A New Consensus Approach to
Firefighter Behavioral Health
Urban Fire Forum, September 13, 2013, NFPA Headquarters, Quincy, MA
NFFF Everyone Goes Home® Project
• The best way to honor fallen firefighters is to reduce the
risks firefighters face in the performance of their duties
• Initiated in 2004 with National Summit in Tampa, Florida
• 200+ fire service leaders created strategies to meet bold
safety objectives
• Produced 16 Firefighter Life Safety Initiatives
• EGH Revisited, March 10, 11 and 12 – Tampa 2
16 Firefighter Life Safety Initiatives
1. Define and advocate the need for a cultural change within the fire
service relating to safety; incorporating leadership, management,
supervision, accountability and personal responsibility.
2. Enhance the personal and organizational accountability for health
and safety throughout the fire service.
3. Focus greater attention on the integration of risk management with
incident management at all levels, including strategic, tactical, and
planning responsibilities.
4. All firefighters must be empowered to stop unsafe practices.
5. Develop and implement national standards for training,
qualifications, and certification (including regular recertification)
that are equally applicable to all firefighters based on the duties
they are expected to perform.
6. Develop and implement national medical and physical fitness
standards that are equally applicable to all firefighters, based on
the duties they are expected to perform.
7. Create a national research agenda and data collection system that
relates to the initiatives.
8. Utilize available technology wherever it can produce higher levels of
health and safety.
9. Thoroughly investigate all firefighter fatalities, injuries, and near
misses.
10. Grant programs should support the implementation of safe
practices and/or mandate safe practices as an eligibility
requirement.
11. National standards for emergency response policies and procedures
should be developed and championed.
12. National protocols for response to violent incidents should be
developed and championed.
13. Firefighters and their families must have access to counseling and
psychological support.
14. Public education must receive more resources and be championed
as a critical fire and life safety program.
15. Advocacy must be strengthened for the enforcement of codes and
the installation of home fire sprinklers.
16. Safety must be a primary consideration in the design of apparatus
and equipment.
Firefighters and their families must have access to counseling and
psychological support.
Elements of FLSI 13 Strategic Plan
• Structured knowledge translation processes
• Consensus group model matching:
– Leading research groups in specific topic areas
– Subject matter experts in best practice domains
– Fire service constituency organizations
• Three working groups contributed to generating these
proposals
– Traumatic Exposures in the Workplace
– Member Assistance Programs
– Peer Support Practices
FLSI 13 Consensus Project
Research and Practice
National Center for PTSD
National Institute for Occupational
Health and Safety (CDC)
National Crime Victims Research and
Treatment Center (MUSC)
USUHS Center for Study of Traumatic
Stress
Employee Assistance Professional
Association
Firefighter Health Research Group
Fire Service
International Association of Fire Fighters
International Association of Fire Chiefs
National Volunteer Fire Council
National Fire Protection Association
National Association of EMS Physicians
North American Fire Training Directors
Curbside Manner:
Stress First Aid For
the Street
Peer
Support
No
Stress First Aid for
Fire and EMS
Personnel
After Action
Review
No
Trauma Screening
Behavioral Health
Questionnaire
Assistance Program
No
No
Cognitive
Behavioral
Therapy
Curbside Manner:
Stress First Aid for the Street
• For use by Fire-EMS personnel in service encounters
• Evidence supported best practice for immediate assistance
• Based on military Combat and Operational Stress First Aid
• Seamless delivery in performance of duties
Curbside Manner:
Stress First Aid for the Street
• Add an extra dimension of service and care
• Not just a “feel good” approach
• Based on 2 decades of research on what helps
people recover from crisis events
Objectives of Curbside Manner
•
•
•
•
•
•
Establish a respectful, helpful connection
Restore/support a sense of safety
Calm and orient distressed individuals
Connect to sources of social support
Improve ability to address critical needs/concerns
Help limit self-doubt and guilt
Curbside Manner Core Actions
1
Cover
2
Calm
3
Connect
4
Competence
5
Confidence
Available on the Fire Hero
Learning Network
• Online CE program
• CE package for download:
• PowerPoint (slides and video)
• Instructor Guide
• Student Manual
Military After Action Review (AAR)
• Backbone of the operational
culture
• Monitors capacity, enhances
capability, maintains
accountability
• Done at every level for every
operation—large or small,
simple or complex, critical or
routine
Advantages of AAR Hot Wash
• Meaningful mechanism for review/questions
• Supports on-going learning environment
• Focuses on professional impact
• Often relieves anxiety and uncertainty
• Permits safe transition into emotional
impacts if indicated
Foundation for Effective AAR:
The Unit Level “Hot Wash”
Five simple questions after every activity:
– What was our mission?
– What went well?
– What could have gone better?
– What might we have done differently?
– Who needs to know?
The best company officers have been doing this
for years . . .
• “Kitchen table review”
• “Tailboard critique”
• Informal firehouse learning is an honored
fire service tradition
AAR, like ICS, provides a way to ensure
a consistent, reliable benefit
Available on the Fire Hero
Learning Network
• Online CE program
• CE package for download:
– PowerPoint (slides and video)
– Instructor Guide
– Student Manual
• Support materials
Trauma Screening Questionnaire
Brewin, Rose, et al. (2002):
• Four to six weeks post impact
• Arousal and re-experiencing cardinal indicators
• Any six of ten symptoms endorsed as “twice or more in
past week”
• Those showing positively referred for full evaluation
• Specificity >.86; sensitivity >0.93
• Overall efficiency > 0.90
Available from the NFFF/EGH
• Print and electronic copies of TSQ
for download
• Pursuing funding to create apps to
assist individuals, family, coworkers,
and peer support personnel in
identification and referral
Behavioral Health Assistance Programs
• Impacts can be wide ranging
• Often brings other issues to surface
• Providing clear guidance, service standards,
and outcome expectations
Behavioral Health Assistance Programs
• First working group determined that
significant changes were required to ensure
that programs were able to deliver intended
outcomes
• EAP researchers and practitioners worked
with fire service organizations to identify
best practices and how to implement
• Specific desire to strengthen and clarify
Principal Needs from BHAP
•
•
•
•
Accessible resource for problems and issues
First point of access for assessment and referral
Consistency of model, service, and performance
Clear service objectives, treatment standards,
and outcome expectations
• Consensus recommendations for revisions to
NFPA 1500 (Chapter 11)
Available from the NFFF/EGH
• Model template for Fire Departments to
assist with developing Request for Proposals
• Examples for Scope of Work
• Help for vendors in using FLSI 13 resources to
built responsive BHAPs
When Clinical Intervention is Indicated
• Treatments typically used in routine counseling
are rarely effective
• Cognitive Behavior Therapy (CBT) with graded
exposure holds best evidence
• Not widely practiced at levels of care
ordinarily available to firefighters
• How can we help those who treat our
personnel acquire critical skills?
Helping-Heroes.org
•
Targeted at educating providers of treatment for
firefighters on evidence-based protocols for
behavioral activation, in-vivo & imaginal
exposure, & relaxation
•
10 education modules + 1 training & website
evaluation module
•
Each module contains pre- & post- knowledge
check questions, videos demonstrating application
of technique, & videos of answers to common
questions
Stress First Aid for Fire
and EMS Personnel
 We become most proficient at things we do
consistently
 We seek consistency where performance is
central to our values
 We default to those consistent practices
under duress and demand
Everyday use of CM-SFA for the Street
builds reliable, consistent skills
that provide the foundation for
structured peer support assistance
that reflects current
evidence supported best practice
Stress First Aid Principles
• Based on a careful review of the empirical literature
from many fields, as well as from the broad
experiences of experts involved in work on disasters,
terrorism, war and other mass casualty situations
• Stress First Aid was adapted from the Stress and
Combat Operational Stress First Aid model for Marines
Corps and Navy personnel
Functions of Stress First Aid
• Reduce the risk for stress reactions
• Monitor the stress of fire and recue personnel
• Recognize individuals who are reacting to a wide
range of stressors
• Provide a spectrum of one-on-one interventions
• Monitor progress of recovery
• Bridge individuals to higher levels of care as needed
Knowledge/Skills for Every Member
of Organization
• Recognize when a co-worker may have a stress injury
• Know how to break the code of silence that
surrounds stress injury
• Know at least 3 trusted support resources that could
be used to help a co-worker
Stress Continuum Model
READY
REACTING
INJURED
ILL
(Green)
(Yellow)
(Orange)
(Red)
DEFINITION

