PTSD 360: Size-up and Tactical Considerations

By Jeanna Setera Hopkins

Post-traumatic stress disorder (PTSD) is real and personal. PTSD related suicide took more firefighters in 2017 than line-of-duty deaths.(1) A comparison to our efforts on the fireground is appropriate. We are appropriately dumping water on this fire. We flow Critical Incident Stress Management (CISM) through the window to knock it down from the outside. We have a hoseline through the front door with counseling. We have the Suicide Prevention Hotline, Code 4, and Safe Call Now for Mayday responses. Some states are conducting a prefire planning with PTSD-presumptive legislation. It’s always good to get water on the fire, but we are forgetting the 360º size-up.

I recently walked a PTSD 360 fully bunked in standby. My husband and I are both firefighters with some time in. He was seeing a counselor for PTSD symptoms from cumulative exposures. The call that “put him over the edge” was not all that different from any of the others, but it required a second alarm. I am a Lieutenant. I established command. More fire, more resources, more water. He took time off on a work-related post-traumatic stress injury (PTSI). I took time off on dependent care. Two lines through the front door, deck gun, ladder pipe, big hole in the roof, and the fire wasn’t going out. 360 complete?

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I started my 360 from a unique perspective. I have listened to 25+ years of calls as a wife, friend, and fellow firefighter. I heard these stories in the shared context of his life experiences at home and work, anchored by my own 19 years of firefighting. Let’s continue to use the language of the fireground to address these issues. Following are some short reports from my 360:

• Scene safety: Accept that this is a real and potentially dangerous condition. Firefighters will deny injury and minimize the effect of our calls and stress. We fight being the patient. “We don’t call 911; we are 911.” Firefighters know the suicide questions and consequences causing many of us to “deny until we die.”
• Never go into a hazardous environment alone: We need our partners and crew before, during, and after our incidents. Check in. Don’t be afraid to show up…and stay. After a PTSI, have a designated person to help walk the injured member through the process. It can be overwhelming to simply make appointments and fill out forms.
• Give a positive short report: We remember traumatic events, stuff that happens all the time, and the last thing. Most of our memorable calls are bad. To combat this, when we greet the firefighter replacing us on duty, try to pass on something positive. After the standard information about the rig, share something good from one of your calls. It can take effort to find the positive spin. “We got the family photo” (from the devastating fire), “let me tell you something interesting I learned about this person” (who we picked up for umpteenth time this month). The entire ugly story is true, but trust me on this, it helps to say the positive out loud to the oncoming crew and share the good parts of our calls with our family when we get home. 
• Establish RIT early. Know how to access available resources before you need them. My husband had an established relationship with a therapist; a core group of my amazing firefighter friends and CISM team members were staged and responded to our mayday. I was trying to drag my husband out of a fire while I was low on air myself. ‘Buddy breathing’ got us out.
• Every fire is different: It may not be the “big” incident that gets you. We need to recognize our own triggers and support crew members who may have a uniquely personal and significant response to an incident.
• Overhaul is critical to prevent a rekindle: It takes time to recover from the fight/flight hormones following a bad call. Sometimes a few extra minutes or hours before returning to service is enough, but it may take days or months. We need to allow each other, and ourselves, adequate time. As with any injury, returning too soon can significantly extend recovery time.
• Control ventilation: Counseling is not always confidential. HIPPA laws don’t protect you if you file a work-related claim. This can allow unfettered employer access to counseling chart notes. Consider a “no note” counseling agreement.
• Basement fire: How we start our day. We talk about the impact of stress at home, lack of sleep, and prior personal trauma. What we don’t talk about is the impact of an unwelcoming or hostile work environment. Certain people and populations (under-represented groups, probationary, or “unique”) too often start work with higher levels of stress hormones because of bully behaviors that may or may not meet the legal definition of harassment. Their PTSD pump is primed prior to incidents. We need to put this out early.
• Attic fire: The analogy here is how we are treated after the call. Are we met with administrative support or betrayal? According to Dr. Ellen Kirschman, “Betrayal: The Hidden Driver of PTSD for Cops,” “administrative betrayal comes from a superior officer and constitutes both ‘sins’ of omission and commission. It makes everything worse.” (2)  I would like to add, from personal experience, that administrative support makes things better. A small act of support cuts that hole in the roof making it easier to move past the incident.

Initial PTSD/PTSI response tactics:

• Seek professional help and follow recommendations.
• Be there. Slow down and be patient.
• Shut out the noise. Don’t worry about what everybody else says or thinks.
• Take the time you need.

To: Safety Committee, Close Calls, Safety Chief, Company Officer, Every Firefighter

I used the fire analogy for a reason. We recognize the hazards of firefighting and the associated risk of injury and death. The 2017 statistics regarding PTSD-related suicide (most likely under-reported) provoke us to ask, “Where was the safety chief or the RIC/RIT?” Are PTSIs being reported to the safety committee? Where do we report PTSI close calls? We have training resources for legitimately important Mayday training, self-extrication, and air management. How do we keep from falling into the PTSD basement or having the PTSI roof collapse on us without adequate resources and training?

I was home for more than 30 days with my husband because of his PTSI. We spent lots of time talking, walking the dogs, resting, and talking. We talked about “the incident.” We talked about his calls, my calls, our experiences, and “the incident.” We found that, among other things, hostile attitudes and behaviors, how we framed the calls, and administrative betrayal or support were significant contributing factors to how these incidents were processed. When I returned to work, I was acutely aware of how these factors affected me as well. You got the short report; let’s talk tactics.

