Leave the Baggage Behind


New Trauma Screening Questionnaire helps firefighters feel less stigmatized than traditional counseling methods

A reprint from FireRescue Magazine/FirefighterNation.com. This article appears in the August 2013 edition. The information here and in upcoming posts comes from the National Fallen Firefighters Foundation's Behavioral Health Conference I attended in March of this year. The work presented during that weekend highlights the years of research and testing done involving various forms of counseling to find what approaches work best in the fire service. If you approach it with an open mind and leave behind the baggage of traditional counseling models, you will be open to what can help you and the people you work with. – Bill

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Editor’s Note: The NFFF recently introduced a new Behavioral Health Model that changes the way the fire service assists firefighters and others on the path to healing. In his first article, Bill Carey addressed the after-action report (aka curbside critique) and how this well-known element of the job—coupled with a new concept called Curbside Manner—can be employed to help firefighters handle potentially distressing calls. Check it out at http://tinyurl.com/July-AAR. In this article, Carey addresses 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.

It had been a couple of weeks since Engine 3’s C shift had run the apartment fire with people trapped. The lieutenant remembers the look on the face of the young firefighter riding the back-up position when the occupant had fallen from the third-floor window. They were advancing the hoseline into one of the many garden-style apartments in their first-due area when a woman suddenly hit the ground right next to the firefighter.

The firefighter seemed to freeze for a moment, folds of hoseline in his hands, staring at the twisted body that almost landed on him. She looked his age, even while writhing in pain. A quick shout from the lieutenant redirected him, and the company went on to extinguish the fire, knowing that the EMS crew on the scene would quickly tend to her.

In the three shifts since that incident, there have been other fires, and the lieutenant noticed that the young firefighter has been quieter than normal. He thinks back to the after-action report (AAR) conducted after the fire. They went over the five simple AAR questions: What was our mission? What went well? What could have gone better? What might have been done differently? Who needs to know?

Everyone had a lot of good input and seemed to be doing fine on their own, except the young guy. His confidence and sense of humor have been replaced by quietness and, at times, brief moments of hesitation. “I’m no counselor,” the lieutenant thinks to himself, “but something’s different about the kid.” On the computer in his office, the lieutenant pulls up the newly created 10-question Trauma Screening Questionnaire (TSQ) from the National Fallen Firefighters Foundation’s new Behavioral Health Model. After reading it over, he decides to have the young firefighter answer the questions when he’s done entering some of the day’s reports.

Out with the Old
The TSQ is part of a new approach to behavioral health that includes after-action reports (AARs) and the Curbside Manner concept. The new approaches are part of an effort to revamp the NFFF’s Life Safety Initiative #13 (“Provide firefighters and their families access to counseling and psychological support”) and help firefighters become more in tune with each other and those signs of possible trouble.

In the past, dealing with stress in the fire service involved traditional methods designed for civilians in a blanket approach usually reserved for large-scale tragic events. This cookie-cutter counseling approach clashed with the fire service’s culture of bravado, and over the years, there developed a resistance to forms of help aligned with the words “stress,” “debriefing” or “PTSD.”

Further, the NFFF’s early work with the FDNY Counseling Services Unit revealed that efforts to deal with traumatic events were not effective and, in some instances, did more harm than good. So the goal became trying to identify what worked well for the fire service culture.

Beginning with lessons learned about behavioral health models since 9/11, the NFFF has spent the last four years working on a new behavioral health model for the fire service, and combined it with the LSIs created to reduce line-of-duty deaths (LODDs). The new, easy-to-use material gives firefighters better tools for dealing with potentially traumatic events in ways that don’t carry the baggage of traditional counseling methods.

Dr. Richard Gist of the Kansas City Fire Department told attendees at an NFFF conference in March that over the last 10 years, researchers have gained a good handle on dealing with traumatic events by referencing military models. Using an approach from the United States Marine Corps, the Curbside Manner was developed with a focus on knowing your people and what’s happening in their lives.

Focus group studies determined that positive programs focused on knowing your people, what is happening in their lives and what they needed, as well as those programs that could recommend support and additional services. Simply bringing in counselors after a department experienced a traumatic event in a “one-size fits all” approach is no longer an option.

