In a recent meeting with Dr. Richard Gist, assistant to the chief at Kansas City (Mo.) Fire Department and well-known expert on behavioral health in the fire service, he was explaining the shifting paradigm on how the fire service sees mental health.
For decades, behavioral health has been viewed as being similar to a heart attack — a catastrophic event that needs immediate attention and intervention to fix the problem. There are times this is true.
When a firefighter is actively suicidal, it is important to act immediately to ensure he or she doesn’t cause self harm. There are instances when a call or event, like a line-of-duty death, is so extreme that it leads to a clinically diagnosable case of PTSD specific to that event.
What the data suggests is more common in the fire service, however, are the behavioral health challenges that are more like hypertension — an accumulation of the effects of exposure to repeated trauma. It is the collection of memories of the worst calls that add up over time.
Hypertension is a symptom that can lead to a heart attack, similar to the way repeated exposure to trauma can lead to a catastrophic behavioral health event. Some people are more prone to hypertension the way some people have a harder time managing the impact of trauma.
It also is true that different events can effect two people on the same crew differently, and what effects one significantly does not necessarily effect the next firefighter the same way.
Under lock and key
In working in the area of behavioral health with firefighters, I have heard a lot of different perspectives and am always humbled when people choose to share their experiences.
Deputy Chief Jeff Grote of Central Jackson County Fire Protection District and 30-year veteran of the Kansas City (Mo.) Fire Department explained that firefighters handle the stress of the job by treating it as a room in their minds where they lock away the worst events.
He said firefighters know those memories are always there and are careful about when they open the door and who they allow to have the key.
His metaphor also speaks to the importance using of behavioral health providers who are well trained and sensitive to the job of first responders. Understanding the importance of educated providers has led to the development of trainings for employee assistance programs on how to work with firefighters, on explaining the job, and on effective coping techniques.
Other departments are seeking resources in their communities and identifying therapists who work well with first responders.
Fortunately, firefighters are generally a very resilient group. Dr. J.S. Lee and colleagues studied 552 Korean firefighters and found that resilience was able to buffer the negative impact of exposure to trauma.
Even data on rates of firefighter PTSD and depression, while often showing higher rates than the general population, are lower than one might expect given the job and that an average day for a firefighter can put them ring side to any range of death or destruction.
Long-term treatment approach
While fire and emergency services will always require people to be in harm’s way and exposed to tremendously stressful experiences, there are ways to effectively manage the stress.
Firefighters least likely to experience behavioral health issues are those who have strong social support from other firefighters, friends and family.
Viewing behavioral health as hypertension instead of as a heart attack — understanding it as a locked room that you always carry — also has implications for how firefighters manage the challenges.
Treatment for hypertension is a long-term process and involves a commitment to monitoring, appropriate treatment and dedicated health-promoting behaviors.
Similarly, effective management of behavioral health for firefighters needs to be a long-term commitment to being vigilant and aware of the symptoms of concern. That management must be both of self and others.
Firefighters should be taking their mental health blood pressure on a regular basis, paying attention to feelings of depression, changes in sleep patterns, increased anger, use of drugs or alcohol to manage stress, nightmares, difficulty concentrating or feeling tired and lethargic.
Possibly as important as self-monitoring is paying attention to changes in crew members and the work family.
Like the firefighters who are oblivious to their behaviors that feed hypertension, the downhill slide people experience is a slow progression that they aren’t aware of until the symptoms are heart-attack severe.
