1. Firefighter Behavioral Health: Protecting Our Own Keeping Firefighters Happy Mike McEvoy, PhD, NRP, RN EMS Coordinator – Saratoga County EMS Section Board Member – IAFC

2. Mike McEvoy, PhD, NRP, RN, CCRN www.mikemcevoy.com

3. NYS Department of Labor Grant NYS DOL Hazard Abatement Board – Training and Education Grant Training program Resource kit – Awareness flyer, poster, web page… www.nysfirechiefs.com/eap.php

5. Objectives 1.Promote Behavioral Health Awareness 2.Improve resiliency in firefighters 3.Discuss behavioral health resources for individuals and departments

6. Outline: Why behavioral health? CISD isn’t enough. Why? Stress and the firefighter personality Promoting resiliency in the fire service Protecting our own: an inside job Tools and resources

7. August 21, 2012 Call from Duty Chief 7:30 am response to suicide by hanging Patient is a fellow medic, 31 yo joined department 5 months ago, well liked, full time employee

8. Suicide Among Firefighters/EMTs No comprehensive data available Some believe rate is high FF/EMS represent the highest risk population: – 72% suicides: white males – 90% suicides: white males + females – Age 18 – 29 most common for suicides – FF 96% male, 85% white, young – Medics 69% male, 93% white, young

10. Facebook Page Post

11. Suicide Warning Signs Lack of support system Rejected by peers Separation from family or friends Loner or newcomer Feels like no one cares

12. Direct Clues

13. Important Questions Have you thought about killing yourself? –When did you last think of suicide? –Have you ever attempted suicide? –Has any family member attempted/committed suicide? Do you have a plan? Do you have the means? How specific is your plan?

14. Principles of Suicide Prevention Encourage help-seeking behavior High risk population = more intensive effort (like bringing a brother in) Can we prevent every suicide? 

15. We do fantastic funerals! We should not glamorize suicide Fire Service Suicides Happen

16. Resilience: psych & behavioral lingo Resilience = ability to withstand negative pressure Resilient people experience negative circumstances associated with poor psychological and social outcomes yet despite odds, they end up healthy & productive: Mentally ill or abusive parents Deprived social or economic conditions Major stressful events

17. What makes some people resilient and others vulnerable to life stressors?

18. Personal Resilience related to: 1.Biology – temperament, emotions, intelligence, creativity, immune resistance, genetics and physical condition 2.Attachment – capacity for bonding (forming significant relationships with others), capacity for empathy 3.Control – mastery over one’s environment, social competence, self-esteem, personal autonomy and sense of purpose

19. “Am I different?”

20. One Word: Adrenaline 90% of population lack traits needed to perform well as an emergency responder Emergency responders are “Adrenaline Junkies” Average citizens are not

21. The “Adrenaline Junkie” Control oriented

22. The “Adrenaline Junkie” Attentive to detail

23. The “Adrenaline Junkie” Traditional

24. The “Adrenaline Junkie” Strong role identity

25. The “Adrenaline Junkie” Action oriented

26. The “Adrenaline Junkie” Risk takers

27. The “Adrenaline Junkie” Highly dedicated

28. The “Adrenaline Junkie” Family oriented

29. The “Adrenaline Junkie” High expectations

30. The “Adrenaline Junkie” Strongly rescue oriented

31. Control oriented Attentive to detail Traditional Strong role identity Action oriented Risk takers Highly dedicated Family oriented High expectations Strongly rescue oriented “Adrenaline Junkie” Issues

32. Control oriented Control oriented Attentive to detail Traditional Strong role identity Action oriented Risk takers Highly dedicated Family oriented High expectations High expectations Strongly rescue oriented

33. Emergency Services Stressful?

34. Most Stressful Jobs in US: 1.Firefighter (71.59) 2.Enlisted military personnel (70.78) 3.Military General (63.11) 4.Commercial Airline Pilot (60.46) 5.Police Officer (50.82) 6.Actor (50.33) 7.Broadcaster (50.30) 8.Event Coordinator (49.93) 9.Photojournalist (49.22) 10.Newspaper Reporter (48.76) Careercast.com 2015/Forbes magazine 2015

35. Most Stressful Jobs in US:

36. Fire Service Stressful occupation Expect to see others in trouble Routinely manage crises

37. “John Wayne Syndrome”

38. “You ain’t hurt unless there’s a bone stickin’ out”

39. Pathological Stress Acute Stress Disorder (ASD): – Symptoms experienced during or immediately after the trauma, last for at least 2 days, and resolve within 4 weeks. Post-Traumatic Stress Disorder (PTSD): – Symptoms begin within 1 – 3 months after the event, may last months to years. – Lifetime incidence: 7.8% – Population prevalence 0.8 – 4% – Lower incidence in emergency responders Javidi H, Yadollahie M. Post-traumatic stress disorder. Int J Occup Envir Med. 2012;3:2-9.

