, mental health issues, and we also have some adolescent treatment options. The IAFF is the union that career fire service members can choose to belong to. That would be professional fire fighters, paramedics and other dispatchers. There are just over 300,000 IAFF members in the United States and Canada.

Because the Center of Excellence is a partnership between the IAFF and ARS, it’s exclusive to those IAFF members. So far we have treated someone from every state in the United States except for Alabama, as well as some individuals in Canadian provinces, which is super cool. We have a really far reach, which I think is awesome. To date we’re a little bit over 1,200 members served at the Center of Excellence.

It sits on a 15-acre property. It’s a rural setting, which is super conducive, I think, to treatment. It’s very peaceful. There’s lots of lands surrounding it. It’s 64 beds and it’s also a co-ed facility. We have some really cool amenities as well, both indoor and outdoor. We try our best to give our clients choices during treatment, and so they have a lot of different leisure activities that they can choose to participate in. There are walking trails, basketball courts, volleyball courts, there’s an awesome gym that a lot of people choose to use. We also have some recreational therapists that can come in and help people address some physical needs if they’re interested in that. We also have an outdoor swimming pool, so when the weather’s nice, our clients can use that as well.

Because we’re specific to this one subgroup of people, we were able to model our facility after a firehouse. So, the campus is very fire-oriented. On the slide there, you’ll see some pictures of that facility. There’s the entrance, and you can see the IAFF logo, a Canadian flag, United States flag, and I think the other one is the IAFF flag, I could be wrong. But you’ll see the IAFF logo throughout the campus, which I think provides a level of comfortability for the clients. We also have a lot of fire memorabilia in the nursing building, which is that small picture there on the left. Along the walls, there are different patches from all of the departments of the clients that we’ve been able to serve. So I think we do a really good job of honoring their work and just try to make it comfortable for them.

Okay. So now we are going to do a little clinical overview of the program. We’re a dually-licensed facility. We have a primary mental health and a primary substance abuse license, which means that we can help individuals who are struggling with just mental health issues like PTSD or symptoms of PTSD, or people who are just experiencing substance abuse or any combination of the two. I would say usually there’s more combination than just one isolated issue going on. Trauma is also a really big focus of our program, and we try to include mindfulness as much as possible as well.

We offer a full continuum of care. First things first, we have a supervised medical detox. Anyone that has some substance abuse issues going on, they can detox while they’re with us on campus. Then we have a residential level of care, which is that traditional sort of rehab program that comes to mind. They’re living on campus. They’re engaged in programs from the time that they get up to the time that they go to bed.

Then we have an extended outpatient model for our partial hospitalization and intensive outpatient programs. Extended outpatient basically means that people have the option to live onsite with us while they are at those lower levels of care and have less programming hours. Since we’re treating people from across the country and Canada, it makes sense that they would need a place to stay while they’re with us. We just do everything that we can to try to accommodate those needs.

The program is also holistic: we are looking at every aspect of the people that we’re treating. Starting with our clinical treatment, we utilize the popular trauma treatment modalities like cognitive processing therapy and cognitive behavioral therapy with a trauma focus. We do EMDR when appropriate and when the client is willing to engage in that. We also want to make sure that there’s someone afterwards that can continue that type of care, too. And then we’ve also had clinicians who can offer dialectical behavioral therapy and accelerated resolution therapy. It just depends on the skills of the clinicians that we have onsite with us as far as different modalities that we can offer. We also try to incorporate things like meditation, trauma-informed yoga, and various alternative therapies like music and art therapy. We’ll also do some equine therapy off-campus.

We will also incorporate AA, NA, and Smart Recovery into our program for anyone that’s admitting for substance abuse issues. We meet with clients individually, in group settings. We’ll incorporate the family as much as possible.

We also have a huge peer support component to our program that, in my opinion, starts to resemble some experiential type therapy because our clients are connecting with one another and engaging in ways that they really haven’t ever before. They’re getting sober, they’re being vulnerable, and they’re having authentic interactions with each other, sometimes for the first time ever. It should come as no surprise that that brings up some anxiety and makes it difficult, so they really have a safe place to process things like that and figure out who they are and how they want to best interact with other people.

In addition to the clinical program that we have, we also have the same sort of robust programming in place for the medical side of things. Our medical director, like I mentioned, is Dr. Abby Morris, and she oversees the medical portion of our care. We also have primary care physicians, lots of nursing staff, behavioral health techs that look out for patients and we can provide traditional and general medical care for clients while they’re with us too.

Our case management team, as Kelly mentioned in the intro, I kind of have a little bit of a role in it. I work pretty closely with Genesis, who is our case manager, to try to create really strong aftercare and discharge plans for people. We are regularly connecting alumni with new providers, meaning that people are coming in not having a therapist or a psychiatrist in place prior to seeing us. We want to make sure that they have really good people when they go back home because continuity is super important.

