Roundtable: How to fix firefighter PTSD
This panel of firefighters and medics are not only experts in mental health, they've gone through PTSD; here's their take on the state of firefighter mental health and how to make it better
This feature is part of our Fire Chief Digital Edition, a quarterly supplement to FireChief.com that brings a sharpened focus to some of the most challenging topics facing fire chiefs and fire service leaders everywhere. To read all of the articles included in the Winter 2016 issue, click here.
Fire Chief: What are the key mental health issues for the fire service?
Dr. Will Brooks: The major mental health issues firefighters deal with are clinical depression and anxiety. Those would be the same issues for the general public. However, the reality of PTSD as a development from mainly job stressors has been raised in the past few years.
Depending on the source, the actual numbers of PTSD sufferers varies a great deal. The media have begun to highlight this issue, which may make the total severity seem higher than it is. This is never to suggest that PTSD does not exist, but to point to the need for more and better-designed research.
The impact of anxiety and depression on the firefighter and hence the job and home are clearly significant. If left unrecognized, increased intensity of either behavioral constellation can impair the firefighter, lead to family distress and workplace inability to perform well. In the worst case, suicide can be the outcome.
Leckey Harrison: I agree with Dr. Brooks. The other day I got a call from Camp Lejeune, one of the largest Marine bases in the U.S. I spoke with a woman from their behavioral and psychological health and TBI (traumatic brain injury) program. I asked what was new with them, because really, they're facing some of the same issues as the fire service. She said they're looking at traumatic brain injury. I don't know that we look at that so much in the field.
I look back at my 15 years of being a firefighter and EMT, and I didn't hit my head that much and only one ceiling collapsed on me. So the issues to me would be depression and post-traumatic stress disorder.
Where I think it affects the first responder the most is in the smaller communities. I've always served in small districts, and my experience is that because we're helpers, and because we're the one who answer the 911 call, we're going to hide the stuff. I mean, I did for years.
Part of it is you have to be willing to know. Everybody gets into this business, and they're young and might not understand all the symptomology surrounding mental issues. Unless somebody actually says, 'Hey, that might be such and such,' you're just thinking you're going nuts. So you're not going to say anything.
Nathalie Michaud: The main issue is the depression that often is misdiagnosed. You'll end up having the symptoms of anxiety, anguish, panic attack and so forth and a lot of general practitioners are very quick to say, 'This is depression, here is a pill and we'll try to help you sleep.'
In my experience, PTSD is basically a sleeping disorder. The more that you lack sleep, the more hyper vigilant you become and your brain basically becomes one big 911 switchboard.
If you have that one incident that really has an effect on you — that one incident within itself can cause just the post-traumatic stress without necessarily becoming the actual disorder. But then there are the cumulative effects throughout the years. The fact that we don't talk about it or that we're not asked about them, the cumulative effect becomes actually bigger, as if it was a huge incident.
My husband, who was my fire chief at the time, committed suicide because of undiagnosed PTSD in 2010. And unbeknownst to me, that created PTSD within me — not just because of what happened, but also because I found him. If I had known (about PTSD and the warning signs) — and had people around me that were also aware of it — most of my PTSD symptoms would probably have been addressed quicker.
Because it is a brain injury, your brain is just not functioning properly. It's been proven, and anybody that has read up on it can see it.
I'm not the only person that has gone through this. We're small communities and we do have a lot of firefighters that end up committing suicide. And they all do what my husband did; they go to a fire station and do it there. So there's always a firefighter that eventually finds them; that's never addressed with them and I find that extremely, extremely sad.
Dr. Will Brooks is a retired firefighter who lives in Lunenberg, Nova Scotia, and has many years of experience in the fields of clinical psychology and post-trauma where he's been an academic, a researcher, a debriefer, a supervisor for candidate psychologists and the chairman for several psychological association committees. He has written and given presentations on fire-fighters and critical incident stress.