40. Impact of Major Stressors Have you ever had any education on this?

41. Pathological Stress Acute Stress Disorder (ASD): – Symptoms experienced during or immediately after the trauma, last for at least 2 days, and resolve within 4 weeks. Post-Traumatic Stress Disorder (PTSD): – Symptoms begin within the 1 – 3 months after the event, may last months to years. – Lifetime incidence: 7.8% – Population prevalence 0.8 – 4% – Lower incidence in emergency responders Javidi H, Yadollahie M. Post-traumatic stress disorder. Int J Occup Envir Med. 2012;3:2-9. We must teach this to recruits!

42. ASD and PTSD 1.Reliving the event 2.Emotional anesthesia 3.Persistent anxiety  DSM-5

43. ASD and PTSD Revised 2014 1.Reliving the event 2.Active avoidance 3.Emotional anesthesia 4.Persistent anxiety  DSM-5

44. Firefighter Stress Is our stress different than in other professions?

45. Firefighter Stress FEMA funded 3-year, 5- state study of CISD, firefighters’ disposition, and stress reactions. Included personnel from Murrah building bombing in OKC.

46. Fire Service Stress Social support structure of fire service is protective Firefighters are quite resilient Firefighter social support comes first from family, then from friends and coworkers

47. Fire Service Stress The majority of firefighters would seek support from clergy (40.9%) over professional counselors (7.4%) Firefighters tend to have positive views about the world despite continued exposure to traumatic events

48. Stress in EMS Providers 1,600 EMTs and Medics surveyed 100% reported exposure to traumatic events PTSD incidence lower than general population Significant relationship between ETOH use and PTSS Donnelly E. Work-related stress and post traumatic stress in emergency medical services. Prehosp Emerg Care 2012;16:76-85.

49. Immune to Stress? NOT… Firefighters are human They are highly effective on the job They also have families, bills to pay, cars to keep running, homes to maintain and lives to live outside of the firehouse

50. Compare FF to John Q Public: Substance use/abuse – Alcohol, drugs, tobacco Sleep disorders Depression PTSD Suicide Anger management, violent behavior Marital, family, relationship problems

51. Tobacco FF substantially lower smoking rates than military and civilian populations Very high rates of smokeless tobacco use Poston WS, Haddock CK, Jitnarin N, Janhke SA. A national qualitative study of tobacco use among career firefighters and department health personnel. Nicotine & Tobacco Research. 2012;14:734-741. Haddock CK, Jitnarin N, Poston WS, Turley B, Johnke SA. Tobacco use among firefighters in the Central United States. Am J Indust Med. 2011;54:697-706. Sarna L, Bialous SA, Nandy K, Antonio AL, Yang Q. Changes in smoking prevalences among health care professionals from 2003 to 2010. JAMA. 2014; 311:197-199.

52. Alcohol Use Among Firefighters Binge drinking common (56% monthly) – Chiefs lowest, ff/paramedics highest – Little difference between career/volunteer – 10% reported driving after drinking Haddock CK, Jahnke SA, Poston WS, Jitnarin N, Kaipust CM, Tuley B, Hyder ML. Alcohol use among firefighters in the Central United States. Occupational Medicine. 2012; 62:661-664.

53. PTSD and Firefighters Low rates of PTSD among FF (4.2%) – Wide variations in other studies (6-32%) – These data comparable or < civilian PTSD FF are very resilient Alcohol use among FF > civilians PTSD risks = lack of support & higher level of life stressors Meyer EC, Daly E, Zimering R, Knight J, Kamholz BW. Predictors of postraumatic stress disorder and other psychological symptoms in trauma-exposed firefighters. Psychological Services. 2012;9:1-15.