I think this population especially needs supportive clinical relationships and strong social support when they get back home. Just one little thing that I think about all the time and have a lot of empathy for, is that fire service members, I think, have a harder time reintegrating back home after treatment versus the civilian or general population person. If they go to substance abuse treatment, for example, they may have the luxury of finding a different job or moving somewhere different or recreating their social support.

But for this population of people, the fire service can be really ingrained in who they are and their identity and gives them a lot of purpose. They want to go back to those environments and to those people and that work. So they have a hard time thriving or succeeding in the environments that ultimately were hard to navigate to begin with. I really think this speaks to the importance of them meeting an A+ therapist and psychiatrist and medical doctors too, for when they return home. That way they can have just another buffer or protective factor in case they do need some support following discharge.

Now we’re going to talk a little bit about the outcomes that we’re seeing at the Center. Each year we collect data from our clients, and this data right here on the slide was collected from October 2018 to December 2019. We collected at admission, at discharge, and then we have regular follow-ups. These are just some numbers on outcomes. You’ll see there that over 90% of clients who sought treatment at the Center of Excellence described the care as either very helpful or mostly helpful, and 66% of patients reported that coming to treatment also had a positive impact on how they were viewed at work afterwards. I think that this is interesting, and the reason that I include it is because there are some really strong stigmas about mental health treatment in this population. There’s fear, too, from the members themselves that if they seek treatment, they may be ostracized. But, our data is really proving that to be untrue for the most part, which I think is super cool to see.

That third data point talks about the relationships with significant others. Historically, this population has had an even higher divorce rate than the United States as a whole, which is scary because we know that the general population already has a high number of divorces. What’s promising is that maybe treatment can help drive down those percentages because our data is showing that relationships are improving when members seek treatment. You’ll see there that there’s a drastic difference at the time of.

Lastly, over half of our alumni say they wouldn’t have sought out help if it weren’t at a treatment facility that was exclusive to fire service members. The brotherhood, the sisterhood and trust is super important to this group, and they like being with their own. A lot of times they feel like no one can truly understand them but each other. I think they need a safe place like the Center of Excellence to really figure out, “How am I going to be vulnerable?”, “How am I going to share my thoughts and feelings so that I can grow and recover and be the functional, happy person that ultimately everyone wants to be?”

With that being said, now we’re gonna jump into the objectives for the rest of the presentation. That third objective there at the bottom, “learn about the Center of Excellence and our program structure.” We’ve already covered that. If you have questions about our program, drop those in the chat and Kelly will keep track of it and I’ll be sure to cover it at the end.

I want to be sure to cover, too, why we are doing these webinars. We want to provide our communities with education on what it means to work in the fire service and also share the experiences that we’ve had in our clinical setting, so that clinicians, prescribers, case managers, just any kind of treatment provider can participate and learn more about these cultural differences so that way they can be better professionals, too. By participating in this webinar, it will by no means 100% prepare you to be effective and successful in your work, but I think what it will do is give you some background information on the fire service so that if you’re working with fire service members, in any sort of capacity, you don’t have to waste time asking logistical or departmental questions.

What we have heard a lot, and sadly, we’ve heard it over and over again, that these men and women will eventually get over that stigma or get over the barriers to treatment, and then they go to treatment for the first time, go see a therapist, and that therapist is asking questions about their day-to-day life. Or, they feel like they’ve traumatized the therapist because they weren’t ready to hear the details of what they were sharing. We just really want to plant the seed in those people that are working with fire service members so they can figure out what the gaps in their own knowledge is. Then we’re going to go through some common behavioral health issues that we’ve seen and just some different clinical considerations to take into when you’re working with them.

So these next few slides are some really basic information about the fire service. Some of it you may already know, but I figured I would just get as detailed as possible. The fire service culture is unlike cultures in most professions. The men and women who work in this field have very unique work schedules. Their job responsibilities and the societal expectations that are placed upon them are also unlike any other line of work. And then on top of that, the fire department culture is very different from police culture or working in an ER or any other type of frontline worker.

On top of that, each department is very unique. Even a department, a station, or a shift can have their own personalities too. It’s really important to keep in mind when you’re working with these folks that they’re not all the same, but for the most part, they’re all kind of running similar calls. That includes fire calls, fire alarms, explosions, automobile accidents and medical emergencies. A common misconception is that fire fighters are only fighting fire, but medical calls actually make up about 70% of their call volume.

In addition to running these emergency calls, they are also responsible for cleaning the firehouse, doing daily equipment checks, and they have to do training on a pretty frequent and regular basis. There’s some community involvement, and then they’re also expected to engage in physical activity or, you know, self care and keep up with themselves. They don’t all too much have the option of just kind of sitting around and doing nothing. I think that it’s safe to say that they prefer it this way, especially when they’re on shift, because who wants to be at work for 24 hours and be bored? They really try to do things and stay busy.

