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The Push to Get Firefighters the Therapy They Need

When psychologist Jolee Brunton lectures classes of new firefighters and police recruits, she asks how many of them have seen a dead body outside of a mortuary.

“A few hands go up,” she said, because some of them are ex-military. She increases the number. “How many of you have seen five bodies?” Most hands go down. “Ten? Twenty?” All hands go down. “Except for the officers around the room that are helping me teach the class,” she said. “I get to 100 dead bodies and their hands are still up. Their normal is not everybody else’s normal.”

For first responders just starting out, Brunton believes an important part of the training for their chosen careers is anticipating the day-to-day stresses of the job they’ll need to get used to. “Most people thinking about being firefighters, they think about fighting the blaze, saving the house,” she said. “But the trauma involved in seeing people injured or killed — they’re not really prepared for that. There’s no way to prepare. It’s a skill set, and you can’t really learn it until you start doing it.”

Firefighters, along with police officers, paramedics and lifeguards, make up the bulk of first responders. These populations have been at the center of Brunton’s work since 1984, when she founded Focus Psychological Services in San Diego with the goal of providing mental health support to people who sometimes see more tragedy in a week than most people see in a lifetime.

When Brunton started Focus, the mental well-being of first responders received little attention and even less funding. But things are changing, particularly in firefighting, where the work is grueling and the emotional toll can be profound. Firefighters (as well as police officers) are more likely to die by suicide than in the line of duty, according to a recent study by the Ruderman Foundation. The Firefighter Behavioral Health Alliance estimates that only about 40 percent of firefighter suicides are reported, making the actual number of deaths significantly higher.

Fire departments across the country are finding new ways to encourage people who’ve traditionally resisted help to seek out therapy. Such increased emphasis on mental health stands out in a profession where a “tough it out” mindset has long been the norm. But it’s a much-needed cultural shift, according to leaders in the fire service. Firefighters themselves are starting to embrace the same view.

 The perilous demands placed on firefighters have been on display in recent months, with the West Coast having one of its worst fire seasons in years. Already, wildfires in California have burned over 600,000 acres, almost three times as many as last year at this time. For firefighters across California, that means more time away from home, less sleep and extremely punishing schedules. But as many firefighters are quick to point out, battling fires and other extreme weather scenarios is only part of the job, and not necessarily the most traumatic.

“People are hesitant to come forward, especially in our profession. We’re supposed to be the people who help people, not the ones who need it.”

“You can name certain incidents — child drowning, vehicle off the canyon, motorcycle into a tree — they all pop into my head,” said David Picone, battalion chief and health and safety officer for the San Diego Fire Department. “I’m sure it’s affected me. It sticks with you.”

Picone, who has been in the fire service for over 20 years, is now heading up efforts in San Diego to provide emotional and psychological support to firefighters and other first responders. When he looks back on the early days of his career, the need for mental health resources is glaring. “We just didn’t realize the breadth of how bad it was,” he said. “We knew we saw incidents, drinking — I’ve noticed high divorce rates — but we took it as part of the job and didn’t think much of it.”

Back then, it wouldn’t have occurred to Picone to start a conversation at the firehouse following a particularly horrific call. Even as a captain, he would ask his crew if they were OK, and the firefighters would just say they were fine. “Nobody said, ‘I wasn’t able to sleep last night.’ People are hesitant to come forward, especially in our profession. We’re supposed to be the people who help people, not the ones who need it.”

Now the SDFD is taking mental health as seriously as physical safety and cancer prevention. The department has a team of firefighters who are also trained as peer counselors. They assign chaplains to each battalion, and maintain a contract with Focus, offering free therapy to active and retired firefighters, as well as their families.

Peer counselors are trained to be the first line of defense in a mental health crisis. Brunton teaches them to provide support in a few different ways, including by assessing first responders’ levels of distress and keeping an eye out for marital issues. The phrase “my marriage is in trouble” can be a red flag suggesting it’s time for professional help: “Sometimes it’s really hard to shift gears when you go home,” Brunton said.

Peer counselors can help firefighters through temporary bouts of anxiety or distress. But for serious or longer-term problems, counselors will refer firefighters to Focus’ team of licensed therapists.