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PTSD Basement Fire Tactics

There are as many different types of basement fires as there are basements. They range from potentially dangerous to deadly. The same is true for how we treat each other in the fire service. It can be tradition or hazing, joking, hate speech, poor leadership, harassment, bully behaviors, or a hostile work environment. It’s all fun and games until somebody gets hurt. Fire culture that is unwelcoming or mean primes the PTSD pump and makes us less safe the minute we show up to work. If it is a pump can dryer fire or fully involved house fire, put this fire out!

Tactics

• Find the fire and communicate its location. You may not know that my family member is home on hospice when you keep complaining about the 2 a.m. personal service calls. I may not even realize how much your whining bothers me. I don’t know that one of my (not-so-funny) jokes is offensive or hurtful unless somebody tells me. It’s not fair if you don’t share.
• A little fire can create a lot of smoke. It can be as simple as sharing your story or giving people better words. Yes, words matter. You are not “worthless,” you are “priceless.” Simply be nice. We are a team; we win with positive relationships.
• If there are flames visible, call a full response and report illegal harassment, retaliation, and hostile work environments, per department protocol.
• Put the belittling basement fires out! Take out the legalese terms and it all boils down to “grown-up” bully behaviors. Mean does not have to be part of the fire department culture for us to have a good time at work. It’s literally killing us. Bullying is “intentional, hurtful and aggressive behavior that makes others feel uncomfortable, scared or upset.” We have the bully, the victim, and the bystanders. Like the fire triangle, take care of one and the fire goes out.

1. Write policies and enforce consequences for bully behaviors. Don’t be the bully.

2. Don’t be a victim. Call out the negative comments/behavior early to the person or a supervisor and suggest a better behavior to replace it; then let it go.

3. See it, stop it. According to Hawkins, Pepler, and Craig (3), bystanders intervened in bullying incidents only 19 percent of the time, but when they did step in — for example, by simply telling the bully to stop — bullying almost always ceased.

• Give compliments. We don’t need to get all sappy or pass out participation trophies to say thank you or recognize a job well done. Research by academics Emily Heaphy and Marcial Losada (4) examined 60 business leadership teams and found that the highest performing teams held a feedback ratio of 5.6 compliments for every criticism.
• Be inclusive and respectful. Our officers’ association sponsored some national guest speaker “leadership” presentations. Some of their stereotypes and comments distracted from the valuable information. I approached my fire chief with both the concern and a “fix.” Our guest speakers now receive a challenge coin and a letter that welcomes them into our vision of an inclusive culture. “Diversity is one of the five values identified in the Seattle Fire Department’s Strategic Plan: We respect the different identities, experiences, and perspectives of those that we work with and the community we serve.”
• Focus on the fix. Clear expectations and solid tactics give us a safe work space. We all want to live in a healthy firehouse.

PTSD Attic Fire Tactics

We think of the “bad call” as our injury. It is. However, if we feel administrative betrayal associated with the critical incident, we are reinjured. Like a second concussion in the same game, it can cause permanent damage. We can’t eliminate bad calls; it’s our job. We can, however, provide appropriate administrative support after the incident.

Tactics

• Don’t focus on the wheel chocks when somebody’s falling off the ladder.
• Sandwich the feedback. If there are strong criticisms associated with a critical incident, wait three days if possible. (It takes approximately 72 hours for the brain to process a traumatic event.) Then place the meat of the constructive criticism between two pieces of soft bread.

1. Show concern. “That was a tough call.” “How are you and your crew doing?”

2. Provide constructive criticism. “Good patient care at MCI, but you need to wear your safety vest.”

3. Offer support. “What can I do to provide resources and support?”

• Recognize that everybody at the critical incident was impacted. Officers will compartmentalize to run the call and take care of their members, but in doing so they may not recognize their personal response. Administrative support should be provided by somebody who was not involved with the incident.
• Welcome the injured firefighter back to work. If the doctor approves full or modified duty after a PTSI, don’t question the doctor’s recommendation. Provide the accommodations, support, and acceptance due all our brothers and sisters.
• Develop standard operating guidelines for administrative support of firefighters. We have them for everything else.

We recognize PTSD as a legitimate risk factor of our profession and are starting to address many of the mental health components. However, we will still burn the house down if we don’t create a more positive and inclusive culture to extinguish the belittling basement fire. The roof will collapse on us if we don’t articulate and employ solid tactics for firefighter support and extinguish the administrative attic fire.

It’s good to get some water on the PTSD fire. But we need to do a full 360 and get to the seat of the fire so we don’t keep injuring and killing firefighters.

REFERENCES

(1) Ruderman White Paper on Mental Health and Suicide of First Responders, April 2018

(2) Kirschman, Ellen. “Betrayal: The Hidden Driver of PTSD for Cops,” Psychology Today. June 25, 2018.

(3) Hawkins, Lynn. Pepler, Debra J. Craig, Wendy M. “Naturalistic Observations of Peer Interventions in Bullying.”

(4) Losada, Marcial. Heaphy, Emily. “The Role of Positivity and Connectivity in the Performance of Business Teams: A Nonlinear Dynamics Model.” February 1, 2004.

Jeanna Setera Hopkins has been serving with the Seattle Fire Department for 19 years and is a lieutenant on Engine 24. She taught high school science for 16 years prior to becoming a firefighter and has undergraduate degrees in biology and chemistry with a master’s in chemistry.