By Ed Sherman
Members of the emergency services professions frequently encounter and are called on to mitigate difficult and problematic situations. Firefighters are task- and action-oriented and train hard to be prepared to effectively resolve a wide gamut of crises and emergencies that may arise. However, in doing so, the emphasis historically has been on providing the needed services while paying minimal attention to the potential effects associated with exposure to what are now called “atypically stressful events.”1 Although those involved may or may not have discussed the events after the incident, assistance from trained peers or professionals often was not available or considered.
Jeffrey T. Mitchell, Ph.D. began writing about the need for crisis support for emergency services personnel in 1974 and subsequently developed critical incident stress debriefing (CISD). The use of CISD initially came to the attention of first responders when it was employed after significant incidents such as the 1982 Washington, D.C., Air Florida2 and 1986 Cerritos, California, Aeromexico aircraft crashes.3 Dr. Mitchell and Dr. George S. Everly Jr. enhanced and expanded CISD and other critical incident stress management (CISM) services. Other practitioners subsequently developed additional models and theories to help mitigate negative outcomes emergency services personnel experienced from exposure to stressful or traumatic events.4
CISD and other forms of psychological debriefings have achieved widespread acceptance and usage within the public safety professions. Other types of counseling services have also become more recognized and accepted over the years. They include employee assistance programs, the newer and more comprehensive behavioral health and wellness programs, and the use of staff or contract mental health professionals (MHPs). Taken together, these services, along with peer support programs, have become known as behavioral health programs (BHPs) or behavioral health assistance programs.5 Such programs can take many forms; they range from basic to comprehensive with services and resources offered in-house or by external providers. Although first responders have been said to be resistant to using counseling services,6 interest in and use of behavioral health services within the fire service have increased over time and have been discussed more frequently in recent years.
Importance and Value
The benefits and effectiveness of behavioral health services and interventions have been studied and discussed in professional journals and forums over time. Different studies have produced differing findings. It would not be reasonable to assume that any one service produces positive outcomes for all members of any group, including first responders. Nor would it be reasonable to presume that none could be helpful. But, many behavioral health services, whether peer support, psychological debriefings, psychotherapy, or other counseling services, have been found to ameliorate some of the negative or undesired effects emergency services workers have experienced from exposure to stressful and traumatic events.7-10
The important principle in behavioral health, as supported by the research, is that services and resources are made available after potentially or atypically stressful events. Since there may not be any one universally applicable solution for every person or situation, it would be practical and prudent to have a range of options available. As such, assistance can be scaled from peer-to-peer interactions to organized group interventions to therapeutic consultations. By having a variety of services and resources in place and accessible, different solutions for a variety of situations can be implemented as needed.
Failing to provide for these resources beforehand can complicate the aftermath of a traumatic situation: You will attempt to assemble them within an environment in which there is above-average stress. In addition, not being prepared can undermine confidence and cohesion within the organization and send a message, whether accurate or not, that there is a lack of institutional concern for members. In one study in which firefighters were asked their preference for the type of assistance they desired after incidents of varying levels of severity, the “no intervention” option was viewed unfavorably regardless of which scenario was presented.11
Creating a New Behavioral Health Program
Many fire departments may already have a BHP in place or have access to the elements of a BHP such as trained peers or a contract wellness program. Other agencies may have recognized the importance of behavioral health services but do not have any of the components available. Since it is advisable to have one or more MHPs to guide, oversee, and be available for consultation on behavioral health issues, it makes sense to consult a knowledgeable MHP or group when creating a program. It is highly recommended that providers of counseling services be trained and experienced in working with members of the emergency services.
As an aid to selecting appropriate BHP service providers, the National Fallen Firefighters Foundation’s Everyone Goes Home Program offers a helpful document entitled “From EAP to BHAP: A Guide for Fire Departments.”12 It provides an overview of the topic; key elements of National Fire Protection Association (NFPA) 1500, Standard on Fire Department Occupational Safety and Health Program, that relate to behavioral health; and suggestions for selecting mental health professionals, including samples of relevant paperwork.
Identifying Internal and External Resources
When setting up a BHP, poll current members of the agency to find out who is interested in or has had training that may be relevant to such a program. Some members may have taken classes related to peer support or debriefing, have education related to counseling, or simply have an interest in providing aid and assistance to their coworkers and are willing to help lay the groundwork for a BHP. Those members can help spread the word about the BHP program, may be able to assist with some of the preparatory steps in forming the program, and may be scheduled to begin attending peer support classes or training.
Also, there are MHPs who provide services to fire, rescue, and emergency medical service (EMS) agencies. They can be helpful in guiding you to devise the program, train and advise peer support members, and work with members. Ideally, the MHP should fully understand the functions, roles, activities, and needs of public safety professionals.
Fire Service Cultural Competency
Even with the best of intentions, not all MHPs will deliver the same quality of services. To be effective, MHPs need education, experience, and clinical supervision within the specialty of public safety psychology so that they fully understand and can properly assist fire service personnel. If a firefighter seeks assistance from an MHP and realizes that the counselor is not familiar or experienced with the profession, the firefighter may elect not to use the services because he feels that the practitioner cannot relate to, understand, or help him. The firefighter may share this opinion with colleagues, who may form negative impressions of a counselor or the BHP in general.
