Apparatus Driving and Operations
INSTRUCTOR GUIDE
TOPIC: EMERGENCY SERVICES BEHAVIORAL HEALTH ISSUES
LEVEL OF INSTRUCTION: INTERACTIVE LECTURE
TIME REQUIRED: TWO TO THREE HOURS
MATERIALS: APPROPRIATE AUDIO-VISUAL MATERIALS
HANDOUTS
REFERENCES: Fire and Emergency Services Safety Officer, 2nd edition (2015)
International Fire Service Training Association
National Fire Protection Association: Standard on Fire Department Safety and Health Program (2013): Chapters 11 and 12
Firefighter Suicide and Mental Illness. Dr. Beth L. Murphy presentation at 2017 FDIC, Indianapolis, IN
National Fallen Firefighters Foundation Life Safety Initiative #13: Psychological Support
National Fallen Firefighters Foundation Stress First Aid
Firefighter Behavioral Health Alliance
Health & Wellness Guide for the Volunteer Fire and Emergency
Services (2009); U.S. Fire Administration
National Center for PTSD
among-emergency-personnel
rate.html
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PREPARATION:
MOTIVATION: By their very nature, firefighters and EMT’s are problem-solvers who feel rewarded for their actions on an emergency scene. But increasingly, these actions are cumulatively taking a toll on provider’s behavioral health.
OBJECTIVE (SPO): Participants will demonstrate a general knowledge of the mental health issues affecting the fire service, indicators of potential concerns, and corrective action options.
OVERVIEW: This drill is designed to highlight the job-related factors that could adversely affect the behavioral health of an individual responder with potential ripple effects throughout the department. It is intended as an awareness presentation only and is not intended to be an all-encompassing training program. Group interaction, with possible real-life experiences, should be encouraged by the facilitator/presenter. Finally, available resources for emergent actions and training should be presented.
EMERGENCY SERVICES BEHAVIORAL HEALTH
* Individual Member Issues
* Recognition of Symptoms
* Corrective Action Options
* Resources
EMERGENCY SERVICES BEHAVIORAL HEALTH ISSUES
SPO: The firefighter/EMT will demonstrate a general knowledge of the mental health issues affecting the fire service, indicators of potential concerns, and corrective action options.
EO 1-1 Identify the employee mental health issues that may affect members of the fire service.
EO 1-2 Identify the signs and symptoms related to mental health concerns.
EO 1-3 Identify corrective action options for addressing mental health issues.
EO 1-4 Identify resources available to Emergency Service agencies and personnel.
This drill should be conducted as an interactive session since anyone can have behavioral health issues and fellow personnel may be called upon to assist.
I. INDIVIDUAL MEMBER ISSUES (EO 1-1)
A. Physiological and Psychological Stress
1. More individual in nature and is created not only by work environment but also by total life experience
2. Job-related stressors as reported by firefighters in a recent survey:
a. Shift work involving irregular schedules
b. Lack of sleep or interrupted sleep cycles
c. Managerial or organizational problems
d. Inadequate equipment and insufficient resources
e. Exposure to hazardous or toxic environments
f. Polarized work environment (shifting from mundane tasks to emergency response)
g. Lack of control over day-to-day schedule
h. The need for rapid and precise decision-making
i. Having to convey tragic news
j. Exposure to extremes of heat and cold, physical exertion and carrying/wearing heavy Personal Protective Equipment
k. Long shifts with excessive call volume and little downtime
l. Added duties (firefighters performing EMS duties and vice-versa)
m. Personality conflicts with co-workers
n. Lack of job satisfaction
o. Concerns over promotions, layoffs, or retirement
p. Feelings of inadequacy
q. Fear of failure
r. Personal injury to self or co-workers
s. Death of co-worker or family member
t. Personal family problems
NOTE: Problems outside the department such as financial problems, drug or alcohol dependency, problems with children, and/or marital problems can adversely impact the firefighter’s ability to perform.
