Fire Service Behavioral Health

Sure. I am the director of the Center for Fire, Rescue and EMS Health Research, and I’ve been doing firefighter health research for about the last 10 or 15 years.

Grew up around it. My dad retired as a fire chief from Overland Park, right outside of Kansas City. Yeah, grew up with fire service family and then got into research and grad school with military, and then FEMA started funding, through their AFG grants, research on firefighters. And so I took the skills and the folks that I worked with and brought that to work in fire service.

Yeah.

A lot of it was tobacco control, starting out. Currently the team’s working on a DOD grant to look at PTSD treatments and active duty — empirically based treatments for active-duty military providers. Their use of those. Yeah. So, a little bit of everything. I pretty much like to just do research, so.

If it needs to be researched, I’m in.

I totally agree. And I think it’s amazing. I’m very excited about the increased interest in this topic. And I think it’s not by accident. I think there’s been a lot of concerted effort from top-down, bottom-up to increase the attention and awareness on behavioral health issues.

I think there’s been a lot of concerted effort from top-down, bottom-up to increase the attention and awareness on behavioral health issues.

And then I think the more we’ve seen the impact of behavioral health and not treating behavioral health issues or managing behavioral health, then we’ve seen more problems and the need becomes more evident. There’s more conversation about suicide. There’s been a lot of work, like IAFF did a lot of work around reducing stigma.

And I think that it’s working. I think now people are talking about it more. They’re more aware of it. And anytime I’m talking to folks about health and wellness needs, it’s always on the top of the list — cancer, cardiovascular disease, mental health. So, I think it’s amazing to see that shift.

I think there’s been a lot of progress. I’m cautiously optimistic. Oh, I’ve been told that I’m too Pollyannaish about stuff, but I do think that there’s — it’s been a huge growth area. I think there’s still more work to do. I think with everything that we see as we move along the way, we see more that can be done. Which you — which is what you want to — every step that you make progress, you realize, “Oh wait, then what’s the next step after that?”

But I think that there’s definitely a national conversation about it, which is amazing, but I think now it’s at the point where people are talking about it in firehouses. I think the peer support programs, the training resources that are out there — there’s definitely more funding at the national level.

But then I also see that being picked up, and people in states and regions are getting really creative about how they deploy these resources; how they build peer teams; how they support the fire service as a whole. And I think it’s awesome. I always think there’s more work to do, but I think with the stuff that has been developed, it’s just raised awareness about, OK, now — and now what?

It’s like the low-hanging fruit has been picked up, and now it’s like, oh wait, but also, and then what type of stuff, which is again, very exciting.

What was interesting about COVID, just to touch on that:

Quick nerd break. There was actually a study. I think Jeff Burgess’s team worked on it out of Arizona, and firefighters and EMS were more likely to get COVID, substantially more likely than other health care workers. And so then also the stress of taking that home, I mean, everyone talked about the frontline being in hospitals. Frontline was the people who picked you up at your door and took you to the hospital. And then even more, the “fronter-ist” line dispatch and all the like. So, I think the conversation is focused more around behavioral health. I’m optimistic about that, where it seems like it’s more comfortable to have as a conversation. I do think with some of the more specific — like seeking treatment beyond what can be taken care of with peer support — I think that is a kind of next step that we need to work on.

And I think you mentioned medication. I think people are hesitant with medication, so I think that’s a good next step, but I think there’s a normal curve. You have the people who were early adopters, who 30 years ago were sounding the horn for this, but I think we’re starting to get into the middle of the pack.

I think we’re starting to get where the vast majority of folks — you also have the outliers. I’ve heard people in circles that I love and respect who will say something that’s dismissive of someone’s mental health issues, and I’m like, wow, like that’s still out there even with really progressive folks. I think sometimes that gets lost.

And the other thing that you think is so exciting is that the conversation about behavioral health is now being integrated into the conversation about cancer and cardiovascular disease. Right?

… the conversation about behavioral health is now being integrated into the conversation about cancer and cardiovascular disease.

To talk about how that plays into risk for cancer, and then add sleep in on top of that.

So, you have interrupted sleep, challenges with sleep. Often related to behavioral health issues — like there’s no behavioral health issue, depression, anxiety, anything that’s not either affected by or affects sleep. And so, you look at that — and World Health Organization classified that as a carcinogen — you look at the interrupted sleep and the behavioral health issues and how that increases stress, how that increases inflammation in the body, all those types of things.

And then look at that relationship to the other. So now it’s also — not only is it on the bar with that, but it’s also contributing. And then how are those stresses contributing back and forth? If you look at the last 10 years and the work that’s been done and the progress that’s been made in the last decade on this topic nationally, yeah, you’re gonna have outliers, but this is a big deal.

