Communities around the globe depend on firefighters. We rely on them for safety, crisis and medical intervention, and our general well-being. Firefighters are regularly exposed to critical and emergency situations (e.g., fires, natural disasters, crime scenes, medical emergencies), and thus represent a unique and resilient population faced with chronic stress and intense physical demands (Bowers et al., 2020). Firefighters operate in contexts of often chronic occupational stress, including sleep disturbance, and significant physical as well as emotional demands. Yet, research on firefighter behavioral health is in relatively early stages of development. Fire service agencies are just beginning to understand the implications of their work on the behavioral health of firefighters and their families (e.g., Zegel et al., in press).
Not surprisingly, given the stressful and potentially traumatic events encountered by firefighters on a regular basis, posttraumatic stress disorder (PTSD), substance use disorders (SUD) including alcohol use disorder (AUD), and emotional disorders (e.g., anxiety, depression) are prevalent (Bowers et al., 2020). Such mental health conditions are estimated to occur at higher rates among firefighters as compared to the general population, with the caveat that firefighters are exposed to sometimes exceptionally high levels of chronic occupational stress and potentially traumatic events. Suicide risk is elevated among firefighters (Bond & Anestis, 2023; Pennington et al., 2021), and recent data suggest that, among fire service personnel, deaths by suicide may be more prevalent than work-related injury deaths.
A multitude of evidence-based treatment options exist for the psychological symptomatology prevalent among firefighters (Gulliver et al., 2019). For example, programs, such as Stress First Aid, have been developed for firefighters and emergency medical services personnel (Watson et al., 2012) to quickly assess and respond to acute stress reactions in oneself or others. Critical incident stress management (CISM) includes various strategies (e.g., psychoeducation, debriefing) for harm reduction following stressful or potentially traumatic incidents; however, the empirical support for CISM is mixed with some studies suggesting it might be potentially harmful (e.g., Gist & Taylor, 2008; Johnson et al., 2020). Notably, few evidence-based interventions have been developed and evaluated specifically for the unique culture of the fire service. Transdiagnostic treatment approaches may be relevant if firefighters are presenting with multiple psychiatric diagnoses (e.g., Barlow et al., 2017; Meyer et al., 2022). For example, mindfulness-based interventions may be useful for concurrent management of stress- and/or pain-related conditions (Khoo et al., 2019; Shires et al., 2020; Vujanovic et al., 2022). Integrative PTSD/SUD treatments, such as Concurrent Treatment of PTSD/SUD with Prolonged Exposure (e.g., Back et al., 2014), may be indicated for those with co-occurring PTSD and SUD. Cognitive Processing Therapy or Prolonged Exposure Therapy for PTSD may be indicated for PTSD (Lewis et al., 2020). For AUD, harm reduction approaches that integrate relapse prevention skills may be indicated for some, given the role of alcohol use in fire culture; others may ultimately choose abstinence rather than controlled, safer use (Charlet & Heinz, 2017; Grant et al., 2017). Psychopharmacological intervention may be indicated in some circumstances and may require care coordination with primary care physicians or psychiatrists (Fraess-Phillips et al., 2017).
Increasingly, research indicates that fire culture is unique and ultimately may require culturally tailored interventions for optimally effective behavioral health care (e.g., Gulliver et al., 2019). Available interventions thus may need to be tailored to the specific needs of the fire service. Mental health stigma among firefighters presents a substantive barrier to treatment (Johnson et al., 2020). For example, most firefighters in the U.S. identify as cisgender male, heterosexual and white, and emotional and behavioral health struggles may be perceived as ‘weakness’ and thus stigmatized and shrouded in silence and experiential avoidance (Vujanovic & Tran, 2021). Indeed, stigma-related barriers to treatment, as compared to structural barriers, and the expectation of negative outcomes from treatment engagement are identified commonly by firefighters (Hom et al., 2016; Meyer et al., 2019). Shame and reputation concerns are cited as more robust predictors of treatment utilization than pragmatic barriers, such as scheduling or cost (e.g., Hom et al., 2016). However, pragmatic issues such as shift work, sometimes managing multiple jobs and long commutes, and limited health insurance coverage also seem to pose barriers to treatment access or maintenance for some firefighters. Indeed, firefighters in rural and/or volunteer positions are especially at risk of being impacted by such pragmatic barriers (Johnson et al., 2020; Meyer et al., 2019).
In clinical contexts, at least two key considerations are important for mental health professionals to consider when working with firefighters (Vujanovic & Tran, 2021). First, to address pragmatic barriers, providers should consider teletherapy options (e.g., video, telephone), after-hours or weekend care, structured peer support and family involvement (e.g., couples therapy). Transparent communication about fees, health insurance coverage for mental health services and scheduling are important from the outset. Firefighters may be more likely to cancel at the last minute due to work-related duties and crises, and a clear framework for cancellations and tardiness is important. Relatedly, clarifying limits to confidentiality early and often is important so that firefighters understand the parameters and legal standards in place to protect their personal health information especially if care is provided in an occupational context. This careful orientation to confidentiality and its limits is intended to avoid unexpected circumstances in which the firefighter might feel shamed or surprised when the clinician must initiate crisis management protocols (e.g., police wellness checks, psychiatric inpatient care) to reduce safety risks. Assessment of suicide risk and its significant correlates (Henderson, 2022), such as interpersonal disconnection, perceived burdensomeness and firearm ownership and storage (Stanley et al., in press), are highly relevant to developing comprehensive crisis response plans.
Second, firefighters might find it difficult to relate to mental health professionals. Unfortunately, most mental health professionals are not trained in fire service culture and services provision. In some instances, connecting firefighters to peer support programs may be effective. One-on-one meetings or workshops, led by firefighter peers, have demonstrated promise, and peer support can offer an effective collaborative partnership with mental health professionals (Bowers et al., 2020) and a useful direction for the future of firefighter behavioral health. The development of self-help resources and firefighter self-assessment tools, online or via apps, may also enhance dissemination of evidence-based information, assessment and treatment to firefighter agencies (Vujanovic & Tran, 2021). Continuing education on mental health related topics can further target stigma and bridge the gap between firefighters and effective mental health services (Isaac & Buchanan, 2021). As part of this effort, increasing engagement in conversations, from the command staff and through the ranks, about mental health can be effective in promoting awareness and improving service initiation, engagement and maintenance. Attention to especially vulnerable groups within the fire service, such as women, individuals who identify as LGBTQ+ and individuals from racial or ethnic minoritized backgrounds, is essential to create inclusive programming for all who serve.
While more work needs to be done to improve understanding of firefighter behavioral health, we are presently in a more informed place than we were even ten years ago. Mental health stigma is a barrier to wellness, and change will arise ultimately from policy. Thus, increasing awareness of behavioral health in the fire service is an important first step. It is time to invest in research, evidence-based clinical services and policies based in science to better serve those who courageously serve our communities.
Acknowledgements
This contribution reflects a consolidation and update of the following article: Vujanovic, A. A., & Tran, J. K. (2021). Providing psychological services to firefighters. Journal of Health Service Psychology, 47, 137-148. doi: 10.1007/s42843-021-00041-6
About the Author
Anka A. Vujanovic, PhD, is Professor of Psychology, a licensed clinical psychologist, and Director of Graduate Education in the Department of Psychology at the University of Houston, where she is Director of the Trauma and Stress Studies Center and the First Responder Program. Dr. Vujanovic’s research program is focused on understanding the complexity of posttraumatic stress disorder and some of its most prevalent and high-risk correlates, including substance use disorders and suicide risk, to inform treatment development.
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