On average, they work about 10 24-hour shifts a month, and the shift schedules are different. Each department can have their own sort of schedule, but usually it amounts to a 56-hour work week. Some examples of these shifts are 24 hours on and then they have 48 hours off, 24 hours on, 48 hours off, so on and so forth; and then like 48 hours on, 72 hours off, or 24 hours on and 72 hours off. A lot of people will say, “Why don’t they just work 12 hour shifts?” Surprisingly, fire fighters, fire service members, they really do enjoy this type of shift work. It can allow for some really good work-life balance if you have good structure and routine in place.

These types of long work days really can take their toll on both the person and the family if they don’t have that structure. They can get called back into work, they might have to assist when they’re off, but it can, as I mentioned, disrupt home life. Again, balance is really important. So maybe, teaching skills like organization, time management in a clinical setting could help with preventative stuff, ward off some stress, and provide for some more time for self care too, right?

Oh, one last thing here. There are department differences too between rural, urban and suburban departments. The frequency of calls, the types of calls and who they’re running the calls on can also be a factor on stress levels for these folks. In rural settings, they’re going to be running calls on people that they know and they’re going to be triggered maybe more often because it’s a small town and they drive past scenes or places that they ran calls. In urban environments, there may be busier calls at night or more highway crashes. Suburban departments may be a little bit slower, maybe in a more residential setting, so you might have more medical calls, but it all just looks different depending on where they’re working.

Now onto some more one-on-one type information. This is more thinking about the character or personality of the person who’s working in this profession. First and foremost, like I mentioned, the brotherhood and sisterhood is really important. I think that strong bond just naturally happens because they’re running calls with their peers and they’re seeing horrible, devastating things and experiencing tragedy all the time. That really can’t help but build trust and closeness between people. On top of that, they’re spending a considerable amount of time actually living with each other. When you’re on a shift, it’s usually the same people each shift, and in a minute I’m going to show you some pictures of the firehouse and you’ll see that they may be in bunk rooms altogether, they’re eating meals together, they’re watching TV together, they’re going grocery shopping together. So they are spending a lot of time with one another.

But this “work family,” so to speak, really isn’t usually the only family that these fire service members have. I bring that up just to make the point that these folks have a lot of different roles in their life and potentially a lot of different stressors. They could be a fire fighter, they could be on their department’s peer support team, they could be a spouse, a parent, they’re a child of their own parents, they can be very busy. They also may have second and third jobs. Because of that shift work, they have a lot more time potentially to pick up a part-time job. So, a lot of different roles and just something to really keep in mind. They’re busy people.

They also take a lot of pride in their work. I mentioned this earlier, but their sense of identity and purpose is often tied to this profession. A lot of times they grew up in a first responder family of some sort, so their parents, their grandparents, their uncles were firefighters, they were in the military, they were police officers. So that I think also lends to the pride in that sense of identity and their values. Also on the clinical side of things, I think that could be a really important factor to take into consideration as well when you’re looking at family history, so maybe ask those types of questions. “Did you have a parent or grandparent or another close relative or support that was a part of this population or this profession?”

As I noted earlier when we were talking about the Center of Excellence, there are some really strong stigmas about mental health in the fire world. I think most of these stigmas developed a long time ago when society really didn’t know enough about trauma or emotional awareness. I think overall these stigmas are changing and people are becoming more accepting of talking about their mental health, but there’s still a lot of work to be done. That statistic right there says it all: 92% of fire service members still feel fear that they will be viewed as unfit or weak if they seek out treatment. However, if you’ll remember back to that Center of Excellence outcome slide: 65% of our alumni say that when they’ve returned back to work, they weren’t viewed in that negative light. Those are some things that maybe you could challenge clients with or your peers with, too, when you’re having this conversation, and if you’re a fire fighter yourself.

All right, so now we’re going to talk about some basic structure of the fire service. These are things that I didn’t know when I started working with this group, so I just included this here because I think it’s important to know the hierarchy at play. In an urban or suburban department, this may look different than a rural department. But it’s pretty typical. It’s usually on a much greater scale, but I just kind of condensed it so that way it would fit on here and I could talk about it. So, at the top you have a fire chief. This is the director of the department that oversees management of things like personnel and equipment. Then there is the assistant chief or chiefs. Sometimes there can be several of those, and depending on where you’re living or what the department looks like, they may or may not have more administrative functions, but basically they’re providing support to the chief. And then under assistant chiefs in a larger department there may be some deputies, too, that’ll take on some more of that supportive work.

