Understanding Stress First Aid in the Fire Service

Editor’s Note: The National Fallen Firefighters Foundation (NFFF) recently introduced a new Behavioral Health Model that changes the way the fire service assists firefighters on the path to healing following traumatic events. In his first article, Bill Carey addressed the after-action report (aka curbside critique) and how this well-known element of the job can be employed to help firefighters handle potentially distressing calls. Find it at http://tinyurl.com/July-AAR. In his second article, Carey addressed how these new approaches can help identify stress among the ranks without the stigma of “needing help,” as well as how to administer the newly developed Trauma Screening Questionnaire (TSQ) to determine if a referral to a behavioral health specialist is needed. Find it at http://tinyurl.com/August-AAR. In his third and final article in the series, Carey challenges what the fire service knows about traditional critical incident stress debriefing (CISD) and post-traumatic stress disorder (PTSD), and introduces the concept of Stress First Aid for fire and EMS personnel.  

Everyone feels stress. It’s a natural part of life–but one that can sometimes feel overwhelming. In short, stress is the body’s response to a condition or stimuli, usually through the sympathetic nervous system, and it triggers our flight-or-fight response. In other words, do we panic and run from the situation or do we face it head on?

In her presentation on Combat Stress First Aid at the NFFF Behavioral Health Conference, Patricia Watson, PhD, a senior education specialist with the National Center for PTSD, explained that there are two types of stress: necessary and toxic. As the military began recognizing these distinctions approximately seven years ago, its focus was to learn how to treat the toxic type of stress within their own culture.

The Marine Corps took this research even further, studying some of the associated social stigmas, how to cope with stress, and the distinction between bending and breaking with stress. Specifically, bending with stress means that while the situation experienced may cause disruption, the individual can still function well cognitively and without unhealthy effects afterward. Breaking with stress means the individual is unable to properly function cognitively and socially, and having difficulty adjusting after the stressor. The effects cause a breakdown of normal routines, and the individual may even take destructive steps to try and alleviate some problems.

Through their work, the Marines identified four causes of stress, ultimately labeling stress as an actual injury. Basically, they determined that stress is different than PTSD and that stress can have long-lasting damage if left untreated. Thus, much like the physical wounds resulting from an exploded IED, stress needs serious treatment as well.

How does this apply to the fire service? If the Marine Corps is willing to label stress as an actual injury and identify treatment options that work within its culture, I believe it is imperative that the fire service–a paramilitary culture itself–do the same in order to help firefighters deal with toxic stress in a healthy manner and without the associated prejudices of “needing help.”

What Is Stress First Aid?
Stress First Aid (SFA) for fire and EMS personnel is derived from the military’s Combat and Operational Stress First Aid (COSFA) program, and employs seven steps–the 7 Cs–to reduce the risk of more severe stress reactions:
–    Check
–    Coordinate
–    Cover
–    Calm
–    Connect
–    Competence
–    Confidence

Combined with  after-action reports (AARs) conducted after every call and following the Curbside Manner approach, SFA brings one-on-one or group interventions to safely deal with stress and move toward progressive recovery.

The 7 Cs work in a fluid delivery to break down stigmas and negative social elements associated with stress, and become the bridge–not the final solution–to wellness. Each “C” works in a manner that helps ensure safety, reduces risk of additional stress, and promotes returning to full function (see image).

A Sample Scenario
Let’s review a sample scenario of how this would work for fire and EMS personnel, using the Engine 3 firefighter from the previous article, “Leave the Baggage Behind.” It is important to note that this example is illustrative only of the SFA components. This is not a rigid guide and does not take into account individual department policies.

In the scenario, Firefighter Brown witnesses a young woman jump from a third-floor window at an apartment fire and land near his feet. As Firefighter Brown’s officer, you notice that he has been quieter than normal, he is not sleeping well, he suffers headaches, he seems distracted during drills and discussions in the firehouse, and he appears at times to be agitated and jumpy.

Recognizing that this was a dramatic incident for the young firefighter, you already reinforced positive realities by conducting an AAR on the scene. Further, you conducted an informal “hot wash” to see if Brown could react naturally, as a firefighter and witness to traumatic events (e.g, good interaction with coworkers, participates physically and verbally during drills or other times of instruction, offers positive non-verbal communication, able to sleep without interruption, no loss of appetite, following through on tasks in good time frame), but he’s still displaying symptoms of continued stress. The next step: applying the 7 Cs.

Step by Step
Check: Talk with Firefighter Brown in a quiet place. Let him know you are concerned about his behavior. Actively listen to him. Have him take the 10-question Trauma Screening Questionnaire (TSQ) and review his answers.

Coordinate: Contact your supervisor about Firefighter Brown and additional support. The supervisor may meet with Firefighter Brown directly, or they may begin setting up resources to help Firefighter Brown, if needed or required. Contacting the supervisor also prepares them to be alert if Firefighter Brown calls out sick, doesn’t show up for work or has more trouble while on duty. This is meant to allow all parties involved to be prepared and to reinforce peer support for Firefighter Brown in an affirming way.

Cover: Cover yourself so you’re in a safe environment. Discussions or meetings with Firefighter Brown should be held in private, of course, but also in a way and location that reaffirms peer support and reduces the stigma of seeking help. Offer to meet with him and a good friend; consider including another firefighter who has experienced similar troubles and dealt with them in a healthy manner. This creates a safe environment where Firefighter Brown will not feel that his is under attack but instead is placed under cover to heal.

Calm: Provide Firefighter Brown with the tools, techniques and information to safely and positively reduce his anxiety. Reassure him that your efforts are to help him and not discipline him or cause any negative stigma. Reducing anxiety helps support sleep and promotes better decision making.

Connect: Bring in additional support, such as a firefighter who has been through a similar situation, the senior person in the firehouse, the department chaplain or a physician. Support is related to better emotional wellbeing and recovery. It leads to normalizing reactions and experiences, and reminds us we are not alone.

Competence: Continue to have Firefighter Brown engaged in daily or shift activities. Focus on remaining on task and involved in his duties and firehouse activities. Encourage and praise positive behavior. Competence restores the ability to manage daily activities. It increases our trust in our capabilities.

Confidence: Note positive changes in Firefighter Brown’s mood, attitude, appearance and performance. Express your confidence in Firefighter Brown. Self-confidence improves post-trauma outcomes. This helps to reduce any stigma of asking and receiving help.

In Sum
Old methods of handling stress have changed. Civilian models have been proven to be ineffective in the military–and the fire service. Fortunately, the military’s progressive research into the unique stressors involved in combat operations have led to concepts and models that work well for the fire service as well.

We owe it to ourselves to recognize that stress is just as debilitating as a physical injury on the fireground, and we need to treat it with the same level or seriousness. This requires investing in the men and women you ride with. As such, research the behavioral health resources available and the referral processes at your department, and consider and how SFA could be introduced. The NFFF offers online information and training on the new components of Life Safety Initiative #13, and I encourage all firefighters and fire officers to look into these resources (http://flsi13.everyonegoeshome.com).

SFA is meant to be the connector between the AAR, Curbside Manner, the TSQ and reducing the stigma associated with dealing with stress. This model is designed to be flexible–not a cookie-cutter approach for dealing with stress. No departments should be doing SFA exactly as others do, as the dynamics involve much more than simply throwing a counselor at the problem or sending the firefighter off to “get better.” Instead, the new process is designed to recognize stress as an actual injury, use concepts that another high-risk profession deals with, and help foster a healthy path to wellness while eliminating social stigmas.