B. Impact on performance
1. May not be able to concentrate on work
2. Friction with co-workers and supervisors
3. Absenteeism or tardiness
4. Denial of a problem
5. Psychiatric symptoms
a. Depression
b. Sleep disturbances
c. Use of alcohol and/or medications
d. Anxiety disorders
ALL THE ABOVE MAY OCCUR CONCURRENTLY WHICH FURTHER EXACERBATES PROBLEMS
II. RECOGNITION OF SYMPTOMS (EO 1-2)
A. Signs and Symptoms of Stress
1. Firefighting (and by extension EMS) was chosen as the MOST stressful job of 2015
2. The ability to handle stress is contingent on the individual’s personal resiliency
3. Physical: headaches, diarrhea, indigestion, upset stomach, tiredness
4. Emotional: anxiety, irritability, sadness, inability to make decisions, obsessive thoughts, Fantasies or wishful thinking, tendency to withdraw or become isolated
5. Behavioral: lack of interest, sleep problems, clumsiness, overeating or other changes in eating habits, increased use of alcohol or other drugs
6. Job-related: change of performance, being argumentative, isolation, tardiness, excessive calling in "sick"
B. POSSIBLE RAMIFICATIONS OF STRESS
1. Physical Conditions
i. Studies prove that mental health factors are highly influential in the onset of physical conditions such as:
1. Obesity
2. Elevated cholesterol and/or triglycerides
3. Chronic musculoskeletal issues
4. Cardiovascular risk factors
a. Body mass index (BMI)
b. Systolic Hypertension
ii. Fatality rate of firefighters is 4.5 times greater than the national average for the general population
2. Critical Stress (CS)
i. CS defined as the stress we undergo either as a result of a single critical incident that had a significant impact on you, or the accumulation of stress over a period of time
ii. This stress has a strong emotional impact on providers, regardless of their years of service
iii. Recent survey of 4,022 responders showed that 86% experienced CS
iv. Stress highly influences the remainder of the areas covered in #3-#7 below
v. Affects the physiological condition of the individual
vi. Cardiac death, which is influenced by stress, accounts for 45% of all firefighter deaths
3. Depression
i. Illness, not a weakness
ii. May manifest differently in the emergency service population when compared to the general population. For example, increased irritability and sexually acting out as opposed to depressed mood and social withdrawal
iii. Risk factors include:
1. Relationship problems
2. Money problems
3. Pregnancy
4. Alcohol use
5. Loss of family member or work associate
4. Sleep Deprivation
i. Short-term issues
1. Decreased alertness
2. Memory impairment
3. Occupational injury
4. Driving accidents
ii. Long-term issues
1. Increased cardiovascular disease
2. Decreased immune system function
3. Obesity
5. Substance Abuse
i. Fire/Rescue personnel have much higher rate of alcohol usage than the general population (29 percent versus 5.5 percent for the general population)
ii. Other substances include prescription drugs, steroids and illicit drugs (marijuana, cocaine, opioids)
iii. U.S. Fire Administration estimates that as many as 10% of firefighters may be abusing drugs
iv. International Association of Fire Fighters estimates that 75% of total firefighter population in U.S. has used either drugs or alcohol
6. Post-Traumatic Stress Disorder (PTSD)
i. PTSD is a mental health problem that develops after experiencing or witnessing a life-threatening event such as the death of a child or a line-of-duty death or injury
ii. Problem increases if a responder knows or identifies with a victim, as well as very violent incidents
iii. It is normal to have:
1. Upsetting memories
2. Trouble sleeping
3. Feelings of edginess
4. Difficulty doing normal daily activities