Next is the battalion chief and their responsibilities are similar to that of a regional manager at a company. They make sure that daily tasks are completed, that it confirms manpower resources for the day, and they manage schedules. There’s usually only one battalion chief on duty for each shift, and generally they’re the highest-ranked person at any given point in an emergency situation, and they oversee multiple stations in companies.

Then there are the captains and the lieutenants. They have similar roles, and some departments may or may not have both, they could just have one or the other. They manage day-to-day activities on the apparatus there. They also manage their crew and direct operations at an emergency scene, so they’re kind of the ones in charge on a call.

After the Lieutenant is the driver or the engineer, and this person is responsible for driving to the scene of a call and operates the water pump on an engine if they’re working on a fire. Next is the fire fighter, and they’re responsible for all the hands-on action on a call. So they’re running hoses, they are executing the life-saving strategies, they’re operating the rescue equipment, and they’re performing search and rescues, too, if that’s needed. I didn’t put this up there, but there are also probies, and these are new fire fighters who are on probation for about three to six months after completing their Academy.

Now we’re going to talk about gear, which I really like this slide because it tells you the weights of all the different equipment. I’ll show you or I’ll read it off to you cause it might be kind of small, but the helmet is four pounds, mask two pounds, jackets seven pounds, gloves eight pounds, the tool and ax is about 21 pounds, pants with the boots are 14 pounds, and then the air pack is 23 pounds. You’ll hear this type of gear called their turnout gear. That’s a total of 72 pounds of gear that they’re carrying in an emergency stressful situation. I bring that up because I really think that it puts it into perspective how stressful this job really is.

I was really lucky that when I started with the Center of Excellence, I was able to participate in what’s called fire ops one-on-one with the DC fire department, and it was an amazing experience. I really got to learn about the physical and mental toll that this job can take on people. Obviously with my clinical background, I understood the mental toll, but I really didn’t understand how the physical side of things plays into that until I went through this experience. We were putting on all the gear. It was like a six, seven hour day, and we had to wear most of it most of the day. We were crawling into burning buildings. We were busting down the doors, pulling dummies out of smoky rooms, which was really hard. Then we were running up towers to simulate responding to a medical emergency in a challenging situation. It’s all simulated, real-life experiences and just was super awesome, and there’s a lot of these trainings available to the public in different locations throughout the United States.

Some departments will even encourage clinicians or other treatment providers to come do what’s called a ride-along with them, and that’s when you can go with a shift. You could do like a 24-hour period or a 12-hour period. I don’t think there’s any particular time frame, but I think you need to spend as much time as possible going on calls with them, getting used to the sounds of the alarms, and noticing in yourself how that can even pump up your adrenaline, even though you don’t have to do anything when you’re going with them. It’s just that fear of the unknown or what is this going to bring? What am I about to see? Those are some things that if you’re interested in doing, email me, call me, we can talk about it. I can try to connect you to your department, but those are some amazing experiences that I think anyone that’s working with fire service members needs to experience.

Okay. Next up, we have some pictures. These pictures I put up there to represent the different gear and equipment that they’re operating. Several of those pictures show people wearing PPE, and I put that up there because obviously we are in COVID times and I wanted to bring up some of the behavioral health stuff that we’re seeing and honestly didn’t really know how to integrate it elsewhere. So, we’ll just kind of talk about that now.

Historically what we’re seeing is that it’s been unlikely for fire service members to bring anything home to their families. Previous to COVID, they weren’t necessarily worried about bringing home illness or getting their family sick, but now, they’re running calls and being potentially exposed to all sorts of things. That is causing a lot of stress, anxiety and worry on both the fire service members and their families, their spouses, their parents, I mean, anyone that cares about these people is worried that they are putting themselves at risk to get sick. If they are potentially exposed, they then have to go into quarantine. A lot of times that’s away from their families because they don’t want to get them sick. Dr. Morris at the Center of Excellence told me that she’s hearing about a lot more people feeling isolated and excluded and alone now more than ever with the quarantine and stay-at-home orders.

So logistically, this pandemic has been a nightmare in a lot of ways, but we are seeing that things are getting better. There’s been some staff shortages that have been caused by members having to quarantine. Onstead of that 24-hour normal shift that they’re working, that they’re used to working now, they may be working for 48 hours and not getting as much time off, or maybe they’re working 72 hours straight.

But generally this type of overtime is going to put any sort of mental health issue or concern or even the ability to tend to traumatic experiences on the back burner because you’re in survival mode in a lot of ways. You’re more concerned with getting back to sleep or eating or taking care of those physical aspects of yourself. I’ve also heard from clinicians that they’re seeing some clients starting to regress with their sobriety, which I think makes sense if you’re at home, nothing to do, have a lot of thoughts and feelings, or are just bored. It’s an easy thing to turn to.

