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

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. 16 Firefighter Life Safety Initiatives

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

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 FLSI 13 Consensus Project

No After Action Review Stress First Aid for Fire and EMS Personnel Trauma Screening Questionnaire Behavioral Health Assistance Program Cognitive Behavioral Therapy Peer Support Curbside Manner: Stress First Aid For the Street

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 1Cover 2Calm 3Connect 4Competence 5Confidence

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: 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 Unit Level “Hot Wash”

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

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 Behavioral Health Assistance Programs

Principal Needs from BHAP Accessible resource for problems and issues Accessible resource for problems and issues First point of access for assessment and referral First point of access for assessment and referral Consistency of model, service, and performance Consistency of model, service, and performance Clear service objectives, treatment standards, and outcome expectations 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 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 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 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 (Green) REACTING (Yellow) INJURED (Orange) ILL (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!