54. Divorce Calculating population rate is elusive Attorney data suggest firefighters have higher incidence of divorce Family, home and relationship issues likely related to work…

55. Initiative # 13 Firefighters and their families must have access to counseling and psychological support 16 Firefighter Life Safety Initiatives

56. Firefighting is a high-risk occupation which, from time to time, can put the employee and his or her family under extreme stress. They deserve access to mental health care. What Initiative #13 Means If you are feeling stress (depression / anxiety or physical symptoms) seek help from physicians, EAP counselors, and religious or other sources. Don’t “tough it out”; this could lead to bad results for you and your family. Stress-awareness should be part of firefighter training at all levels. Help a buddy you see struggling with stress-related problems. If you are feeling stress (depression / anxiety or physical symptoms) seek help from physicians, EAP counselors, and religious or other sources. Don’t “tough it out”; this could lead to bad results for you and your family. Stress-awareness should be part of firefighter training at all levels. Help a buddy you see struggling with stress-related problems.

57. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, 2013 edition Chapter 11: Behavioral Health and Wellness Program – The FD shall provide access to a behavioral health program for its members and their immediate families

58. Employee Assistance Program EAP NFF: Behavioral Health Assistance Program (BHAP) Regardless of what you call it, they must be familiar with and prepared to treat firefighters!

59. EAP Began in 1800’s to deal with alcohol use – Earliest programs were in fire departments Expanded in 1950’s to mental health – Employers began contracting for EAP services More recently, unprecedented growth – Competition has dramatically lowered costs – Technology leading to phone and on-line EAP – EAP vendors are reaching saturation in U.S.

60. EAP No state recognition/licensure Accreditation varies Requirements: – Counselors are licensed – Program has fire service expertise NFF Life Safety Initiatives template “From EAP to BHAP” aids in soliciting vendors

61. Behavioral Health AKA “Mental Health” Stigmatized by firefighters, medics, cops As important as physical health & safety Left untreated, leads to illness & death Covers a wide range of issues: – Stress, anxiety, sleep problems, anger management, depression, PTSD, substance abuse & addiction, marriage & family issues…

62. What About CISD? Created by Jeff Mitchell at UMB 1980’s Became defacto response to “Critical Incidents” Premised on preventing emergency responder attrition from stress Paucity of research on effectiveness

63. CISD – Summary of Scientific Literature (Peer Reviewed) Mitchell model CISD (not CISM) Emergency Services vs. general population Cochrane Library Database (last CISD revision 14 Nov 2005, last substantiative update Dec 2011)

64. CISD - Conclusions 1.Value neutral to negative 2.Not effective compared to all forms of debriefing vs. no debriefing at all 3.While perceived as helpful, rescuer satisfaction ≠ effectiveness 4.Some evidence of harm to certain individuals, often iatrogenic

65. CISD – General Population Unsafe! Adds to trauma Complicates recovery Should not be used Now banned in most countries US Institute of Mental Health and World Health Organization both recommend AGAINST it

66. CISD – Emergency Services Not appropriate for 60% of police, fire, EMS personnel 85% talk about critical incidents afterwards (colleagues and peers preferred) 15% prefer not to talk at all

67. When Helping Harms (Worsening anxiety, depression, PTSD) Mandatory attendance Discussion of event (relive emotional trauma) – MH error “Mixing” groups – Peripheral personnel with those directly involved in the incident – People lost loved one with people whose loved one survived

68. Who Is At Risk for CISD Harm? Repeated or accumulated severe unresolved stressors Lack of social supports Injury Preexisting psychological problems Traumatic bereavement Strong negative beliefs about meaning of normal stress reactions People who most seek CISD show poorer long term outcomes

69. CISD: Neutral Value? May interfere with natural psychological processing (avoidance and intrusion) May cause members to bypass usual support systems Members may feel they were “healed” by CISD May interfere with natural dept. environment May lead people to expect they will suffer post- traumatic stress, triggering psychological problems Reliving the event might add to the trauma for some

70. CISD – What Now? OK - you made your point. What else should we be doing?

71. Today’s Recommendations: 1.Immediate assistance Starts on scene, informal, “upward contacts” 2.Early, reliable, focused assessment FF are resilient – watch for outliers 3.Stepped care matched to needs 4.Evidence based treatment by competent providers

72. PFA – Psychological First Aid Three basics of psychic resilience are hardwired into our biological makeup: 1.Sense of safety 2.Meaningful social connections 3.Sense of efficacy Protect Direct Connect