And with the addition of the Curbside Manner approach, firefighters learn to look at victims in a more personal way, instead of a task/objective manner. And in turn, this approach helps firefighters identify when a co-worker is experiencing some type of personal conflict.

Administering the TSQ
The whole process begins in a surprising way—by doing very little. Once we use the AAR, the crew simply goes through what is called a “hot wash” or time out. It is not a specific, rigid debriefing but rather a time of reflection to put the event into proper perspective.

Once the hot wash time passes, usually within three to four weeks of the traumatic event, the TSQ (http://flsi13.everyonegoeshome.com/FLSI13TSQ.pdf) can be used to identify whether additional help is needed. This non-invasive measure can be referred by an officer or firefighter—or even self-administered.

Based on findings that criteria for effective screening no longer work for the fire service, the TSQ is a simple, Yes/No 10-question process that takes about five minutes at the most to complete. The questionnaire asks the respondent if they have experienced the following at least twice in the past week:
•    Upsetting thoughts or memories about the event that have come into your mind against your will
•    Upsetting dreams about the event
•    Acting or feeling as though the event were happening again
•    Feeling upset by reminders of the event
•    Bodily reactions (such as fast heartbeat, stomach churning)
•    Difficulty falling or staying asleep
•    Irritability or outbursts of anger
•    Difficulty concentrating
•    Heightened awareness of potential dangers to yourself and others
•    Feeling jumpy or being startled by something unexpected

If the respondent answers “Yes” to six or more of these questions, a referral to a behavioral health practitioner is likely needed. It is important to note that the TSQ is not a formal diagnosis of anything, and it should not be viewed as such. The TSQ should be treated as a gauge, a personal PASS alert if you will, that there is an issue that needs greater attention given for the firefighter’s well-being—as well as for their colleagues. It is a tool for dealing with stress—part of the bridge to a solution, not the solution itself.

Available online and soon as an app on smartphones, these 10 questions are one of the first steps toward a self-servicing behavioral health program that can be tailored to fit your department. It is important to all firefighters, company officers and fire chief to know beforehand what counseling services are available. Look into the details with your employee/volunteer assistance program, department physician and municipal human resources department, or with your local health department and personal physician. If a firefighter finds that they want behavioral health assistance, their first course of action should be to speak with their officer regarding the proper treatment plan options and course of action. This may involve a referral, leave request or other tasks that must be done in a responsible manner according to administrative SOPs. If your department does not have a plan for seeking assistance, then the personal physician should be given consent to speak with the fire chief regarding treatment options.

Change the Culture
The stigma of counseling and therapy will be hard for the fire service to defeat. The old stereotypes of having “issues” or being forced to talk to a counselor will always come up, but if we recognize the hard work and research done by the NFFF and others in developing a new behavioral health model to affect positive outcomes, it is possible to change those negative conceptions related to seeking help related to stressful incidents.

The tools being given to us now are based on team/peer concepts from the military, and are retooled to work within the fire service culture. By dealing with post-traumatic stress in a well-balanced therapeutic relationship, the fire service can make better strides in taking care of its own. As Dr. Gist stated during the conference, “Chiefs can change the rules, but peers can change the culture.”

In my last article in this series on the fire service’s new approach to behavioral health, I will introduce Stress First Aid for fire and EMS personnel.



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Bill Carey is the online public safety news and blog manager with PennWell Public Safety, or more specifically FireRescue Magazine/FirefighterNation.com, JEMS.com, LawOfficer.com and FireEMSBlogs.com. Bill started in the fire service, as a third generation firefighter in 1986, on the eastern shore of Maryland and then continued after moving to Prince George's County. He served as a volunteer sergeant and lieutenant at Hyattsville where he met Chris Hebert and Dave Ianonne, the creators of Firehouse.com. Bill went to work for them back in 2001 and after they transitioned away to new, bigger projects, he was hired by them again in 2009. Bill's writing has been on Firehouse.com, Fire Engineering, FireRescue Magazine, FirefighterNation.com, the Jones and Bartlett 2010 edition of "Fire Officer: Principles and Practice", The Secret List and Tinhelmet.com.

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