Post-traumatic stress disorder (PTSD) has received heightened attention over the past several years – and discussions about the newer term, post-traumatic stress injury (PTSI), is a further indication of the fire service’s focus on providing more directed assistance for the myriad stressors they face on the job.
Chief Norvin Collins, fire chief of the San Juan Island (Washington) Fire District, has witnessed the growing attention over his 30 years in the industry – and has first-hand experience with the need to manage difficult experiences on the job: “As many can relate, there are specific incidents that occurred decades ago that I remember like it was yesterday. The smells, the sounds, the surroundings are crystal clear.”
FireRescue1 spoke to Chief Collins, who sits on the IAFC’s Volunteer & Combination Officers Section (VCOS) board, about the latest information about PTSD/PTSI, and how fire service leaders can support their members who are facing behavioral health struggles or even just have questions about reaching out to someone for guidance.
FireRescue1: Can you define or clarify the difference between PTSD and PTSI and how they may present in firefighters?
Chief Collins: The debate related to the difference between PTSD and PTSI can add to confusion of either the disease process of injury.
Simple definition of the two are as follows: PTSD is post-traumatic stress disorder, and PTSI is post-traumatic stress injury. The psychological definition comes from the American Psychological Association diagnosis manual (DSM-V). This definition of PTSD refers to a disorder. An emerging term, and one that some believe is more accurately descriptive, is PTSI. This definition of PTSI refers to a biological injury.
Emergency responders are exposed both to sentinel events as well as long-term, cumulative stressors. Whether a single event or a career of stressors, the presentation from a biological perspective is similar. Because of these similarities, the developing term of Cumulative Stress Overload is being used in the service. The VCOS Yellow Ribbon Report discusses these terms in greater detail.
For those who have not experienced it or understand its complexity, what is the best way to communicate to firefighters what PTSD involves and how it manifests in firefighters?
Breaking the social norms within the fire service can be difficult to say the least.
The stigma of weakness needs to be tackled first. Having open, honest conversations about how it is OK to feel the way firefighters do, and that it is natural, is a first step.
There must be an educational component. There is a difference between a sentinel event PTSD and cumulative effect PTSD. While a single event may not exist, the cumulative stressors over a career can cause the same manifestation of signs and symptoms.
Another way to help understand the complexity it is to share the education with others outside the service (i.e., significant others). While the individual firefighter may not see some of the signs or symptoms, others might.
Behavioral health issues, PTSD and suicide within the fire service have certainly become more visible topics at conferences and in media in recent years. Do you believe that the messages about these topics are reaching most firefighters, or are we just scratching the surface in terms of reach, awareness and acceptance of the depth of the issue?
The message is starting to get out, but there is a long way to go. The Yellow Ribbon Report has gone a long way with that education. That was always intended as a step to increase awareness, and now a compendium is being worked on as a second edition of the report that will add to actions to take and resources available to help with recognizing and coping with the effects of PTSD and PTSI. Acceptance is still a huge factor in the service, but progress is being made to take aware the stigma.
Can you describe some of the most common symptoms or signs?
There are several signs and symptoms associated with PTSD/PTSI. The following is a brief list of some of the more common ones:
- Reliving the incident
- Avoiding people, places or things that are reminders of the trauma
- Excessive arousal – increased alertness, anger, rage, hatred, difficulty focusing or sleeping
- Negative thoughts or feelings of guilt
- Flat affect
Can you tell me a bit about the Yellow Ribbon Report – its current status and what you’re working on for future changes?
The Yellow Ribbon Report was a first step by the VCOS to raise awareness surrounding the topic of mental health in the emergency services. The goal was to begin changing the culture to one where mental health is recognized and supported. We have too many providers who feel they have no one to turn to, and suicides are on the rise.
The VCOS wanted to change that trend. The report sets the foundation for education and offered resources to help if someone was having a difficult time with stressors. There is also a section for family members to recognize when their loved one needs support.
There have been multiple offerings where VCOS presenters conduct interactive classes on the report and include the IAFC Lavender Ribbon Report that covers cancer awareness. This has helped to change the culture and raise awareness.