Leckey Harrison makes his home in Langley, Wash., and is a certified trauma release specialist and post-traumatic growth facilitator. His passion is to train people suffering from PTSD in stress/trauma release and relief, knowing the difference and which tools to use.
Nathalie J. Michaud served as a master instructor and fire investigator with Québec Emergency Services and brings more than 15 years of experience as a paramedic, firefighter, fire prevention technician and fire investigator. She's also served more than 13 years with St. John's Ambulance including being a regional assistant director and provincial training team and master instructor.
Bree Nowacki lives in Oklahoma City. She works with the U.S. First Responders Association and is a writer and speaker on PTSD and first-responder mental health and hygiene issues. She is a master moulage artist who, prior to her retirement, was an EMT, a community relations officer for the OKC Police Department, a DHS and FEMA community relations expert, and a security technician analyst during mass disaster incidents. Bree is living with PTSD, a traumatic brain injury and multiple sclerosis.
Bree Nowacki: I am a PTSD survivor and I also have a traumatic brain injury and I live with multiple sclerosis. It's important to have pre-emptive care and support before issues such as PTSD, family-related issues or personal issues devolve into depression. We need a program in place from day one of the fire academy or EMS classes to begin learning healthy ways to deal with the stress of the job, personal life and at home.
If learning how to deal with this in a healthy approach is in place from the start, it becomes integrated into who the firefighter or EMT/paramedic becomes. If instead the lessons learned on the job are to 'suck it up, get over it,' or 'just be a man.' Then, when faced with these stressors, they will fail miserably and perhaps even leave their careers.
With this in mind, I contacted my EMS associates in the U.K. to ask them, 'If you could go back to the beginning and be taught healthy ways to deal with stress on the job and at home, do you think it would have better prepared you for the realities of the job?' Their responses seem to overwhelmingly agree that they were not prepared for the on-the-job stressors. But the ones who felt they handled it are the ones with solid home support, are married or have partners who are in the same or similar career field.
The key seems to provide a standard; it's not just one-hour in a class, but a continuing program with no stigma attached indicating that asking for help means you're weak — asking for help means you can't do this job. The idea of waiting until one serious event occurs and then giving support assistance, it's just not enough. It should already be in place.
And of all the responses I received, one that stands out the most is this: It's never the one big thing, which breaks it. It's that small and continuing stream of events, which cause hairline cracks in us until the last one causes us to snap.
Can we separate what is job-related and what is brought from their home life and other activities?
Harrison: The body responds to stress the same way whether it's stuff you do at home or stuff you do in the fire service. Where the difference lies is in a degree of vulgarity. We've already heard there's not necessarily the one event. If we come from a childhood that created developmental trauma, then you're talking about having the possibility of complex PTSD before you even became a firefighter.
And all of those little issues through your life all add up. Then it might be your third call and all of sudden you think, 'Oh no, my first fatality.' And that's what sends you over the edge.
Even watching movies can impact us — horror movies actually count on this. The brain is not going to say, 'Oh, it's only a horror movie; no big deal I guess I don't need to be on.' Just because your prefrontal cortex is saying, 'Well this is just a movie," your fight-or-flight system is already in action. I don't see that you can say this stress is from home or this stress is from my activities as a firefighter. What needs to be addressed is the willingness to say, 'Yeah, I do have issues at home and I do have these issues at work, and the two of them are working together.'
What I experience as a firefighter, I definitely take home. Every time my partner hears a siren, she says, 'I don't know whether you're coming home alive or not.' And that's stress for me and her.
I had this raging case of PTSD years ago. I then take that to the fire station and it's not like I'm going to walk in and say, 'Jeez, things really suck at home.' Although maybe if more of us did that more of us would say, 'Yeah, me too,' and we'd generate that discussion.
Michaud: We can definitely separate what is job-related and what is home. However, whether you're a firefighter, a medic, a nurse, a doctor or a police officer, what normally brings us into the emergency world is the need to help our fellow human beings. And we also normally have a very strong sense of justice. So anytime we're doing a type of job, including firefighting, that goes against justice it kind of plays with that.