“The more severe your symptoms, the more likely you are to need professional help,” said Brunton. “If you run to a call and it’s distressing and you have nightmares the first night, feel a little sick to your stomach the next day, but after three or four days, you’re back to normal, talking to a peer counselor would be fine. But if it’s a week or two later and you’re still having nightmares, you’re not able to eat — it’s probably time to check in with someone.”

It’s crucial for mental health professionals who work with first responders to understand their specific needs. Focus favors short-term, results-oriented therapies. “These guys are pragmatic,” Brunton explained. “You’re not going to do psychoanalytic psychotherapy with them. They want to fix things. They want you to give them tools to use.”

Most of the treatment employs cognitive behavioral therapy, dialectical behavior therapy and a practice called eye movement desensitization and reprocessing, or EMDR, which has proven effective for treating PTSD.

Familiarity with firefighter culture and vernacular is useful too. Telling a firefighter who’s having trouble sleeping to take a hot bath and go to bed at 9:30 p.m. isn’t that helpful. “You have to have enough experience to know that firefighters are at work for 24 hours, and they’re not going to have regular sleep cycles,” Brunton said. “So you’ve got to find ways that they can enhance their sleep given how they work.”

Then there’s the matter of what firefighters want to discuss in therapy. “Some of the things they want to talk about are pretty overwhelming,” she said, so having a therapist who won’t flinch helps. “I have images burned in my head from hearing it secondhand — car crashes, people on fire they can’t get to, shootings — I can only imagine what it’s like to have actually experienced.”

Mickey Stonier, a chaplain with both the SDFD and the San Diego police department, has spent more than two decades working with first responders. Over the years, he’s earned their trust by spending time with them, hanging around the firehouse, becoming part of the furniture. “Early on, I was doing a lot of ride-alongs,” he said. “It’s being visible, being around.”

Stonier thinks some people feel comfortable opening up to him because he’s a chaplain. But he also has a PhD, and is trained in trauma. He’s conducted interventions to get responders to talk about on-the-job experiences, explaining to them how the brain integrates trauma and what they can do to mitigate the impact of stress.

“Back in the day, the culture was: If you can’t handle it, get another job. Buck up,” he said.

Little by little, that attitude is shifting, and Stonier is seeing more receptivity to mental health services. “Some of the older firefighters were like, ‘Wow, I wish I had this when I was younger,’ or ‘You younger guys need to take care of yourselves. I’m on my third marriage, end of my career, I don’t sleep well.’ There are a lot of those stories.”’

Cal Fire, California’s fire protection agency, is now bringing peer counselors to the scene of big wildfires, like the Carr and Mendocino fires this summer, so that trained ears are available if firefighters want to talk. “The whole program is confidential,” said deputy chief Mike Ming, who heads up Cal Fire’s employee support services. “We want to make sure that the employee feels there’s a safe container that they’re able to express their vulnerabilities, right away on the fire line. If we don’t talk about it, that sits inside of us.”

To preserve confidentiality, SDFD doesn’t track the number of people who use peer counseling or professional services, but they do track hours — which have consistently risen. “We know people are calling,” said Picone, and he’s encouraged by the response: “More and more people are using the service; they’re going, ‘Wow, I actually feel better.”’

For newer firefighters, Brunton hopes to normalize self-care and mental health counseling as simply another part of career training. “They don’t know any different. It’s just part of being here,” she said. “You’ve got shift work, you’ve got a captain, you’ve got a psychologist, this is how you run the rig — it just becomes part of the culture.”

But there’s still a long way to go. Funding for mental health support isn’t always readily available to departments. And reports of firefighter deaths by suicide across the country continue to surface. Just last month, a Los Angeles Country fire captain died by a self-inflicted gunshot wound.

“I’m not naïve,” said Brunton. “There are still some people who would never walk through my door. That’s why peer support is important. They can maybe help persuade people who need professional care to come in, and take away the stigma. But when I see an uptick in people who are retired coming in, that tells me we’re getting to them. They’re beginning to understand it’s not rocket psychology. It’s not that you’re crazy.”

“I think we’ll be able to help a lot of people,” Picone said. “Ultimately, if I can prevent one person from doing something that we’d all regret, that makes it all worthwhile.”

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