Optimal functioning

Adaptive growth

Wellness
FEATURES

At one’s best

Well trained and
prepared

In control

Physically, mentally, and
spiritually fit

Mission focused

Motivated

Calm and steady

Having fun

Behaving ethically
DEFINITION

Mild and transient
distress or impairment

Always goes away

Low risk
CAUSES

Any stressor
FEATURES

Feeling irritable, anxious,
or down

Loss of motivation

Loss of focus

Difficulty sleeping

Muscle tension or other
physical changes

Not having fun
DEFINITION

More severe and
persistent distress or
impairment

Leaves a scar

Higher risk
CAUSES

Life threat

Loss

Moral injury

Wear and tear
FEATURES

Loss of control

Panic, rage, or
depression

No longer feeling like
normal self

Excessive guilt, shame,
or blame
DEFINITION

Clinical mental disorder

Unhealed stress injury
causing life impairment
TYPES

PTSD

Depression

Anxiety

Substance abuse
FEATURES

Symptoms persist and
worsen over time

Severe distress or social
or occupational
impairment
Organizational Environment
• Fire Service personnel work as teams with leaders
• Chain of command
• Leaders can apply the principles of SFA to:
– Reduce unnecessary stress
– Recognize when an individual or unit has stress injuries
– Activate early resources based on need not event
SFA Provides a Framework
for Response
•
•
•
•
Flexible, multi-step process
Timely assessment
Peer and leader response to stress injury
Goals:
– Preserve life
– Prevent further harm
– Promote recovery
Available from the NFFF/EGH
• Awareness, Operations, and Technician
level training
• Regional Train the Trainer
• CE packages:
• PowerPoint
• Instructor Guide
• Student Materials
• Ongoing support
• Crisis assistance
Good News About Initiative 13 Model
Information presented is:
• Fully consistent with all elements of Chapter
11 (Behavioral Health Assistance Program)
and Chapter 12 (Occupational Exposure to
Atypically Stressful Events) of NFPA 1500
• Fully consistent with major authoritative
guidelines regarding response to potentially
traumatic events
Questions?
Thank You!