Guidance for developing a fire department behavioral health access program
2nd Alarm Project addresses how to operationalize culture change regarding behavioral health within the fire service
By John D. Dilks Jr., EdD, EFO, Dr. Kellie O’Dare, Dr. Joseph Herzog
Modern fire officers have at their disposal state-of-the-art tools, apparatus and tactics to overcome the largest and most complex fires and mass-causality incidents encountered. Firefighters have thermal imaging cameras and SCBA, allowing for safer entry for search and rescue. Yet, when firefighters face behavioral or emotional consequences from the repeated exposure to trauma experienced during these incidents, many fire service leaders do not have the resources they need to help.
It is incumbent upon fire departments to facilitate behavioral healthcare for their members, particularly as the fire service is now losing more personnel to death by suicide than line-of-duty activities. Unfortunately, the pathway to effective behavioral healthcare is often not clear for the 1,115,000 professional paid and professional volunteer fire service members. Further complicating matters: A stigma surrounding mental health services still pervades fire service culture, making it difficult to break down barriers to useful healthcare programs.
The good news is that emerging research may shed some insight into this issue and help guide fire service leadership so they can start building programs for accessible, confidential, evidence-based and sustainable behavioral healthcare programs. Further, programs exist to help fire departments develop meaningful programs that work to rewrite cultural norms.
Cultural leads to barriers to care
So, what is the fire service culture, and why is it slow to change?
Culture includes the behaviors, attitudes and beliefs shared with a group and conveyed to future members. Culture reflects the collective perception of right and wrong, good and bad, or desirable and undesirable behaviors and characteristics. For the fire service specifically, culture is rooted in a belief in firefighter bravery and the resultant community pride.
How, then, does culture relate to the perceived stigma surrounding help-seeking for mental health services? The leading concerns regarding stigma in the fire service relate to barriers to care surrounding behavioral healthcare. These barriers include not wanting a mental health problem to be on their medical records, feeling embarrassed or ashamed, believing the issues would get better by themselves, solving the problem by themselves, and worrying about work-related consequences.
What can fire chiefs do to address such barriers?
Building a behavioral health access program
Fire chiefs must start by asking themselves what concerns they have regarding their current organizational culture and what behaviors and mindsets must change to reduce mental health stigma. Further, they must consider what they would do to help their firefighters in need of mental health support.
NFPA 1500: Standard on Fire Department Occupational Safety, Health and Wellness Program requires organizations to provide counseling resources and programs to fire service members and families. In addition, the National Fallen Firefighters Foundation's Everyone Goes Home program has placed renewed emphasis on the importance of mental health programs as one of the 16 Firefighter Life Safety Initiatives, resulting in the "From EAP to BHAP" guide.
A behavioral health access program (BHAP) is a comprehensive and operationalized plan that specifies the services that members and families need. The NFPA standards provide guidance to departments for developing a BHAP, including requiring the minimum benefits of evidence-based assessment, basic counseling, and stress crisis intervention, which should be readily available to address, at a minimum, alcohol and other substance use, stress and anxiety, depression, and personal problems that may impact work performance. The standard also requires the BHAP provide sources of appropriate interventions for members who need more advanced or extensive levels of specialty care.
While this is all good, many fire departments struggle to know where to begin in the creation of such a program.
2nd Alarm Project framework
The 2nd Alarm Project, a collaboration of researchers from Florida Agricultural and Mechanical University and the University of West Florida, offers a leadership workshop to help fire chiefs build out their BHAP. (Note: The 2nd Alarm Project is funding through an SAMSHA grant, and there is no cost to any firefighters, departments, or organizations).
The 2nd Alarm Project has developed a framework from which organizations can begin to conceptualize and operationalize their BHAP. The framework considers the required elements outlined in NFPA 1500 and the NFFF guide. Further, the framework utilizes a pyramid approach to conceptualizing the necessary components of the BHAP. Each layer of the pyramid facilitates and supports the adjacent layers. In addition, the layers are flanked on each side by the crucial elements of policy development, planning and implementation, and research and evaluation.
The framework also suggests departments consider the following questions for each level of the pyramid:
- What policy or procedure must be established for each component?
- What resources are already available?
- How well is what we are doing working now? How do we know?
- Who can provide needed elements?
- How do we procure each component?
- How will we implement each component (resources, time, personnel, leadership supports)?
- How will we evaluate and monitor each component?
The first layer of the framework is its foundation: Education. Organizations should develop and deliver a variety of culturally relevant educational opportunities to all personnel regarding pertinent behavioral health topics.
When developing educational opportunities, departments should consider the target/intended population (e.g., new hires, newly promoted, retirees, command staff, AHJ appointed and elected officials, special populations, families), mode of delivery (e.g., traditional classroom, webinar, App, blended) and the topics covered (e.g., basic science of trauma, physiology of stress, leadership and culture change, mental wellness in retirement).
We strongly recommend that departments include all ranks and levels of service when considering the intended audience, including administrators in the municipality or Authority Having Jurisdiction in educational opportunities. Firefighters, officers, command staff and even AHJ-appointed and elected officials can benefit from having a standardized, first responder-relevant behavioral health curriculum. Several organizations have adopted a hazmat approach to developing a behavioral health curriculum, with courses designed for Awareness-level, Operations-level, and Technician-level achievements.