The future holds a second report that aims to updated information on the Yellow Ribbon Report. We are currently working to add best practices for addressing mental health at the station and family levels. We are adding resources and contacts to begin helping and supporting those going through crisis. The VCOS added specific subject-matter experts as we update the report to maintain current or emerging guides. The experts include emergency responders, clinicians, researchers and acute/chronic critical-incident stress management (CISM) practitioners.
What is the first step a firefighter should take if they believe they are suffering from PTSD/PTSI?
The first step to take if an emergency responder believes they are suffering from PTSD/PTSI is to know they aren’t alone, and it is natural.
Many departments have access to employee assistance programs (EAP) that can help. If the department doesn’t have access, consider connecting with programs like Share the Load through the National Volunteer Fire Council (NVFC).
These programs can be intimidating to someone who isn’t sure what is going on in their head. I encourage starting early in developing a relationship with others in the department, like the chief or a company officer. Private companies also have in company resources like CISM-trained members to help debrief after an incident or ongoing stressor.
Bottom line: Talk to someone about your feelings. Repressing the feelings will increase the stress.
Do you have a personal experience with PTSD or PTSI that you would like to share?
I have been in the service long enough and exposed to a variety of incidents that it would be almost impossible for me not to have personal experience with PTSD/PTSI. In additional to personal experience, my daughter is following in my footsteps and is a “black cloud” like me [someone who seems to have a higher number of calls, with many of those calls being unique]. She is experiencing the effects at the early stages of her career.
Let me begin by describing what my daughter has been experiencing. She has been a volunteer firefighter and now a full-time EMT for a private ambulance company in a metropolitan area. Working a 911 response ambulance, she has a paramedic partner and responds in a dynamic area with fire ALS first response.
Her first response on the 911 ambulance was on a pedestrian struck on the freeway. They arrived and blocked the scene when an impatient person heading to work went around the ambulance and hit the person again directly in front of her and kept going. That wasn’t the end of it, though. She has had 14 cardiac arrests, including two pediatric arrests, multiple traumas, suicides, and two homicides over the past year. She has had so many incidents that the private company assigned a specific CISM person to her. I feel fortunate that I am here for her, yet I am glad she has outside support through her organization as well.
I have been in the industry for over 30 years in both the private and public sectors. I have seen the awareness and focus change over time regarding PTSD/PTSI. I would describe my personal experiences in the sentinel exposure as well as the cumulative effects.
As many can relate, there are specific incidents that occurred decades ago that I remember like it was yesterday. The smells, the sounds, the surroundings are crystal clear. All those feelings are present as I write this. I believed I have worked through the events well, yet it is still present.
The bigger realization for me is the cumulative effects of repeated exposures. As my knowledge of the body’s response to cumulative stressors grows, I can see times where I experience signs and symptoms. Because of my awareness, I can respond better to mitigate some of the effects.
Communicating, not only my family’s experiences but my peers and coworkers, is important to me because it is unacceptable to lose lives of emergency service responders to the effects of stressors. We all must continue to share knowledge, understanding and compassion surrounding mental health.
Do you believe that there is the potential for over-diagnosis of PTSD and, if so, whether this could hamper awareness or treatment efforts?
As with most things in life, there is always a possibility of the pendulum swinging too far to one side or another; however, with PTSD, a diagnosis means someone went for help. If the diagnosis demonstrates that it is OK to work through the stressors and have a longer career or stable retirement, that is a good thing.
Combating the stigma of mental health being a weakness is the end goal. There may come a time where an over-diagnosis is reality, but now is the time to change culture. Identify the signs and symptoms, get help and be mentally healthy.
What resources from the IAFC and other organizations do you recommend to help firefighters struggling with PTSD and PTSI?
There are many resources available to help emergency responders struggling. Here are some as starting points:
- The Chemistry of Stress
- IAFF Behavioral Health Program
- Psychological First Aid – Field Operations Guide (2nd Edition)
- National Alliance on Mental Illness
- National Fallen Firefighters Foundation (NFFF)
- National Volunteer Fire Council – Share the Load Program
- NFPA November 2016 Report “Firefighter Suicide and Behavioral Health are Becoming a Concern to the Fire Service” includes a comprehensive list of resources and links