‘Are You Okay?’ Firefighters and Psychological Rehab

By Hirsch Wilson

Writing for National Volunteer Fire Council (NVFC)

Rehabilitation: the action of restoring someone to health or normal life…

I was sitting on the curb by the ambulance entrance to St. Vincent’s Hospital in Santa Fe, New Mexico. I must have been holding my head in my hands. An ED nurse just coming on duty asked me: “Are you okay?” Knowing the firefighter “code,” I said, “I’m fine.”

But I wasn’t. It was my third year as a firefighter-EMT. A mom of two kids had just died in our ambulance of a massive abdominal bleed, a bleed we had missed, a bleed we couldn’t have done anything about. A seat belt dissected her descending aorta in a motor vehicle collision (MVC). The kicker was I had told her kids that their mom was fine, and she would see them in the hospital. Then, she bled out and died right in front of us.

I felt unmoored for weeks; I couldn’t stop thinking about it. I dreamt about it and thought of quitting. (“I’m not tough enough to do this work.”) I was irritated and irritating.

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Looking back on it from three decades as a firefighter, now I can name what I was experiencing. It was a traumatic stress event (I’ll define that in a moment). I went into a month or so of what we now call “Acute Stress Disorder” and then, although the memory of that call stuck with me, the emotional baggage faded.

It helped that I had a department that instinctively knew what to do. We had a chief who took me out to lunch to talk about the call (and told me to not quit, don’t have an affair, don’t start drinking) and other firefighters who checked in on me.

As officers, our primary responsibility is the health and safety of our first responders. If they are physically and emotionally healthy and know they are part of a high-performing team, they can do amazing things under genuinely adverse conditions.

But the fact remains that this vocation is sometimes dangerous, often stressful, asks us to do things with little sleep (and we succumb to lousy nutrition). We are exposed to traumatic events that have the potential to affect our mental health. 

Our Mental Health

We have made great strides in recognizing the threat of cancer for firefighters. So, too, with focusing on cardiac health. It is now standard procedure to have rehab stations dealing with decontamination to remove carcinogens and paying strict attention to cardiac and heat-stress health.

But the next “frontier” is applying the same kind of care and expertise to the mental health of first responders when they are exposed to traumatic events.

The data to support this conclusion is staggering.

According to a study cited in Fire Engineering, more than 45 percent of firefighters have considered suicide, and 15 percent have attempted it. Deaths by suicide in 2018 exceeded line-of-duty deaths.

In a 2018 survey conducted by the International Association of Fire Fighters of 7,000 firefighters nationwide, respondents overwhelmingly reported “that stressful or traumatic experiences on the job have impacted their mental health. Among the struggles they say are directly connected to the job: 19 percent have had thoughts of suicide, 27 percent have struggled with substance abuse, 59 percent have experienced family and relationship problems, and 65 percent are haunted by memories of bad calls.”

We have a mental health crisis. There are broad policy and budgetary implications, but I want to focus on what we can do at the department level.

Before we dive into solutions, here are two ideas that have helped me understand what we are dealing with.

First, a working definition of traumatic stress is “extreme stress that overwhelms a person’s ability to cope.”

Second, traumatic stress is in the eye of the beholder. For example, a one-year volunteer EMT, seeing his or her first MVC fatality, might experience traumatic stress. To a veteran firefighter, it’s just another day at the office. 