Mm-hmm, I think that the resources that have built, like, I like the peer approach, and I love the peer approach. We’ve got some early data that’s really effective, like the — increasing the support and the feeling, like, the department can support you, and the people are competent to support. You have been an awesome thing. I think the challenge with that is it’s always been OK. Now then, what’s the warm handoff to someone who is a professional? If it goes beyond something that can be right.

Well, not everyone in the fire service needs to be in full-time therapy. I mean, I’m a huge fan, personally, of therapy. I don’t think everyone needs to be in it full time. But sometimes it’s at the point where you need some skills outside, and I think traditionally the fire service has relied on EAPs and contracts like that. And I do think the only thing worse than not sending someone to therapy when they need it or to get additional help when they need it is to send ’em to someone who’s not gonna do a good job at it. ’Cause then they’re turned off and shut down.

You, like, have the one shot to get them to buy into it. So, I think making sure that they’re culturally competent folks on the other end that are resources and trained, and it’s hard. I think the medication, which we mentioned earlier, in destigmatizing medication and helping people understand that you can be on medication. There’s a lot of medications you can be on that don’t affect your ability to do the job.

Well, I think it’s really easy to not realize how bad you feel. We’re horrible at monitoring our own mental health. Because that’s another thing. Like measuring, I’ve seen some assessments out there, and I think they do a good job of using validated measures. Like, “Where are you at?”; “Where are you tracking over time?” ’Cause we’re bad at assessing our own mental health and where we’re at.

So, I’ll share that I’ve struggled with anxiety and depression, and — and I’ve periodically been on medication for it. And it’s typically my sisters, ’cause of course, if my husband says it, I bite his head off, but one of my sisters will be like: “You’re not you. Like you need to,” and then I’m like, “OK, I need to step back and think about this.”

But I think that sometimes you don’t go from OK to not feeling OK. Typically, in 1 day it’s typically kinda like the slow downhill slide. And, so, I think you can get to the point. I’ve had people say to me, and I felt this myself, “Man, I forgot I could feel this good.”

Like I forgot that this is what life looks like when I’m not struggling with depression or when my chemicals are in balance. So, I think it gives you that where you get back to, and then it’s not necessarily a lifetime thing. When I think about where we need to go next, I think we do a bad job of supporting leaders in the fire service.

When I think about where we need to go next, I think we do a bad job of supporting leaders in the fire service.

I think the pure approach has been awesome for firefighters, but you also don’t wanna show weakness, you know, if you’re in a leadership position. You don’t wanna go to a new firefighter and go, “I’m really struggling.” And then, “Thanks, Chief, but we really need you to get back out there.”

Right. It’s a little bit like being a parent to be in one of those leadership positions — then where like you have to act sure. You have to act confident. You have to be, and you really do have the weight of everyone, whether it’s in a president of the union or, or fire chief at a department, like there’s a lot of weight on your shoulders, right.

To make sure that everything moves forward. So that’s another one that I think, now that we’ve taken care of the masses, we need to start going, “OK, this is an especially stressful position.” What do we need to do for these folks? Because they don’t have the peer support that the firefighters on the ground do.

So, I think those are the big things that I have.

And you are; it’s a very thankless job. Be in a leadership position. People are always like, oh, you’re not doing that. Or it could be done. Everything could always be done better, but it’s there. There’s not a ton of moments to like step out and just be like, gosh, you’re really killing it. Thank you for not screwing anything up today.

And keeping things moving. And I really appreciated my paycheck this month. All those things that go into running organizations. Yeah. So, I think that’s — I think those are some folks that we need to support a little bit better.

And then the suicide side, I mean, understanding risk, and you know, there’s debate. Is suicide at epidemic proportions in the fire service, or is it just mirroring the general population in terms of the fire service?

We see rates of alcohol use in our studies, and this has been amazingly consistent — the highest rate of binge drinking of any occupational group we found, like there was a study —

There was a study published on the military, not that long ago and made like headlines. Oh my God. It’s 40% or something like that. Yeah. We’re easily career and volunteer about 50% binge drinking in the last 30 years. Yeah.

Yeah. I think the fire service like lower rates of smoking — lower than the military — lower than general population. I think they’ve done a good job of saying this is not what we do. This is not who we are.

So, you brought up something that was interesting when you said people have their outside stuff and like marriages and bad marriages or a challenge like that, which I, yeah, absolutely everyone brings in their own pieces. But I also think being in the fire service changes who you are and what hits your radar.

My kind of standard example is, say you have a pediatric death, pull a dead baby out of a pool Friday afternoon, right. That’s heavy, especially if you have kids at home and all that; different things bother different people at different times for different reasons, but that’s a heavy thing. And then say, you forget your milk on the way home Saturday morning, like you walk in, and when your spouse is like: “I can’t believe you forgot the milk. This is an example of all things wrong in our relationship.” Like they don’t necessarily know that. They don’t have the weight of what happened yesterday. And I think it just takes up a mind space, even if it’s not a conscious mind space, it takes up a mind space. Do that work.