At the same time, anything you experienced — your childhood, school, parents, bullying, I mean, you name it — creates the person that you are. Normally what we find in the emergency services are very strong-willed people who are in many cases hypersensitive. Now I understand a lot more about my personal PTSD. What I went through at home and my childhood, which was alcoholism and violence, made me the person that I became today.
Nowacki: Each person coming into the fire service has a history, which is pertinent to when they will break under the pressures of the job. It is about when, not if, they will break. One thing I understand about PTSD from my experience is it is not prejudice; it does not recognize skin color, income, whether you're male or female, how long you've been on the job. And it does not have any respect to when it will appear.
Dr. Brooks: The body reacts just as Leckey said; it doesn't care whether the stress is at home, in the fire station or part of an incident. I like to think about what are the stressors. You'll have certain stressors that are pretty clearly home stressors, and if you're trying to mitigate those as, you focus on those. If some of the stressors are fire station or incident related, then you try to focus on those. But the body's response is relatively the same.
What would do to address mental health or mental hygiene issues?
Nowacki: I kept hearing that a big key is the fire station family and the shifts that [the individual] are assigned to sets the tone that it's OK to ask for help. It's important to have something in place preemptively that is ongoing so it would take away the stigma of asking for help.
Harrison: One of them is training up front. We get a lot of training as EMTs and paramedics about what to do when we find trauma in the field, how to address this fractured bone, the ABCs and such. But what about taking care of us?
What happens when you come up on the scene and there's a decapitated child? There should be training up front about how we're going to deal with that, and not just after the call is over. So there's training, which would be at the academy level.
The other thing is a policy change. If you've been to an incident and there's a fatality or a severe injury involved, or the victim is somebody you knew, then you are required to speak to somebody (mental health professional, clergy, EAP).
That's where the prevention aspects come in because you've addressed the issue on the front end. So you have a policy that says, 'We know this is going to happen and this is what's going to happen when it does.' And then we give them training at that academy about the policy and how it's going to work. We don't wait for somebody to demonstrate a need [after the fact] because by then, I'm sorry, it's too late.
It sounds like the protocol police have where every instance of an officer-involved shooting is handled the same way.
Dr. Brooks: Even though our work with the military hasn't been a successful as we'd all like to see, there has been some attempt to take the [returning] group into a situation where they can get some — I would call it decompression. It's a beginning to getting back into civilian life, though there's still a huge gap.
I'm convinced that we need to have a built-in process. If you think about it, in firefighting how many times do we practice hooking up to a hydrant, or pulling hose, or doing any number of those things? And we do them all over and over and over again to develop competency. And then we're going to have a one-hour class on critical incident stress. Really?
Nowacki: It's an afterthought; mental health is an afterthought.
Dr. Brooks: But it's getting better don't you think, Bree?
Nowacki: Little by little it's getting better. There are more specialists and that makes a big difference.
Michaud: I agree that you begin with your new recruit. You need to give them the knowledge and the tools. The most important thing to bring them is the awareness that it does happen.
That's the first thing, but there has to be a follow-up within the actual fire services. You have to change the stigma. And to be able to do that, it starts with the firefighters and not the fire chief. Sadly, too many fire chiefs or other senior fire department leaders are from a generation that can be at times less than open-minded on this subject.
And if I look at volunteer departments, which is where the suicidal rate is much greater here in Quebec, people don't really talk. We should have the critical incident stress debriefing after pretty much any call, even if it lasts for five minutes.
After I went public in June  that I had PTSD, the city that I worked for said that I was a liability and I got fired because of my PTSD. So that really does not encourage any other firefighter or EMT to step forward and get help. In my department, there were two guys talking to me about what was going on with them. And now they just completely shut down because they're afraid for their jobs and their reputations. And of course my reputation is shot here because I'm known as a mental case.
We teach firefighters from day 1 how important their PPE is and the consequences if they don't use it. Is that a model for how to protect people from the mental health hazards?