That top left picture is of a fire dispatcher and they have a lot going on, too. They have a whole other level of trauma and stressors that we’re going to talk about in a little bit, but I put that up there just to kind of represent all the different screens and things that they have going on when they’re at work.

Alright, so now we are going to just briefly talk about some of the different fire vehicles. These are three of the most common ones, but some smaller departments have an engine that might carry all of this equipment versus having multiple trucks serving different functions. The picture on the left is of a fire engine, and this type of truck is going to carry a pump and a hose, and its purpose is to extinguish fires. Top right is a rescue truck. These are really common in larger departments, and they are used a lot of the time in water emergencies. So maybe even a smaller department that’s closer to a body of water might have a rescue truck too, but they also can be used for confined spaces and collapsed buildings. They serve a number of purposes really. The bottom right is a ladder truck, and it is most commonly used for life-saving operations and rescuing people from burning buildings or ventilating your roof, so that way the firefighters can get in there and put out the fire. They kind of work in tandem, the ladder truck and the engines on a call. I didn’t put up an ambulance that sometimes people call a bus, too.

These are the pictures of the firehouse that I mentioned earlier. There’s two pictures of the standard kitchen, then there’s two pictures of a bunk room. Some departments or station houses will have individual rooms, but I think, for the most part, they share. Let’s see. These pictures, I think, do a good job of reinforcing that sense of community that they have because they’re making meals together. They’re sleeping next to each other and they are eating together. There’s the common saying that all the world’s problems are solved around the firehouse table. So they’re spending a lot of time with one another, talking, engaging, socializing.

Alright, now we’re going to get into the behavioral health side of things. So the next few slides are going to cover the most common issues that we are seeing at the Center of Excellence. It’s important to remember here that there are so many layers to each one of these things, and there are a lot of contributing factors. We aren’t going to cover every one of those factors in detail, but I think that this is some good introductory information.

So, depression and anxiety are two of the more mild, so to speak, diagnoses that we are seeing, and I think it’s interesting because when I think about a fire fighter, very rarely do I picture someone who was sad. I think I had the stereotypical image of someone who’s happy and outgoing and engaging, but they are experiencing depression and anxiety at higher frequencies than the general population. You’ll see there that second kind of sub-bullet point says 11% of fire service members experienced depression or depressive symptoms at least once in their career, and 75% of the patients at the Center of Excellence meet criteria for major depressive disorder. To go back to that 11%, to give you a comparison, the general population, it’s around 7%, so a little bit higher there for these folks.

Also, interesting that depression is so high in common because people generally think of depression as more of a feminine mental health issue and the fire service is about 90% men. It’s very interesting that they’re experiencing these things, too. Depression definitely looks different in the fire service because of stigmas and this mentality of “pull yourself up by your bootstraps,” “don’t show emotions,” so it can be hard to spot and comes up in a covert way.

I think for the most part, that covertness looks like staying compulsively busy and working lots of overtime and really avoiding thoughts and feelings. A lot of people can fly under the radar in this way because when you envision someone who’s productive and a hard worker, you’re thinking, “Wow, this person really loves their job. They have so much time and so much energy. What a great work ethic.” You’re not thinking, “Hmm, I wonder if they’re sad.” That’s just not an afterthought in that scenario at all. So there can be some things really building under the surface.

Anger is another really common symptom for depression in this population, and it creates a pretty dangerous intersection, I think, because when someone’s angry  people don’t often want to be around them. It’s not pleasant to be around someone who’s irritable and easily agitated and always in a bad mood. Then you think about somebody who’s angry and then also depressed. They want to be alone and isolation feels good, but they also need that connection. So I think the anger just furthers the symptoms or makes things worse a lot of the time.

It ties back to that covertness as well. When someone’s angry, you might not initially jump to depression. You’re just like,” Wow, they woke up on the wrong side of the bed,” but a lot of times that can mean that there’s some pretty strong emotions building up under the surface. Spouses can be a really great resource in a clinical setting. They can provide a lot of insight into symptoms, mood and behavior changes. A lot of times they’re the first ones to notice some of these things popping up.

Increased substance abuse is also super common with depression and anxiety. We’re going to talk about substance abuse throughout this presentation. I honestly think it’s on every side, but alcohol misuse and abuse is pretty popular with this group, and it is really effective as well at masking negative thoughts and feelings.

Seventy percent of clients at the time of admission at the Center of Excellence meet criteria for generalized anxiety disorder. Dr. Morris, the medical director, talks a lot about seeing social anxiety as well. It’s pretty hard to meet criteria for social anxiety, and she estimated with me that about 40% meet that criteria, but maybe even a higher percentage is experiencing some of those symptoms. And I think for social anxiety, the general population, it’s like 7% meet criteria for that, so huge difference there.