Preparing for Traumatic Stress Events

1. Fire officers are not professional counselors. But we need a working knowledge of the signs and symptoms of traumatic stress and PTSD.
2. We need to recognize what are traumatic events (even though it is always in the eye of the beholder). For example, traumatic events could be trauma or death involving pediatric patients. They could be multiple casualty scenes, burn patients, line-of-duty deaths, suicides, or the death of someone known to department members.
3. As an officer, you probably have a list of resources, from backhoes to animal control. It’s essential to also have a list of mental health resources, from a chaplain to counselors and trauma specialists. (A note: It’s crucial that they are familiar with working with first responders.) Here is the list from the National Volunteer Fire Council (NVFC) of local behavioral health specialists.
4. Officers need to leave their assumptions about mental health, mental “illness,” and firefighter “invulnerability” at the door. Thirty-five years has taught me that very few are immune to the trauma we see. Invulnerability is a myth. The more important question is how we can help firefighters become more resilient.
5. Publicly acknowledge the issue. Talk about mental health issues and include those issues in trainings. Put up suicide awareness and post-traumatic stress disorder (PTSD) awareness posters. Post the phone numbers of suicide helplines and the Employee Assistance Program number. Access the NVFC’s Share the Load program. Make suicide awareness, understanding stress, resilience, and recognizing PTSD part of the department’s annual training curriculum.
6. Have the “talk.” A powerful tool is for a chief or senior firefighter to sit down with new firefighters and openly talk about trauma and the stress of the vocation. It’s crucial to hammer home that everyone experiences stress differently — there is no “one way” to feel. Next, emphasize that the department “has your back,” and the goal is to get you through your career physically and mentally healthy.
7. Set up a peer counseling program. The most potent early intervention tool is us. A career firefighter-paramedic, who regularly sees a counselor as part of her mental health regime, told me that once she sat down with her counselor and described a call she had had that week. The counselor — a professional — began to weep. The point is twofold. First, it is often hard for civilians to cope with what we see, and it is hard for us to talk to people outside the vocation about what we see. Often our best counselors are firefighters who have been there. It takes skill and training to be an effective peer counselor. There are all sorts of resources available to help departments (or a collection of departments) develop peer counseling programs. But informally, just the ability to sit down with another first responder and honestly talk about a call, or series of calls, can help re-orient perspective and, if needed, point a fellow firefighter towards clinical help.

 Psychological Rehab

As an officer, when you roll to a structure fire, on your checklist is setting up a rehab station. In the same way, when we roll up on what could be a traumatic and stressful call, we need to think about psychological rehab — we may not need it, but our job is to be prepared.

1. Debrief the call. Do a quick “tailboard” conversation. It doesn’t have to be long or emotionally draining. Just get a sense of how everyone is doing. Make sure you have eyes on everyone.
2. Follow up. Whether person to person, or by phone, text, or Zoom, make sure you touch base with everyone involved in the call.
3. Do you need a professionally run Critical Incident Stress Debriefing (CISD)? The data on the effectiveness of CISD is mixed, thus it is important that it is voluntary. Even without intervention, most people can resolve their symptoms within three months. But a CISD can help you identify individuals who may need more help.
4. Keep an eye out for different behavior. We had a young firefighter who had erratic attendance. We didn’t think much of it until we had a car fire in our district, and we found him in the car, using drugs. We got him out, and it turned out that he attempted suicide in our district so we would find him. (He survived.) Minor changes in behavior can be an indicator of more serious problems.
5. A chaplain is your friend. The chaplain has played a traditional role in the fire service. By tradition (and law in the United States), they cannot proselytize. When there are fatalities, a family losing their home in a fire, a line-of-duty death, or a first responder suicide, the chaplains are the ones who step in. They help manage the logistics of tragedy, the handling of chaos. This is crucial when shock and grief are overwhelming everyone, whether among civilians or in the department. 

Over the past decades, the workload of officers, both volunteer and career, has increased exponentially. (My one piece of advice is to delegate, delegate, delegate.) But the North Star for any officer is the health and safety of the people. We want them to be able to bounce back from tough calls and, most importantly, finish their careers mentally and physically healthy.

And finally, it is always okay to ask one of your firefighters: “Are you okay?”

Be Brave. Be Kind. Fight fires.

Author’s Note: I’d like to thank Chief Sean Daniels of the Mt. Lebanon Fire Department in Pittsburg, Pennsylvania; Mike Bucy, Fire Chief at Stevens County (WA) Fire Protection District #1; and Captain Faith Applewhite, Santa Fe City (NM) Fire Department, for help with this article.  

Hersch Wilson is the retired assistant chief of the Hondo Volunteer Fire Department in Santa Fe County, New Mexico. His latest book, Firefighter Zen: A Field Guide for Thriving in Tough Times, can be purchased at your local bookstore or online.