Michaud: I agree completely. You show up on the scene of a fire and you're fully geared up, prepared and trained. You know you've done the same thing over and over again and you can pretty much do the job [blindfolded], but you can break a leg. You're out of commission. You can't do your job fully. Not because you don't want to, your body's just not physically capable.
And what are they (your bosses) going to do? They're going to assist you. You're going to get treatment, worker's compensation and/or insurance is going to help you pay your bills — and you're not going to get fired for breaking a leg on duty. You know you're going to get fixed up.
But because it's up here (your brain) and nobody sees it — nobody recognizes it. And even moreso for the person who's suffering from it the first time because it takes a while before they actually recognize, 'Oh my gosh. My brain is broke.'
Nowacki: We cover for ourselves and for others when we're having problems, and we all do a lot of that. You don't share it with the boss and you don't share it with others. Because there is the stigma and like Nathalie said, we accept physical injuries because we can see them, we know the person will heal.
But are we actually harming them? Maybe we're supposed to support each other; we're supposed to protect each other because we have to depend on each other. But what if we're hurting them worse because they're not getting help?
Michaud: I just wish that fire chiefs would talk to their firefighters and be open about PTSD. When I came out for the first time and said I've been diagnosed with PTSD, I was fortunate to find a person, Wayne Jasper, who went above and beyond.
He's across the country from me, so a lot of the times we were on Skype. And I spiraled downward to a very, very low point where I was drinking a lot and taking drugs. I was just trying to self-medicate and pretty much knock myself out every night so I could finally get rid of the nightmares and try to sleep a little bit.
It brought me to the point where I was sitting on train tracks. I was hoping that the damn train would show up, but it didn't. It's a good thing now, I realize.
I was very lucky to find a private center for first responders only and I accepted to go. It was my last chance. Wayne really held me. Had he not been there, honestly I'm not sure I would still be here.
Was there a critical factor in your relationship with Wayne?
Michaud: The friendship I had with Wayne and the comfort level, especially that he was asking me questions, was the key. For anybody stuck with PTSD, you don't necessarily want to talk about it, but you get asked some very personal and pointed questions. And people don't want to ask them because they're very afraid of making the other person uncomfortable. On the contrary, it made me feel better because it was like, 'Yes, I do want to talk about this. I just didn't know that I could. But now that you're asking the question, thank God I can talk about it.'
Any other coping techniques to share?
Harrison: I had a captain say to me, 'Before you get on that truck, and I don't care where you're going, you are going to take three deep breaths.' So one day, I began to move the truck and he said, 'Stop the truck. What did I tell you to do?' I'm drawing a blank because we're supposed to be responding on a call and he says, 'We're taking three deep breaths right now.'
It works and is one of the coping tools that we teach because it starts the downgrading of the sympathetic nervous system's response to stress.
Michaud: I'm going definitely with Leckey on the whole breathing thing. If you start doing that with your body, then whatever you're going through at the time with any external stimuli, your brain is going, 'OK, I'm cool with this.' So instead of absorbing the experience and panic, you're actually living it through with your brain going, 'OK. We need more oxygen. We're relaxed. We're good. We're safe. We're OK.'
And what often triggers post-traumatic stress is that your body is already clenched up and stressed out. Whether you like it or not, you're already on adrenaline. Any experience that you're getting, you’re absorbing and it's doing an imprint in your brain with that adrenaline all the way up, which augments the potential for a post-traumatic stress episode.
Michaud: I now have a PTSD service dog in training. He's eight-months-old and we've been together for about a month. And even though he's not fully trained yet, I sleep better. I'm actually taking walks on my own now, which I had stopped doing. Public places still suck. But, I can sleep better and I feel safe in my own home.
I know he's a false sense of security for my false sense of panic because a lot of the stuff I fear is nonexistent, but it's very real for me. The Citadel canine society helped me get my dog. They're the first association who help not only military, but first responders. I was actually their first guinea pig. Now there's police officers here in Quebec that are getting service dogs and more firefighters will be eligible to apply.