Dr. Morris shared with me some advice on screening or starting the conversation for social anxiety with fire service members because if you ask them, “Are you anxious in social settings?” they probably will say no. She suggested asking questions like, “Do you feel like people can see through you?” or “Are you worried that someone’s going to be able to figure you out?” and typically, she says the answer is yes. It connects some dots or allows for some education around what social anxiety is and some coping mechanisms that can be developed there.

So now we’re going to talk about addiction, and alcohol is by far the number one abused substance in this population and at the Center of Excellence. You can see there that about 85% of fire fighters report having drank alcohol in the last month. That came from a study published in the Occupational Medicine Journal, and it’s not surprising, right? Because we all know how accessible alcohol is, and it’s very easy for it to become a filler activity on your days off.

The culture in the fire service in terms of alcohol can definitely reinforce the use of alcohol and maybe even reinforce coping with alcohol because what do people do when they want to go talk or build a closeness with someone? A lot of times that happens over a meal or at a bar over a drink or something like that, so it makes sense. I don’t think there’s malice or bad intention there, but you’ll see it at celebrations, you’ll see it for boredom, you see it to have fun, you use it when you’re sad. It’s just really easy to create an alcohol use habit.

And unfortunately too, in this population, abstinence isn’t really received too well, especially again, when all the social activities are surrounded around drinking it’s really hard to know how to behave in those situations. So if you’re someone that’s sober, do you really want to put yourself in a risky situation? Or, on the flip side of that, if your peer just recently got sober, do you really want to invite them out to the bar? How do you engage them? You have to be creative and really mindful of making those people still feel a part of the community or that brotherhood or that sisterhood.

Along those same lines, recently, I have heard of a lot of interest around the time that COVID started. I think if anyone can start this in your home, in your local area, this would be an amazing resource. It’s one of the biggest gaps that I see in terms of treatment when I’m doing my community outreach. If you want to talk more about that let’s connect offline so we’ve incorporated that. Beyond that, if you work with a client or if you’re a firefighter yourself, keep that in mind, that it can do crazy things to your nervous system and it can exacerbate  things like anxiety, which no one really wants to feel. It can also make you impatient.

Nicotine is also another problem and again, makes sense to me that it’s an easy habit to form. Despite all the calls, despite all the excitement and day-to-day responsibilities at the firehouse that we’ve already covered, there are lulls in a 24-hour period, and smoking can become a really easy thing to reach for when you’re bored. It makes sense that it’s also a huge problem because of the cancer risk involved, which is already a huge risk with this population because of the things that they’re exposed to like smoke and stuff like that, but that is a whole other topic. It’s just something that we see commonly at the center.

Prescription stimulants like Adderall, Ritalin, Vyvanse can also be over-prescribed with this group. Obviously there is a high level of trauma, which is the next side, and we’re going to talk about it in this population. Chronic stress from working 24-hour shifts can cause problems in concentration, memory, word finding, learning, all of which are ADHD symptoms. So these people are going to the doctor and expressing these symptoms, and then maybe they’re getting prescribed a stimulant and then they can’t sleep at night and then maybe they’re getting some sleeping medicine. So it starts to become this recipe for disaster if all the providers aren’t talking to each other.

Over-prescribing of opioids can also be a problem. This is a physical job. That’s a no brainer. There are going to be painful injuries, and pain medication definitely serves a purpose, but we also all know how addictive opioids can be, and unfortunately fire service members can become hooked on opioids just like anybody else. But unlike anyone else, firefighters are a very trusted group of people, and doctors want to help the helper. Maybe someone gets hooked on pain pills unintentionally or intentionally and then they are able to acquire those on a regular basis because they’re so trusted by their doctors that doctor shopping or things like that doesn’t have to necessarily take place. It can just be all prescribed, which again is very scary. It definitely reinforces the importance of providers talking to one another, so continuity of care is really good so everyone’s on the same page.

Okay, trauma. Fire service members are exposed to trauma on a regular basis as a part of their job, and at certain points it can definitely take its toll on someone. Exposure to chronic stress and trauma on a continual basis can make it much more difficult for the brain to process traumatic experiences or related symptoms. About 63% of new admits at the Center of Excellence meet criteria for PTSD, and I think that high percentage really speaks to how much need this population has in terms of quality, clinical care and strong social supports.

Just going to say a time-out right here for a second. I just noticed the time. It’s 10:53. I know we said that this was going to be an hour long. Or 10:53 my time. I’m in Colorado, 12:53 on the East Coast and we said this was going to be an hour. We’re just going to keep going. If you can stay, stay. If not, you can find this video recorded on our website. We’re also going to be hosting these at least once a month for the foreseeable future. So if you need to hop off, totally get it. If not, please stay with us. Okay. Time back in, okay.