iv. If symptoms DO NOT go away within a few months, you may have PTSD
v. Focus increased on this subject as a result of the events of 9/11/2000 and the Gulf Wars
vi. Studies show as many as 37 percent of firefighters may exhibit symptoms of PTSD
vii. Four types of PTSD
1. Reliving the Event
2. Avoiding situations that remind you of the event
3. Having more negative beliefs and feelings
4. Feeling keyed up (hyperarousal)
7. Suicide
i. A department is four times as likely to experience a suicide death of a member than a line-of-duty death (National Firefighters Foundation)
ii. Statistics specifically for firefighters are not well documented
1. 69 percent of U.S. fire service is volunteer, so complete records are often not available
2. Fire service affiliation is not usually linked to death certificate
3. Firefighter Behavioral Health Alliance confirms 360 fire service firefighter suicides between 2000 and 2013. The actual number is likely much higher
4. Survey (mentioned in CS section above) showed 37% had contemplated suicide and 6.6% had actual attempted to take their life. These rates are 10 times greater than the national average (CDC figures)
iii. Not discussed in the open or adequately treated
iv. Creates a perceived sign of weakness or carries a stigma
v. “Firefighters help others, they don’t need help”—therefore they don’t ask for help. 40% of study respondents had access to support but didn’t seek help
vi. Some sample comments from survey respondents:
1. “Fear of being fired. We’re not allowed CISM at our service”
2. “I asked for help and ended up losing my 22-year career”
3. “Asked for help and was laughed at”
4. “Was told to go back to work. Was told I signed up for it so deal with it”
5. “It wasn’t offered even though we all though it should be. One co-worker stated it didn’t even bother him. A different co-worked who heard about it made comments about me being ‘mentally fit enough to be on a truck’ because the kid’s death bothered me”
vii. Specific warning signs include:
1. Loss of ability to feel joy and pleasure
2. Sudden weight changes
3. Increased anger or irritability
4. Feeling fatigued, sluggish and physically drained
5. Thwarted belongingness (belief of being alone, isolated and not part of your family, friends or work)
6. Perception of being burdensome
7. Talking about suicide
8. Giving away possessions
9. Higher-risk symptoms
a. Derealization
b. Depersonalization
i. Event happening in slow motion
ii. Feel like you’re standing there watching it happen over and over
III. CORRECTIVE ACTION OPTIONS (EO 1-3)
A. National Fire Protection Association (NFPA) 1500 Requirements
Member Assistance Program and CISD; (ref; NFPA 1500 ch.11 and 12) The fire department shall provide a member assistance program [MAP] that identifies and assists members and their immediate families with substance abuse, stress, and personal problems that adversely affect fire department work performance. The wellness program shall provide health promotion activities that identify physical and mental health risk factors and shall provide education and counseling for the purpose of preventing health problems and enhancing overall well-being. The fire department shall establish a program designed to relieve the stress generated by an incident that could adversely affect the psychological and physical well-being of fire department members. The program shall be made available to members for incidents including but not limited to mass casualties, large life loss incidents, fatalities involving children, fatalities or injuries involving fire department members, and any other situations that affect the psychological and physical well-being of fire department members.
