Implementing Posttrauma Programs
HEALTH AND SAFETY
Part two in a three-part series which will help you to implement and maintain an effective program before trauma strikes.
A posttrauma program, to be successful, must be supported from within the department by personnel at all levels. Without that support, the confidentiality, the willingness to discuss personal issues, and the full participation in training required to operate the program won’t be possible. How can this be accomplished?
Encourage participation. Give people decision-making positions in the program. Using an advisory council or some other group to spread responsibility for programrelated tasks will ensure that a large core group will have a stake in the program’s outcome.
Spread the word. Make sure that the people who are supportive of the posttrauma program are letting others know why that support is so important. “Cheerleaders” should be respected members of the department of various ranks and responsibilities.
Be consistent. It will be much easier to promote confidence in the program if deadlines are kept and policies are respected. For example, plans and announcements should be made only when an activity is ready to begin.
Find reasons to celebrate. Have a get-together to introduce the mental health professionals and formally announce the names of the peer supporters. Use the department newsletter or magazine to announce training sessions. Use every opportunity to keep the program in the spotlight.
Posttrauma program components
In the first part of the series, we briefly described the types of services necessary to create an adequate posttrauma response program. The best intervention is one that is relatively inexpensive, takes the minimal amount of the firefighter’s time, and reduces the probability of long-term psychological consequences. Duty-related trauma training, peer support, debriefing sessions, and posttrauma counseling are all components of this “continuum of care.” (The word “continuum” refers to the concept that not all those experiencing duty-related trauma require the same response.)
Posttrauma program components vary in cost and time. Training can be provided by a training officer or other staff person, and it’s relatively inexpensive compared to the cost of a mental health professional providing posttrauma counseling to an individual firefighter. If having a peer supporter make contact with personnel is all that’s required in a given situation, a more expensive intervention might be circumvented. In some situations, only posttrauma training and peer support will be necessary to prevent long-term problems.
Posttrauma training
The goals of posttrauma training are to prepare personnel for the normal psychological consequences of exposure to potentially traumatic incidents; to teach basic, after-the-incident coping skills; to assist in creating a supportive environment throughout the department; and to describe the components, procedures, and regulations of the posttrauma program.
Personnel at all ranks should receive no less than three hours of training that includes information on: the nature and definition of duty-related trauma and the identification of potential critical incidents in the fire service; the normal results of trauma after exposure to critical incidents; suggestions for recovery skills if dutyrelated trauma is experienced; and building support skills for firefighters.
Posttrauma training is somewhat different from other kinds of fire service training. Instructors should allow discussion of personal experiences and feelings rather than relying solely on lectures and materials. Firefighters not only learn important information about duty-related trauma, but also begin to discuss their feelings with others.
The mental health professionals who will be providing debriefing and counseling services should, if possible, participate in the training. This allows all personnel to meet and begin to interact with those who will be providing posttrauma services. Mental health workers will seem a little bit less like strangers during debriefings and posttrauma counseling if they’ve met with personnel during training sessions.
Since firefighters know the most about potentially traumatic calls, they’re the logical choice as peer supporters.
Although mental health professionals can participate, it’s possible for others to conduct the training. (A detailed outline of the training procedures and materials is available in the March and April 1988 INSTRUCTOGRAM, published by the International Society of Fire Service Instructors, or by contacting the authors.)
The more quickly all personnel can receive posttrauma training, the sooner the program can be fully implemented.
Peer support programs
The peer support component’s purpose is to ensure that all personnel involved in potentially traumatic incidents will receive the support and services necessary to make a successful recovery. Without individuals in the organization to monitor potentially traumatic calls, some incidents will certainly be overlooked. Those who know the most about the calls being run are firefighters, so they’re the logical peer supporters.
Peer supporters are not counselors. Their task is to contact their fellow emergency professional, remind him or her that others in the department are concerned about their welfare, allow them the opportunity to discuss the incident, assess the need for further posttrauma services, and remind the firefighter about productive coping skills taught in the training sessions. They may also participate in debriefings to assist mental health professionals.
Peer supporters act with the consultation and advice of the program’s mental health professionals and should receive about 20 hours of training from them. On occasion, a department asks for assistance from counseling services in developing a peer support program without professional backup. The rationale is usually financial: The department wants to save money.