The next level up on the pyramid is peer support. This is the heart of any resilient organization, and a comprehensive BHAP is only as good as its peer support program. While peer support among firefighters is as old as the fire service itself, research indicates a strong correlation between formally trained peer support teams and attenuation of mental health concerns among members. In developing a peer support program, organizations should consider how they will train and select peers, clarify the roles and guidelines for team members, maintain support, and provide CEU opportunities for their teams.
Departments should also consider the role of critical incident stress management (CISM) and critical incident stress debriefing (CISD) and other deployable behavioral health resources, such as a clinician response team, along with developing their peer support programs. The 2nd Alarm Project strongly encourages departments to consider implementing evidence-based peer support training programs, such as those provided by the IAFF and the University of Central Florida Restores REACT program.
The top two layers of the pyramid represent access to care when a member needs services beyond education or peer support. Finding the right mental health provider can often be difficult, overwhelming and time-consuming. The 2nd Alarm Project advocates utilizing a behavioral health navigator (BHN) or embedded/integrated clinician model when possible to link members into the best fit services.
A BHN is a skilled mental health professional (typically a licensed, master’s-level provider) who can guide members through and around barriers in the complex mental health system. BHNs improve access to quality behavioral health services through integrated health practices. A BHN can provide an initial evidence-based assessment to a member and then facilitate linkages to appropriate levels of care within the community. The BHN can also work with the peer support team to vet local area providers to ensure seamless and efficient access to providers is available in routine, urgent, and crisis situations.
As education and peer support engage in increased outreach and awareness, organizations must be prepared to facilitate linkages between members and readily accessible and proficient providers at outpatient and inpatient/residential levels of care. Often, members encounter extended wait times, insurance plan denials and/or a limited number of providers, particularly those with experience and proficiency working with first responders when reaching out for services under an EAP or commercial insurance carrier. We strongly encourage organizations to thoroughly evaluate the accessibility, capacity, wait times, utilization data, proficiency with first responders, and member satisfaction with any providers included in the BHAP.
For inpatient and residential levels of care, to ensure the safety of our first responders and increase positive treatment outcomes, we strongly suggest that BHAPs work with providers to establish policies and procedures for managing members in crisis, including developing MOUs and partnerships with inpatient facilities for specialized intake (and transport if needed) for first responders.
Cultural change through BHAP
No one-size-fits-all behavioral health program will inherently improve mental health culture in the fire service, especially when firefighters are known to present with ideations different from the general public. Fire chiefs must start by creating a safe and open environment for communication regarding behavioral health issues. Further, they must create a mission and vision for a behavioral health program within their organization, including capacity building for peer support teams, inspiring ownership in caring for the behavioral health needs of their personnel, purposefully engaging with firefighters, and welcoming and encouraging difficult conversations regarding mental wellness in the fire service.
The culture and stigma seen within the fire service must start with meaningful change, and these changes must include guiding the new recruit in fire-safe activities, instilling at all ranks that it's OK to admit that they're not OK. Finally, fire chiefs must engage in these elements to support mission readiness, preserve the force, and improve the long-term health of all firefighters, from recruitment to retirement.
About the Authors
Division Chief John D Dilks Jr. (ret.), EdD, EFO, began his career in the early 1980s as a volunteer firefighter in central Florida. After serving as a security police officer in the U.S. Air Force, Dilks completed an associate degree in fire science and began a career with the Tallahassee (Florida) Fire Department. He ultimately achieved the rank of division chief of training before his retirement in 2013. Chief Dilks previously held an adjunct faculty position at Florida State University and served as program director for the Medical Response Unit, a collegiate EMS system. Dilks holds a bachelor’s degree in public administration, a master’s degree in emergency management, and a doctor of education in educational leadership and policy study from Florida State University. He is a graduate of the National Fire Academy’s Executive Fire Officer (EFO) program. Dilks currently serves as program coordinator of field operations for the 2nd Alarm Project.
Dr. Kellie O’Dare is an assistant professor of health policy and management with the Institute of Public Health at Florida A&M University. She holds a Ph.D. in social work from Florida State University, where she also earned both master of social work (MSW) and master in public administration (MPA) degrees. Dr. O’Dare is the spouse of a current professional firefighter, and is the niece of Shawn T. O’Dare, firefighter/paramedic killed in the line of duty in Miami-Dade County in 1985. O’Dare is the principal investigator and co-director for the 2nd Alarm Project.
Dr. Joseph Herzog is chair and professor in the Department of Social Work at the University of West Florida. He graduated with a master of social work (MSW) from Florida State University in 1992 and a Ph.D. from the University of South Carolina in 2008. From 1998 to 2008, Dr. Herzog worked as the clinical director at the Frasier Center, a nonprofit mental health center. His work at the Frasier Center with service members and their families led to his dissertation research on secondary trauma in military families. Dr. Herzog has since written 14 journal articles, seven book chapters, and co-authored the textbook “Social Work Practice with Military Populations.” Dr. Herzog is the co-director of Leadership Initiatives Lead at the 2nd Alarm Project.