Fortunately, public safety psychology is a specialty within the counseling profession, and there are MHPs with the expertise to work with emergency services agencies and first responders. Check with other public safety agencies that have a BHP in place; ask who is providing the service and if the department is satisfied with the results. You could also perform an online search using terms such as “public safety counseling.” Also, as mentioned above, the NFFF document includes information about MHP selection.13
Evaluating an Existing BHP
The benefits of BHPs have been well-documented and continue to prove their value, but how can an agency know if its BHP is accessible and effective? The easiest and most direct way is to ask the people likely to use the services, your department members. Ask not only about the services of MHPs but also whether the agency is doing a good job of informing them about available BHP resources, the ease of accessing those resources, and the quality of the services offered.
If your agency has a comprehensive BHP but members are not aware of it, they won’t use the services. To be effective, the BHP should be active and ongoing—it should be explained not only on implementation but also be discussed periodically to sustain members’ awareness of the program. The discussions should be interactive and continually seek the input and feedback of the members about the program in general, specifically about its accessibility and quality, and whether any revisions are needed.
Obtaining Valid Feedback
There may be some drawbacks to having members participate in public discussions about the BHP. For example, those who seek or have used BHP services may hesitate to acknowledge this. They may be dealing with situations in their lives that are private or sensitive and may not wish to disclose this fact to other members or their superiors. Also, the culture in public safety agencies sometimes is less than supportive toward BHP services, which may inhibit some firefighters from discussing such matters. In addition, members who may want to share valid concerns about the resources offered may fear being identified as complainers or critics.
An alternate way to obtain member feedback is to anonymously survey department members (and their families) eligible for the services. Anonymous feedback also has limitations, such as submitting intentionally erroneous information; however, it is much more likely that those wanting to share their opinions will respond honestly. The survey can present open- and closed-ended questions, which would solicit responses from those who prefer to check boxes or provide ratings based on a numerical scale as well as those who want to give more detailed information.
Assessing Program Effectiveness
Effectiveness can be interpreted in various ways. You can rate a BHP’s effectiveness on personnel productivity, staff morale, or an economic cost/benefit analysis. However, the most important criterion should be if the program services are helping those for whom they are intended. The best sources of this information are the people who have used the services. MHPs would evaluate the program’s performance on its clinical efficacy—have the services mitigated psychological conditions or disorders? However, an evaluation of this complexity is not necessary to determine if the BHP is fundamentally beneficial. The department members who have used the services can answer this question. Ultimately, the consumers of the services should be satisfied with what is offered. Their evaluation of the BHP will determine whether it is used and, therefore, if it is a practical investment of the agency’s effort and money. Fortunately, if some aspects of the BHP are not working as desired, you can make improvements.
Even if a BHP is running well and receiving positive reviews, there may be enhancements that could make it more useful. For example, many good BHPs offer services to department members but not to family members. Since positive relationships at work and at home are important for maintaining wellness, it is beneficial to provide these services to significant others, children, and other close relatives. Even BHPs that are rated well by staff members may be improved through the addition of warranted changes or enhancements. Encouraging members to take an active role in evaluating the program is likely to promote involvement and participation.
References
1. National Fire Protection Association (NFPA). (2013). NFPA 1500, Standard on Fire Department Occupational Safety and Health Program. Quincy, MA.
2. Mitchell, J.T. (2015). Critical incident stress management (CISM): Group crisis intervention (5th Ed). Ellicott City, MD: International Critical Incident Stress Foundation.
3. Sherman, E.R. (1986, November). Aeromexico plane crash: Cerritos, California. Fire Engineering, 48-52.
4. Kinchin, D. (2007). A guide to psychological debriefing. London, UK: Jessica Kingsley Publishers.
5. NFPA 1500.
6. Shallcross, L. (2013, August). “First to respond, last to seek help.” Counseling Today. Retrieved from http://ct.counseling.org/2013/first-to-respond-last-to-seek-help.
7. Tuckey, M.R. & Scott, J.E. (2014). “Group critical incident debriefing with emergency services personnel: A randomized controlled trial.” Anxiety, Stress & Coping, 27, 38-54.
8. Garner, N., Baker, J., & Hagelgans, D. (2016). “The private traumas of first responders.” The Journal of Individual Psychology, 72, 168-185.
9. Fay, J., Kamena, M D., Benner, A., & Buscho, A. (2006). A residential milieu treatment approach for first-responder trauma. Traumatology, 12, 255-262.
10. Prati, G. & Pietrantoni, L. (2010). “The relation of perceived and received social support to mental health among first responders.” Journal of Community Psychology, 38, 403-417.
11. Jeanette, J.M. & Scoboria, A. (2008). “Firefighter preferences regarding post-incident intervention.” Work & Stress, 22, 314-326.
12. National Fallen Firefighters Foundation, Everyone Goes Home. (n.d.) From EAP to BHAP: A guide for fire departments. Retrieved from https://www.everyonegoeshome.com/wp-content/uploads/sites/2/2014/04/ EAPtoBHAP_Guide.pdf.
13. NFFF, Everyone Goes Home.
Ed Sherman, Psy.D., is a 40-year public safety veteran who has served as a firefighter, paramedic, and law enforcement officer. He holds a doctorate in clinical psychology, has performed research in firefighter safety and survival, and has been actively involved in critical incident stress management. He is a mental health clinician for The Counseling Team International in San Bernardino, California, and specializes in assisting public safety agencies and professionals.