A peer support group without professional backup is a very dangerous proposition. While not common, individuals experiencing the consequences of duty-related trauma may have severe depression and anxiety, and may even consider suicide. Even effective and trained peer supporters shouldn’t be expected to handle these difficult situations alone.
Peer supporters must be carefully selected and trained. The most important characteristic of peer supporters is the ability to maintain confidentiality. A peer supporter who — even once — shares information with others in the department can easily destroy a posttrauma program’s credibility.
Other selection criteria for peer supporters include:
personality style: Peer supporters should be the type of people others will feel comfortable talking to. It’s hard to define this quality, so it’s important to trust your instincts in making the selection;
listening ability: A major task of peer supporters is to listen to others talk about the traumatic event and their feelings. The listener must be able to hear and respond appropriately without interrupting. The ability to listen should exist to some extent before peer support training begins;
openness to new ideas: The whole concept of posttrauma services is based on the importance of understanding and talking about potentially traumatic events that have normal and inevitable consequences. These ideas are in opposition to the “macho” myths suggesting that personnel shouldn’t let anything bother them and that it’s their job to “tough it out.” Those who find it hard to accept these new ideas will find it difficult to complete their peer support tasks;
different ranks: Those involved in potentially traumatic incidents should have options concerning with whom they discuss their feelings. Some like the idea of the peer supporter being someone with higher rank. Others have said that they’d refuse to talk to an officer, crew chief, or supervisor. The inclusion of peer supporters of all ranks means that even the chief or director of an organization will have support available;
ability to follow through: potentially traumatic incidents may not occur in departments for some time after the program begins. This means that peer supporters may have to wait and continue in training for a period of time. Patience and the ability to follow through — do what they say they’ll do —is an important quality for a peer supporter to have.
The actual selection process can be accomplished in different ways. In some departments the chief simply chooses the peer supporters. It’s also possible to use a selection committee or have personnel nominate potential peer supporters. Remember, it’s not always the individuals who volunteer that make the best peer supporters. People may volunteer for this important position for many different reasons, some of which may not be helpful to the program.
Use the selection process that seems to best fit your situation. One chief gave those selected as peer supporters the opportunity to withdraw after the training. Many of those he chose weren’t sure about what peer supporters were actually going to do but gave it a try. Only those who were committed to and comfortable with the role of peer supporter actively participated in the program.
Peer supporters must not only understand the consequences of exposure to duty-related trauma, but must also have the skills to assess the need for debriefing and posttrauma counseling. They must also be able to effectively listen to personnel. Thus, the training of peer supporters should include basic information about duty-related trauma, listening and crisis intervention skills, methods for assessing the need for posttrauma counseling and debriefings, and working with mental health professionals as co-debriefers.
Peer supporters won’t feel 100% prepared after their initial training period and will benefit from continued training and regularly scheduled meetings. The content of and need for this training will be discussed in the last installment of this series. Peer supporters often find it helpful to discuss their contacts with personnel with mental health professionals.
Debriefings
Debriefings are carefully structured meetings which occur after a potentially traumatic incident. Dr. Chris Dunning of the University of Wisconsin at Milwaukee determined that there are two main types of debriefings, didactic and psychological. Didactic debriefings may include large numbers of personnel and focus on educating participants about posttrauma consequences and effective coping skills. Some who participate in didactic debriefings choose to seek the services of mental health professionals. Psychological debriefings, on the other hand, are designed for smaller groups of personnel (a maximum of 20) and focus on preventing long-term posttrauma consequences and the need for additional services.
It’s been our experience that the psychological debriefing is the more effective of the two (especially when part of a planned and coordinated posttrauma program), although there are some disadvantages. The main disadvantage of the psychological debriefing — the time it takes to detail and discuss the traumatic event, posttrauma consequences, and coping skills — also translates into its main strength. Psychological debriefings of three to five hours aren’t unusual. Most who participate in this type of debriefing need no further services other than a routine debriefing follow-up. Those who might require posttrauma counseling can easily be identified by the mental health professionals.
The most serious difficulty with the didactic debriefing is that it doesn’t allow all participants to discuss their personal experiences. Our posttrauma counseling experience with many other survivor groups — such as rape and other crime victims, automobile, home, and industrial accident survivors, and those experiencing sudden family losses — has shown the importance of each individual sharing his or her experience during a traumatic event and posttrauma consequences with one or a group of people. Didactic debriefings with large numbers of participants don’t allow such discussion.