73. Recreate sense of safety Immediate physical needs (self-care) – Bathroom, food, fluids, breaks, clothing changes, sleep, time off… Protect from onlookers & media Walk-Around – supportive presence & monitor well being (chaplain, peer, etc) Protect

74. Meaningful social connection Help connect with family, friends, children, significant others – Talking in homogenous groups (ie: firefighters vs. heterogeneous strangers) Provide information on normal signs and symptoms including suggestions for what to do Educate significant others on s/s and how they can help Direct

75. Reestablish sense of efficacy Recognition for job well done Encourage normal routines & roles Discuss self care strategies to reduce anxiety – Exercise, rest, relaxation Encourage people to support and assist others Identify resources that promote effective coping (printed materials) Accurate, simple information about plans, schedules, events MH follow-up assessment @ 3 months Connect

76. PFA Protect Direct Connect

77. You have a situation… Recommended protocol for Occ Stress: 1.Determine if traumatic event 2.Time out/hot wash 3.Trauma Screening Questionnaire 4.Complete assessment 5.Treatment by qualified clinician

78. 1. Is this a traumatic event? Every firefighter is different How to ask: – Not, “how ya doing?” – But, “What can I/we do to help you?” Expressing support may be enough

79. 2. Time Out/Hot Wash Based on military after action review (AAR): 1.What happened? 2.What was successful? 3.What could have gone better? 4.How might we improve? 5.Who should we tell about what we have learned? Halpren J, Gurevich M, Brazeau P, Bishop S, Schwartz B. Rethinking critical incident stress: Coping strategies in emergency medical services personnel (NAEMSP Abstract). Prehospital Emergency Care. 2006;10:107-149

80. 3. Trauma Screening Questionnaire If PTE, used 3 – 4 weeks afterwards Identifies who is doing well and who might need additional help 10 questions about recent symptoms > 6 positive responses suggests need for screening by a behavioral health professional

81. 4. Complete Assessment Referral to Behavioral Health Assistance Program (BHAP, EAP…) Manage symptoms Deal with non-event stressors that may be complicating recovery (marriage, financial, etc)

82. 5. Specialty Clinical Treatment When intensive treatment needed (PTSD, anxiety disorders, depression), must be provided by specialist with advanced training appropriate to needs

83. What makes some people resilient and others vulnerable to life stressors?

84. Resilience: The Bottom Line Problem-focused coping increases resiliency while emotion-focused coping impairs resiliency When faced with a setback or challenge focus outward on the things that must be handled, not inward on emotions Emotions cannot become the focus of attention.

85. People who focus on solving their problems are the most resilient.

86. Problem Focused Coping: 1.Examine the situation to see what solutions may be possible 2.Consider various actions 3.Select the best 4.Take action 5.Observe effects of action 6.Modify for best results

87. Resilient People Have: Caring and supportive relationships High expectations for success Opportunities for meaningful participation Positive bonds Clear and consistent boundaries Life skills

88. Resilient People Are: – Sociable (form healthy relationships) – Optimistic (positive about the future) – Flexible (change easily) – Self-confident – Competent (good at something and proud of it) – Insightful (understand people and situations, able to see other sides) – Persevering (don’t give up) – Objective (view crises as challenges, not insurmountable obstacles) – Self controlling (manage strong feelings and impulses)

89. Vulnerable people exhibit: Substance abuse Poor anger management Lack of community integration/social isolation Multiple chronic illnesses (or symptoms with minimal, vague or inadequate organic basis) Chronic dysthymia and/or anxiety Dysfunctional relationships Inadequate school/work/community performance

90. “You play the hand you’re dealt. I think the game’s worthwhile.”

91. Promoting Resiliency 1.Leadership 2.Social support

92. Do you know a “Happy Person”?

93. Happy People Choose to be Happy

94. Miserable People Choose to be Miserable

95. Most of us are somewhere in between

96. Many of us would like to be happier

97. How Can I Be Happier? Less stress Improved outlook Better Health More success…

98. Stress Prevention Well run incidents Well managed organizations Well prepared providers Well conditioned personnel Well grounded lives

99. What You Need 1.Protocol for events 2.BHAP (or EAP) 3.Chaplain 4.Forms: TSQ, Information for families 5.Educational resources

100. Resources www.nysfirechiefs.com/eap.php NFF NVFC EAP Forms Etc…

101. Summary People are resilient Friends are important Conversation helps Time is a great healer Look out for others while you look out for yourself - Gist, et al., The origins and natural history of debriefing, 1998.