So 63% of new admits at the Center meet criteria for PTSD, but with that being said, you have to think of trauma on a spectrum. These folks may be meeting criteria for posttraumatic stress disorder, but they also may be falling more into post traumatic stress injury. There’s kind of a blurry line there, but that’s the range that we’re seeing people at.

On the far left side of that spectrum is just general exposure, which is the nature of this job. There’s going to be some symptoms with that, but they’re not prolonged, they’re easily managed, they’re processed, and you just kind of move forward.

But now we’ll talk about symptoms and where it becomes a problem. On that same spectrum scale, in the injury to disorder, maybe more on the injury side, you might see some longer-lasting symptoms like skewed threat perceptions and hypervigilance, especially in public places. A common example I hear, and I’ll even hear fire fighters themselves making jokes about it, but they never have their back to the door, they always need to be able to see all the exits and the whole room. Sometimes they’re even cued into the people who are around them so they know what people are doing, or maybe even if they’re close enough, they can hear what people are saying. Hypervigilance and those types of quirks can be a telltale sign that maybe there’s some unresolved trauma taking place and they may need to talk to somebody. They might not be at full blown PTSD, but it might be a symptom that definitely needs to be checked.

Another point that I just want to drive home in regards to trauma is not every fire service member is going to develop PTSD. Not every fire service member is gonna develop an injury. It all has to do with coping, it has to do with connection, it has to do with your support. There’s a lot of contributing factors, but not everyone is going to suffer as a result of this job. We do have to be mindful that some people may, and it all goes back to you know, their genes and the environments that they grew up in and things that they experienced pre-fire world. So you can’t get into the space of judging other people based on the expression or their ability to process trauma. Just my little soap box there.

Alright, so since 63% of patients we’re treating at the Center fall into that injury disorder category, we’re teaching them about the brain and what cortisol dumps can do to the body. We’re explaining how their nervous systems are working in overdrive because their baseline is basically fight-or-flight mode all the time when they’re at work. Where we’re all down here, they’re all the way up here, just ready to go at a moment’s notice.

We’re also teaching them that when an alarm bell goes off at the station, it doesn’t matter if that call is to go save someone’s life or it ends up being a false alarm, the body is going to release a flood of stress hormones and chemicals that are really helpful in an emergency, and they’re really unhelpful if they get there and it’s a bogus call or you know, there’s not something to tend to. Then they have to go back to the station and they sit and they wait for the next alarm to go off or try to go back to sleep in the middle of the night and they have all of these chemicals swirling around in their bodies.

We’re trying to teach fire service members the importance of getting rid of that, whether it’s taking a walk or doing some deescalation techniques, some grounding, mindfulness, just trying to get back to that baseline or be able to get back to some level of peace of mind. In a clinical practice, that could be something to incorporate as well, whether it’s deep breathing or grounding, whatever it looks like. I think that could help or go a long way.

I mentioned earlier that I was going to talk about dispatchers. This is a huge problem for dispatchers as well, that cortisol dump. They have a really difficult job of sitting all day and listening to people who are committing suicide. They’re hearing gunshots on the phone, or they’re hearing people, you know, fight for their lives. They’re not hearing people calling them saying, “I’m having a great day. How are you?” They’re hearing the worst of the worst, and so their bodies naturally have this flood of hormones as well. They, just like people who are out in the field responding to these emergencies, need to get up, move around, and get that cortisol out of their body and de-escalate too. Something else to really keep in mind.

Oh. One more point here (sorry about that): substance abuse or misuse, another big symptom of PTSD. In fact, people who experience PTSD or have PTSD-related symptoms are twice as likely to misuse substances. Since we already know that alcohol is a big part of the culture, the risk is already there. Substance abuse or misuse definitely makes sense because again, it’s a super easy way to cover up or avoid emotional pain that can come with trauma. Those feelings like guilt and shame and anxiety, fear, depression? Alcohol does a really good job of helping you to forget about that, but then when you get sober, those feelings come back tenfold. It creates this nasty cycle.

Dr. Morris told me that oftentimes when she’s seeing someone for substance abuse at the Center, they are seemingly unaware of trauma symptoms. They’re not really talking about calls that they’ve seen or things that have been difficult for them to process or move forward from, and then they get sober and they’re able to see that, wow, these traumatic experiences are really driving this other behavior. There’s a super strong correlation there.

Moral injury is also another big thing with trauma that we’re seeing. It’s a lot of, “I should have done this,” “I could’ve done that,” “If I hadn’t have been here, then this wouldn’t have happened.” Just tons of rumination, and I think teaching how to change those perspectives is really important too in clinical work.

Symptoms related to trauma can also have a later onset. So similarly to getting sober, retirement can provide for a lot of opportunity to reflect on calls or memories and bring up a lot of things that maybe someone has been avoiding in the past, which makes sense because they also have a loss during this time and they’re no longer working and they don’t have all these protective factors at play. They’re losing that sense of connection, which is huge for trauma and depression and anxiety and substance abuse, so it all kind of plays together.