And you have to be able to compartmentalize it and pack it away. But milk this morning is not gonna make — you’re like: “I saw someone lose their kid last night. Let’s hang out and drink some coffee on the patio.”

So, my dad retired and then bought a company. He builds fire training towers now. And, so, he has a fairly large company. They do a lot of work. He employs a lot of people.

He was a different person as a fire chief because it was life and death stuff. It’s not life or death if someone’s training tower shows up on-site 5 days late; um, it is if someone shows up five minutes late. So, I think he was a different person when he was in the fire service than he is now. Like you could see his mind constantly working; there’s always a weight there. And I think it’s just different. And you’ve mentioned this before: it happens in your own backyard too. Right? So, you’re that.

So often too, I mean, one it’s socially acceptable to say, like, in that setting, to go: “Hey, we’re gonna meet up. Let’s meet at Johnny’s for drinks and dinner, or whatever.” It’s not socially acceptable necessarily to go, “Let’s go have coffee and talk about our feelings.”

But you do go to the bar and have — and talk about having — and talk about your feelings, but it’s not how — it’s not how you present that, and I think you’re absolutely right. People self-medicating with alcohol, but not recognizing it often. Right. And when we’d ask that question in qualitative work, the answer was obviously: “No, I don’t. I totally don’t do that.”

Now if I’ve had a hard day, I’ll go home and have a couple drinks. And I’m like, that is the definition of what I just asked you, but it was not. Yeah. It’s not, you realize.

No, because thinking of it that way also opens up this.

OK, then you gotta do something about it, right? And that’s scary too. If we have a project right now — a FEMA-funded research project on alcohol use — then it’s interesting. ’Cause one of the things — interventions for college students — to look at — norms and what do they think they are. Friends are drinking, mm-hmm, and then renorming it.

And being like, you think they’re all drinking all the time, but they’re not, and here’s the actual numbers. And, so, then people have this better self-regulation, ’cause they realize that they’re overestimating everyone else’s drinking. So, 1 of the early-on hypotheses was, “Could we use that with the fire service?”

No, because people know that they’re drinking a lot. They’re very accurate. Yes. About how much, yeah? Their colleagues are drinking, but their colleagues are just drinking a lot. And I, actually, am personally not one who thinks that it — we should advocate for no alcohol use. I don’t. Definitely not. But I do think we need to start thinking about that in terms of everything else.

… I do think we need to start thinking about that (alcohol) in terms of everything else.

And in terms of, if the crew is off duty and drinking a lot and volunteer fire service, they have to regulate that like even more, which is a challenge, but I think we need to start bringing it into the behavioral health conversation and the overall health conversation. So where —

Spots?

I think medication and really starting honest conversations about that. I think the leaders is a blind spot. Definitely treatments. What good treatments are. Yeah. I think that’s a — and what treatments are out there and then how do you find them? How do you know what might work for you? What might not work for you?

There are empirically validated treatments for the challenges that firefighters face. And I’ll say, like, for everyone, I think it’s challenging to find the right fit treatment wise, but we know that there are things that do work and how do you locate them? How do you access them? What questions do you ask a provider? All those types of things.

And that’s not really the way our system’s set up. Yeah. And our system is set up, like you go to a provider, and they tell you what they’re gonna do. But I think we need to start educating the fire service on, “Here’s some treatment options that we know work, particularly for what you’re struggling with.”

And, so, what are those treatment options? So EMDR eye movement, desensitization. So that in cognitive behavioral therapy, there’s some written exposure therapies. So really the exposure therapies were basically you retrain your brain. All of them are focused on taking the emotional response out of the memories of the brain.

And it really is the retraining — your brain retraining those pathways. So, I think those are definitely good ones. There are some talk therapies that are good, but we know that some of these more like practical move through that’s beyond just problem-solving stuff, mm-hmm, are effective. So, I think those are definitely—

I will be completely transparent that when I first started and I was in grad school, I was like, this seems ridiculous, but it really does make sense. So, some people use tapping, sometimes it’s a light, and there are different ways that they manage it.

But that idea being that you can’t really have 2 feelings at the same time. So, when you have a thought or you’re remembering a really traumatic event, you know, that feeling where you’re just washed — overwhelmed with emotion. If you’re concentrating on something else, you can’t really be overwhelmed with emotion, mm-hmm.

So, if you’re concentrating on whether it’s moving your eyes or tapping back and forth, it’s rewriting that script in your brain where it’s going through the experience, but then also replacing that feeling with a calmer — you’re doing a movement. You’re doing the tapping, or you’re doing whatever it is that the therapist recommends.