1. Member Assistance Program
a. Need for Employee Assistance
1) Levels of stress normally encountered by firefighters can result in dependence on tobacco products, abuse of alcohol or drugs, domestic violence, excessive gambling, and financial difficulties
2) Because it is often impossible for a fire department to provide professional counseling services to meet these needs and ensure complete confidentiality, an MAP often includes outside contract counselors to provide services
3) Company Officers must be aware of symptoms of alcoholism, drug abuse, and other types of abuse in order to provide direction and care as soon as possible
4) Studies indicate that as many as 80% of those individuals who receive counseling return to full productive status with workforce
5) MAPs can reduce cost of prolonged medical care and lost-time benefits
6) Standard provides for assistance to immediate family members through MAP
b. Counseling may include the use of Critical Incident Stress Debriefing (CISD) following a particular incident or one-on-one counseling using department, governmental, or private resources
c. CISM should be led by mental health professionals/clinical psychologists. Was never designed to be conducted by peers
d. Counseling should be provided not only to the firefighter but to others affected including family members because issues in the department may carry over into the home or issues in the home may affect the department
e. Psychotherapy: Two types—Cognitive Behavioral Therapy (CBT) where you learn skills to understand how trauma changed your thoughts and feelings, and Prolonged Exposure (PE) where you talk about your trauma repeatedly until memories are no longer upsetting
2. Provide Stress First Aid to all personnel
a. Developed by the National Fallen Firefighters Foundation
b. Seven core actions (overview)—
1) Check. This SFA core action involves paying attention to fellow crew members and colleagues, noting persistent or significant changes in behavior that may indicate elevated stress levels
2) Coordinate. There are two broad goals of this function:
a. Inform those who need to know
b. Obtain other sources of assistance or care
3) Cover. Reduce any immediate threats to safety that may result from an individual’s response to stress
4) Calm. Slow down and reduce stress reactions in the mind and body
5) Connect. Connect with someone they trust and feel safe with
6) Competence. Enhance and restore the loss of skills, abilities and coping mechanisms that have been depleted or lost
7) Confidence. Restoring individual’s hope and rebuilding realistic self-esteem
A. Encourage Support and a Change in the Culture
a. Have the tough conversation and “dare to intrude”
a. A supportive and encouraging environment can cut suicide contemplation rates in half and attempted suicides by 66%
b. Show compassion
c. Must be supportive, not punitive
d. Talk to all emergency responders early in their careers, and continually throughout, about the stress they will face in the course of doing their job
e. Support effectiveness is greater when the provider attends voluntarily versus instances where they are mandated to attend
f. A conscious decision needs to be made to make a positive change in the prevailing culture
g. In a profession that boasts that no brother or sister gets left behind, we don’t do a good job in supporting our fellow responders who are experiencing emotional and psychological vulnerability
h. Nobody needs special training to support their “brothers and sisters”
i. Listen when members of your department talk. Don’t turn a blind eye
B. Crisis Intervention Team
1. Use team as a resource for emergent situations
2. Use as a training resource for personnel
C. Implement a Behavioral Health Training (BHT) program in your department or region
1. One example is First Response Resiliency developed by Michael Marks, PhD and Philip Callahan, PhD
2. The First Response Resiliency curriculum focuses on 12 skills:
a. Goal setting
b. Nutrition
c. Exercise
d. Sleep
e. Relaxation
f. ABCs (activating events, beliefs and consequences)
g. Perspective
h. Self-defeating thoughts
i. Empathy
j. Wins and losses
k. Reaching out and
l. Social support
D. Create A Resource List Of Who’s Available Within Your Community or Region.
1. Counselors
2. Chaplains
E. Don’t Forget About Retirees
1. When you walk out the door all the issues and memories walk out with you. You don’t leave them at work
2. In retirement, there’s nothing left to drown them out
3. Sense of identity also lost—if you’re not a firefighter or paramedic anymore, who are you?
4. Creates a “Perfect Storm” for depression and other problems
IV. ADDITIONAL RESOURCES EO 1-4
1. Safe Call Now () 206-459-3020
2. Firestrong ()
3. National Suicide Prevention Lifeline () 800-273-TALK (8255)
4. National Fallen Firefighters Foundation ()
5. National Volunteer Fire Council ()
888-731-FIRE (3473)
6.
7.
8.
REVIEW: Emergency Service Personnel should remember:
* Individual Member Issues
* Recognition of Symptoms presenting in yourself and fellow providers
* Corrective Action Options available to you and your department
* Resources for emergencies and training opportunities
REMOTIVATION: The career experiences of firefighters and EMS personnel sometimes magnify the stresses and strains of everyday living. Additional demands of family and work can add up to an unhealthy mental environment. Before we know it the “walls are crumbing” around us, and we’re often the last one to notice. Good behavioral health is an ongoing process. As one clinician put it, “You may be looking for a quick fix [to behavioral problems], but there is no quick fix here” Dr. Richard Gist, Department of Preventative Medicine, Kansas City University. It is an on-going process that needs to continue throughout your career.
Remember, EVERYONE GOES HOME not only refers to physically, but mentally as well.
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