All right, now onto suicide. This is the last topic that we’re going to cover today, and it’s really where a lot of the behavioral health initiatives within the fire service started from.

Before I get started going into these different percentages and data that we’re seeing, I always like to mention that fire fighters, or fire service members in general, have those stereotypical or common characteristics of someone who in general is just more likely to attempt or complete suicide. They’re generally white, middle-aged working men with access to firearms. In terms of risk factors, they already have those, so it may exasperate some other things.

Fire service suicides are also really hard to track, but no doubt, we have started to notice that it’s happening more and more. People have to come together to try to figure out why and try to figure out what we can do. How can we prevent this from happening? You’ll see that 47% (just shy of half) of fire service members have suicidal ideation at least once in their career and almost 20% develop a plan and then 16% attempt. I’m getting tongue-tied with all these numbers. These are much higher than the general population. Only 6-14% of civilians experienced suicidal ideation, 4% develop a plan, and only 2-9% attempt. Really stark differences there.

There’s a lot  down here at the bottom, 93 on the job, or 103 firefighters died by suicide in 2017. That came out of a study with the Ruderman Family Foundation. They found that in that year, that was how many died by suicide (103) in addition to 93 job-related fatalities, so it shows you there is some difference.

There’s a lot of really great data and theories out there on why people go to suicide, but I think Dr. Thomas Joiner’s theory explains it best for this population. So Thomas Joiner is a psychologist who developed this theory on why people die by suicide after his father took his own life. He ended up doing some research and then wrote a book called Why People Die by Suicide. He didn’t understand why that happened to his father, and so he just kind of dug and dug and dug to figure out what was at play for him, and then that led him to do some research with other people too. He found these three things that most people had in common in terms of suicide. He then found that if you have all three of these, then you’re more likely to attempt or complete. We’re going to run through each one of these, and I’m going to give you some examples of how this can play out in the fire service just to kind of bring it full circle for you.

Number one, he found that the perception of being a burden to others is a huge risk factor for suicide. In the fire service this can come up a lot of times. In fire service, they’re the helper and they’re the rescuer. They won’t ever let you call them a hero, but I think that they are. To be in a position to feel like you are putting someone else or burdening someone else with your own problems, makes them feel very uncomfortable. Unfortunately there’s a lot of opportunity for them to feel this way, whether it’s because of an injury or financial strain or an illness, or maybe they made a mistake at work and somebody got hurt. Those could all be reasons why they feel like burdens, just to name a few.

Number two: a low sense of belonging. It was found that if someone had some sort of loss of connection and they felt like a burden to others, then that increased their risk for suicide. In terms of the fire service, retirement (I mean, in terms of everyone: retirement) it’s a growing population of people who are completing suicide. It could also come from the death of a family member or a spouse or a parent, it could come from feeling like you don’t have any friends. Again, that anger and depression intersection, or maybe you don’t have very high self-esteem. There’s a lot of different ways that someone could feel like they don’t belong.

Number three: desensitized to pain and death. That is an inherent nature of the fire service. They are seeing tragedy and they’re being exposed to death and other people’s pain every time they’re running a call or responding to some sort of emergency. So again, all three of these together, that’s a lot of times what leads someone to suicide.

Just thinking about all of that, if you can, it’s very easy to see this come up in someone’s life or you hear them talking about these three things, that should definitely be a warning sign for you.

So, moving forward, our goal today was to just give you some background information, provide some insight and plant some seeds for continued education, and really just to open the door for a lot of people out there on what the fire service culture is and how to work with them and build relationships with them. If you want to connect with your local department or if you’re a firefighter yourself and you want to connect with some clinicians, please reach out to me via email or by phone and we can start networking that way.

Peer support teams: they are huge, I briefly touched on them in this presentation, but they have a huge initiative and a huge stake in the behavioral health world. They want to be there for their members. They want to be proactive, they want to be preventative. They don’t want to have to have people go away to treatment. They want to develop coping skills. You know, they want to make the world better. So if you want to work with those folks, if you want to learn more about what they’re doing, please let me know.

I think all of that: ride alongs, peer support teams, continuing education,  just kind of thinking about all of these things as how we will change stigmas, not only in the fire service, but I think in the world as a whole. We’re going to keep doing this. We’re going to keep providing education with whoever. We’re going to keep talking about the fire service, we’re going to keep helping firefighters for as long as we can, and we just want you to join us in that. So again, we’re going to keep posting these videos, so stay tuned. Thank you for joining us. Please visit our website IAFFrecoverycenter.com for future training opportunities and recorded webinars.

Thank you for all you do.