So, you’re purposely bringing things up that are issues. And it’s the same, like with exposure therapy, there’s some studies where you’ll list your worst exposures, worst to least traumatizing. And you’ll go through ’em either backwards or forwards. OK. And you basically talk through ’em until — basically talk the emotion out of it.

And so, I think any of those. Cognitive behavioral therapy is more focused on how do you take the cognitions that you have and the thoughts that you have, and either pair them with behaviors or change the thoughts to be more helpful? A lot of times people will get to the point with anxiety or panic that they catastrophize things.

And it’s really thinking through, OK, wait a minute. How logical is that? What am I telling behind what I’m thinking? Yeah.

It up. Well, some of it I think is even just the process of talking it out. So, I was a therapist for a while. That was my plan. And I said I would never do research.

And here I am, not doing clinical work, but doing research. But sometimes you would see people talk about things before you share it. It feels so heavy. I would have people who would come in, and they would have conversations with me, and you could feel the weight of the world on their shoulders. And then they would start talking about something.

And one of the things that we would learn as a therapist was just a — be there. And as they unpack, you’re not taking the weight from ’em, but you’re just watching them unpack it. And when they see that they take out like their worst, darkest, deepest secrets or whatever, which is not what everyone has to share in therapy.

But as they say these things, like I feel this, or I feel this is what I’m worried about, and you unpack it. And I always thought of it as unpacking a suitcase. Like you take it, and you lay it out, and then you realize it’s OK. That’s not that a bad. This horrible thing happened to me. And then once you talk through it, and someone else is: “OK. Yeah, that’s horrible. OK.” And then it loses its power, yeah, over you. Which is what I think is the beauty of therapy is. I think to be able to have those conversations, and then you pack it up, you take it back with you, right. Pack it back into the bag or pack back into the filing cabinet. But it’s just lighter once you do that.

Yeah, that — that.

Whatever it is. Yeah, it’s OK. If, ’cause some people said, “Well I’ve seen horrible things, and it doesn’t bother me.” And I’m like, that’s OK too.

OK, we got it. Another thing is, I think but — that we have to keep the message out, though. It doesn’t bother you today. You feel fine and that’s fine, but you have seen these horrible things, and it’s totally fine that you’re OK today. But if tomorrow you realize that you’re not OK or something comes back, or that’s fine too.

It doesn’t bother you today. You feel fine and that’s fine, but you have seen these horrible things, and it’s totally fine that you’re OK today. But if tomorrow you realize that you’re not OK or something comes back, that’s fine too.

Every day is a new day, and you might be OK today and tomorrow. This something might come back and bother you. And then what do you do? Because I’ve talked to a lot of people, especially after they retire. And I hear the same thing with ER physicians and ER nurses that you just get it all packed away.

Duh, it’s in the drawer. And then once they’re outta that setting, it’s like they’re mind — whew, OK, take a breath. But now it’s all still there. Yeah. Another blind spot. ’Cause I love that question. I think we don’t do a good job of defining what it is that we’re seeing in the fire service; we call it post-traumatic stress disorder.

We’re actually doing a project right now where we’re looking at developing or tailoring what’s being used in veterans and military groups within abbreviated treatment for nightmares and post-traumatic stress. And we’re starting with all these interviews. So, I’m like, what do we call it? Do we call it PTSD?

Do we call it PTSD? Do we call it PTSD? But when you really dig down and if you look at the measures, there’s everything from 25% of the population to 3% of the population are struggling with this. So, what is that? I don’t think it’s not that it’s not that, specifically, because most of the measures are diagnostic and statistical manual.

That is where they diagnose, you know, come up with a list of how you — how you file insurance, basically, was what it’s based on. Just aped complex trauma, which is typically repeated exposure to abuse or something like that, which I think is closer. But most of the measures, say, “Do you have nightmares about the traumatic event?” That criteria.

And criterion A is you’ve been exposed to something that is threatening to your life or the life of someone else. And there’s a big, you know, in the scientific community where you have to have criteria in A, and I’m like, by definition, the fire service you’re 1 week on the job before you’ve someone’s life threatened, mm-hmm, in a very major, traumatic way.

So, everyone’s like criteria in a check box, but people are not experiencing a memory of a thing. It’s really more. Your worst calls. Some people will explain, like we, in our early work where we did qualitative pieces around this as components of post-traumatic stress. Sometimes it’s nightmares, sometimes it’s flashback, but it’s not to the traumatic event.

It’s to this cumulation. Yeah. Yeah. It’s cumulative. And I just, from the scientific side, I think we don’t do a good job because it’s not, “What is the prevalence of PTSD?” It’s not necessarily prevalence. PTs, none of those names really capture it. Sure. So that’s another one that that’s on my professional bucket list.

I think we covered it.

So fun.