The fire and rescue service is one of the first services at the scene of accidents, suicides, acts of violence, acts of nature and major disasters. They retrieve badly injured people and bodies from buildings, road traffic collisions, air accidents and sometimes, this has to be carried out in the context of family and friends standing by watching the horror unfold. They, at times, also have to deal with the people who may have caused death and injury.
Protecting a firefighter’s emotional and psychological health is as important as protecting their physical safety. Exposure to traumatic incidents, in the course of their work, leads to a possibility they could develop significant psychological distress in the form of Post Traumatic Stress Disorder (PTSD). PTSD is caused by involvement in traumatic events and, as a foreseeable work hazard, the organisation is obliged to identify, act on and monitor the risk of the firefighter being routinely exposed.
Nineteen years ago a member of the former Somerset Fire Brigade1 committed suicide. At that time there were no measures in place to assist the psychological welfare of personnel in their work and no formalised support for those affected by the death of their colleague.
As a result of this tragic event, myself and a colleague were asked to set up a support service which involved both counselling/treatment and a proactive/responsive intervention aimed at dealing with the impact of traumatic incidents. What has evolved over the last nineteen years, and continues to be open to scrutiny and evaluation and adaption, is a counselling and trauma service that is now part of the culture of Devon and Somerset Fire and Rescue Service (DSFRS).
Post-Traumatic Stress Disorder (PTSD)
Firefighters are a psychologically resilient group who are trained to deal with the extreme nature of their work. It is normal to be temporarily preoccupied with a traumatic incident in some way or to have intrusive memories of it. When this does not fade or the firefighter does not experience a gradual relief from symptoms then there is a possibility that PTSD may develop.
In 2013 DSFRS attended 112 incidents which met the criteria for being critical (those involving fatalities or potential fatalities). Any one exposed to a traumatic event is vulnerable to PTSD. Firefighters have a different response to each call out they respond to. There is little to predict or identify which call will result in PTSD. It can be a cumulative experience or a one-off, hence the need for on-going proactive and reactive support.
PTSD is an awful, debilitating illness that touches every part of a firefighter’s life. It not only affects an individual emotionally and behaviourally but has a strong physiological impact as well. Along with the intrusive experiences (nightmares, flashbacks) and the attempts to decrease the distress through avoidance or withdrawal there is the constant hyper arousal/hyper-vigilance of a body that is in alert mode. Each time the memory of the incident is triggered whether by a sight, sound or smell the firefighter is flooded with the sensations they had at the time of witnessing the trauma. The process is exhausting and the firefighter is drawn into engaging in behaviours that halt or minimise the distress whether this be avoiding the triggers or more worryingly easing the feelings through alcohol or other medications.
Reactions to trauma are complex and not easy to predict but research shows that some factors make a firefighter more vulnerable to the risks (low social support and other concurrent stressors such as divorce or bereavement).
So how many firefighters go on to develop PTSD following a traumatic event? In 2009 a joint study by the University of Ottawa and the University of Washington focused specifically on PTSD and duty related trauma within fires services in Canada and the US. In Canada 625 firefighters were surveyed. The study found that 1.2% of the Canadian community male population had PTSD while 17.3% of Canadian firefighters were found to have the disorder.
Closer to home, the report ‘Psychological Resilience to Stress in Firefighters’ (Durkin & Bekerian, 2002) found that in sections of the UK fire and rescue service the incidence of PTSD was around 20%.
In 2013 DSFRS attended 112 incidents which met the criteria for being critical (those involving fatalities or potential fatalities).
Given this level of risk DSFRS utilises a strategic model of crisis intervention that is not a stand-alone process but one that is linked to pre incident education, peer group ‘defusing’ meetings, ongoing follow up and monitoring and fast track referrals for psychological treatment.
The aim is to build upon the resilience and coping that is core to a firefighters skills. Understanding what a normal reaction is, what are good coping mechanisms, paying early attention to symptoms, identifying and attending to possible emotional injury to them and that of their colleagues and teaching awareness of what support is available is just some of the psycho-education. DSFRS do not focus on those most at risk following exposure as it has been the experience that firefighters have trained together, worked together, faced trauma together and thus work in crews and therefore intervention need to mirror that. In addition, the aim is to intervene at the beginning. As Durkin said; “Watchful waiting is like telling fire-fighters to stop doing first aid at road accidents and wait and see who gets worse before requesting an ambulance.” The aim is to make the psychological intervention a normal part of the culture as the operational debrief or fire investigation.
Following a traumatic incident the crew return to their station with their colleagues to be met by a peer supporter. They then participate in a group meeting that is about psycho-education, group ‘story telling’ that is combined with practical information aimed at normalising reactions to the traumatic event. It is a psychological first aid response. The peer supporter is also assessing whether a full psychological debrief, carried out by a trained psychological professional is needed. Each meeting is monitored, actions taken outlined, risks noted and follow up organised. The participating group are also sent evaluation forms which assess how prepared for the session they were; the effectiveness of the introduction, the ability of the peer supporter, the firefighters knowledge of PTSD prior to the meeting and afterwards, how helpful the session was and an overall evaluation of the meeting.