Didactic debriefings also require personnel to determine for themselves if counseling is required. Since some individuals may deny the traumatic nature of the event or numb their feelings after an incident, they may not be aware that they might benefit from these services.
Finally, the mental health professionals conducting the didactic debriefing may have difficulty ensuring the psychological safety of all involved. When the didactic debriefing has many participants, it’s virtually impossible to monitor the responses of all involved. In particularly difficult incidents, posttrauma consequences can be quite severe and personnel should be monitored as closely as possible.
There’s no one way for mental health professionals to conduct psychological debriefings. There should be, however, discussion of ground rules and agenda for the debriefing (including confidentiality), description of each person’s experience of the incident, description of each person’s posttrauma consequences, and presentation of information concerning duty-related trauma (including coping skills for recovery, a contract for recovery, and time to discuss the debriefing and offer comments).
Talk to the mental health professionals about the debriefing process they plan to use to make sure it will work best for your department. Don’t hesitate to make suggestions, and ask for the rationale of various components. There should be logical and understandable reasons for each element.
Scheduling and arranging for debriefings must be planned before the incident so that the debriefing occurs within two to four days after the incident.
The following decisions must be made:
Who will make the final decision to plan and schedule a debriefing? Usually, this is a joint decision between peer supporters, mental health professionals, and administrators.
Who will be responsible for ensuring that all participants are notified of the debriefing and scheduling for coverage, if necessarv?
Where will the debriefing take place, and who will be responsible for preparing the site? The debriefing site should be away from other personnel and as comfortable as possible. Participants must not be on duty and radios should be shut off. Restrooms should be available; offer refreshments, if possible. Debriefing materials must also be prepared.
How will follow-up be ensured? The debriefing leaders and responsible administrators should plan the follow-up before the debriefing begins to make sure that the time and date are acceptable. All participants are required to attend the follow-up session.
Coordinating the debriefing component of the posttrauma program requires the most planning, and it’s important that all the details have been arranged before the first traumatic incident.
Posttrauma counseling
Very few firefighters who participate in a debriefing require further services in the form of counseling. Those who do generally require three to four sessions of special posttrauma counseling.
The mental health professionals leading the debriefing generally are the ones who recommend further counseling for a firefighter. Such a recommendation is made if: I) severe posttrauma consequences are reported; 2) there is evidence of serious levels of depression or suicidal ideas; or 3) some aspect of a firefighter’s participation in the debriefing has indicated that counseling would be helpful. Recommendations for counseling are made by the mental health professional either during breaks during the debriefing or after the session is over. All discussions of this type are confidential.
Counseling sessions are extensions of debriefings and include continued discussion of the traumatic event and posttrauma consequences. There’s a heavy focus on coping skills for reducing the probability of long-term posttrauma consequences. Posttrauma counseling sessions are different from many other kinds of counseling and psychotherapy in that they are almost exclusively oriented to the “here and now.” While some mental health professionals spend considerable time with clients discussing events in the distant past, those working with traumatized firefighters deal almost exclusively with the traumatic event and efforts toward recovery.
Confidentiality
Firefighters participating in posttrauma counseling are not mentally ill or “crazy.” Rather, for various reasons, they’ve experienced an event that’s quite traumatic and, as a result, will benefit from a longer period of support during their recovery period. All counseling sessions must be confidential. Any breach of confidentiality by administration or mental health professionals will seriously impair the program and the recovery of those involved.
There are two exceptions to confidentiality. If a firefighter is considered a risk for suicidal or homicidal behavior, mental health professionals must ensure the safety of all involved. Also, they must inform the appropriate officials if there is a genuine concern for the job performance of the individual. Serious impairment is a risk to firefighters and the public.
Other considerations
It’s important that program requirements and operations be described in the department’s policies and procedures manual. This legitimizes the functions of the program and describes the responsibilities of all personnel.
Some departments choose not to keep records of posttrauma program operations. Others require written reports of debriefing sessions to be submitted to administration. It’s best to clear the content of all written reports with those involved before submission, allowing areas of disagreement or discomfort to be rewritten.
In Part III of this series, the maintenance of posttrauma programs will be discussed. Since a department may go through periods with no incidents requiring the operation of the program, it’s critical that departments plan maintenance strategies along with the other program components.