The peer supporter has undertaken training to equip them with a range of skills to be able to run the meeting, identify those more at risk, carry out a risk assessment, plan follow up and refer to appropriate psychological support. Peer supporters are monitored and supervised as well as expected to attend regular CPD events in order to maintain their expertise.
The M5 Motorway Collision
At approximately 2025hrs on November 4th 2011 thirty four vehicles were involved in one of the worst motorway disasters in UK history. The incident occurred on the outskirts of Taunton, Somerset and saw a response of fifteen fire appliances and one hundred and sixty one firefighters from DSFRS. The incident resulted in seven people losing their lives and a further fifty one were injured. By the next morning the emergency services had carried out their rescues and the motorway between the junctions remained closed for repair. By 0900hrs the following day the psychological care for those involved had already begun.
All those involved engaged in a peer group meeting on return to their stations. Three days after the tragedy the twelve members of the first crew at the scene were invited to attend a full psychological debrief. A total of two of these debriefs were held, both of which lasted over 4 hours. This decision was made to undertake the debriefs due to the scale and complexity of the incident and the fact that these crews were confronted with the whole incident whereas later attending crews were given direction and specific roles on arrival.
The group meetings were facilitated by an experienced psychological therapist. In addition these firefighters were all contacted by the counselling service and offered immediate 1:1 support of which many took up in the week that followed. They were offered support that met with their individual needs.
All those attending were followed up at 1 week, 1 month and 3 month intervals. A letter was sent out to all involved detailing the support available as well as the support being offered to families.
For most of the firefighters and emergency fire control staff this incident represented an unprecedented episode in their careers. Fire Control staff could see the live feed on television of what they were dealing with while many of those involved expressed disbelief and shock at what had happened and what had been witnessed. It was an ever changing and dangerous environment for those attending which inevitably involved scenes of horror. Despite achieving multiple rescues and engaging in challenging firefighting actions, many expressed the feeling of powerlessness and helplessness in the face of their experiences and a sense of frustration as the scene became more hostile for them to work in.
Whether the interventions were effective would require specific research; however a meaningful measure, given the absence of direct psychological measures for all those who attended, would be sickness absence statistics for the two months following the incident in addition to measuring the number of firefighters who have been diagnosed with PTSD one year post incident. Looking at the statistics available none of the personnel involved took psychological related sick leave in the two months following and at the one year follow-up only thirty three days were lost to stress related illness, although this was not necessarily related to M5 incident.
Through the group meetings, individual sessions and follow ups those involved were able to have the opportunity to hear the collective and individual experiences of experiences that was outside the normal range of critical incidents DSFRS are used to facing. This enabled them to gain vital understanding of what happened, how it was dealt with and how they worked together as a strong and cohesive team in the worst case scenario. From the 61 completed evaluation forms;
- 51 reported the ‘helpfulness’ of the group meeting to be good or excellent while the remaining 10 found it averagely helpful
- 56 rated the ‘overall experience’ of the group meeting as good or excellent
In terms of the participants knowledge of PTSD prior to the group meeting twenty rated this as poor or average with this changing to only five reporting they had an average knowledge of PTSD following the meeting.
More importantly when asked to evaluate what they found beneficial many said that it was talking about their experiences with colleagues which they found important;
“Being able to talk about feelings as quite often it is assumed that because we do this job we can cope with anything”
“I found it very beneficial to be able to openly express my feelings and talk about what’s had experienced”
And that what they were experiencing was normal;
“It made it clear to me what I think is normal and acceptable”
“It normalised my thoughts and feelings”
And for a lot it provided some sense of closure;
“An opportunity totals about it to the point of closure”
“Having an end to the incident as well as closure”
Providing a Service
One of the most important aspects of providing a service that involves counselling and trauma intervention is that the interventions mirror the values and work of the fire and rescue service and involves being flexible and responsive in meeting the organisations and individual’s needs. Our work, like firefighters, is also about prevention and protection served by professionals with a range of specialist skills – anything less would be potentially harmful. The service has to be able to incorporate, the worst case scenario, and act accordingly to respond quickly and effectively to restore psychological well-being as soon as possible so the firefighters can go back to saving lives.
Thus response times have to be good and in my experience when a firefighter requests psychological support they want to be seen as soon as possible. At Hammet Street Consultants, on average, firefighters are seen within three days, however this means that there is a very real threat of the firefighter being involved in another traumatic incident before being seen.
It’s important that a service has therapists who are qualified, experienced and have continual supervision and Continual Professional Development to update their skills. Services need to be delivered in line with current guidelines; National Institute for Clinical Excellence, 2005 – Eye Movement Desensitisation and Reprocessing (EMDR) – trauma focused Cognitive Behavioural Therapy (CBT) and if necessary links with other professionals involved in the psychological care of the individual.
Due to the nature of PTSD and the percentage of sufferers who go on to manage their symptoms through substance abuse, alcohol abuse or other addictions it is vitally important to have specialist in this area as part of the team. If they do not have the skills required then they have to have referral routes in place which means the person can be quickly referred to someone who can help.
Durkin, J. & Bekerian, D. A., 2002. Psychological Resilience to Stress in Firefighters, London: Psychology Department, University of East London.
National Institute for Clinical Excellence, 2005. Clinical Guidance 26. London: National Health Service.
1 The former Somerset Fire and Rescue Service combined with Devon Fire and Rescue Service in 2007.