First to mind

Anyone who’s had to call for emergency responders—be it the result of a car accident, a fire, a home burglary or an assault—knows that it can take a while to recover from the stress and the toll it can take on one’s mental health. But what about those people on the other side of that 911 call? How do the people whose job is it to help regular citizens through the toughest days of their lives keep themselves mentally healthy?

The answer to that question lies in a decades-old stress management procedure, and the ways that first responding agencies like police and fire departments are adapting, rethinking and supplementing it to create environments where mental health is more than an afterthought in the wake of frequent trauma.

Critical thinking

Critical Incident Stress Management (CISM) has been in practice for decades. It's a system that was designed to help emergency responders deal with the trauma to which they're regularly exposed.

CISM was developed in the 1970s by Jeffrey Mitchell, a clinical professor of Emergency Health Services and former firefighter and paramedic. Today, Mitchell and others in his field run the International Critical Incident Stress Foundation (ICISF), which offers training courses in CISM to first responders from thousands of agencies across the country and the globe.

CISM, according to materials on the ICISF website, has seven core components. These include (1) pre-crisis preparation through stress management education and mitigation training; (2) disaster and community support programs like “town hall meetings;” (3) defusings, which are three-phase group discussions for first responders that happen within hours of a traumatic event; (4) critical incident stress debriefings (CISD), which are seven-phase group discussions for first responders that usually happen several days after a traumatic event; and—when necessary—(5) one-on-one crisis intervention and counseling; (6) family crisis intervention; and (7) follow-up and referral procedures for those who may still need additional help.

Number four on that list is the one with which some civilians may be familiar. Stress debriefings have long been a standard practice for local police and fire departments. But, increasingly over the last several years, local agencies have been incorporating new tactics in response to what they see as the shortcomings of CISM and debriefings.

“There was much more that needed to be addressed—the day-to-day stuff that needed to be addressed, which CISM does not address,” said Randy Vawters, a sergeant with the Washoe County Sheriff's Office.

Derek Reid, a captain with the Truckee Meadows Fire Protection District agrees.

“For years, there's always been CISM,” Reid said. “The issue with that is it's more reactive. If there's an incident, they usually will call a critical incident stress debriefing. And Critical Incident Stress Management is usually after the fact. … So, we've never been in front of it. We've always been on the tail end of it, which is, ‘Oh, man, we were exposed to this massive amount of trauma on this call, and now we're trying to pick up the pieces rather than hit it on the front end.'”

Both men have taken part in the CISM process during their careers and both are a part of their agencies' respective peer support teams, which are working to change the way local emergency responders care for their own mental health by being resources for those dealing with work-related and even personal problems.

Peer-to-peer

Reid, whose career in public safety includes five years as a medic and 20 as a firefighter, is the leader of TMFPD's peer support team. The newest among the local agencies, it was started less than a year ago. Reid said his interest in the team was spurred in part by poor past experiences with CISM.

“A long time ago, the defusings didn't help me,” Reid said. “They actually made me more angry. One of the reasons is because the people that were facilitating the debriefings weren't public safety people. We've done better on that side, where the people who make up the team are first responders. And they have an understanding. They've done the job. They've had the calls. So there's more trust built into that model.”

Building a trusting environment is one of the biggest goals of the peer support teams at all of the local agencies. In fact, leaders at local agencies say its the first step to even getting a peer support team off the ground.

At the Washoe County Sheriff's Office, Sheriff Darin Balaam said the first step to ensuring the success of peer support efforts to remove officers' fears of reprisal should they seek help.

“There is this barrier and fear within law enforcement that if they come out and people find out in the organization, ‘I'm going to lose my job,' or, ‘Others are going to think I'm crazy,'” Balaam said. “The big push for us … is that we've been trying to break those barriers within the organization and change the culture. We're not here to take anybody's job. We know we're all human. We all put our pants on the same way. But we also know that we lead the nation in suicides. And it's time to stop that.”

Vawters pointed out that confidentiality laws passed in the past several years have helped lessen these concerns.

“All of the conversations we have on our peer team are bound by law to be confidential,” he said. “We can't talk about it, nor can we be mandated to talk about it.”

But, according to Balaam, “Traditionally, we've never talked about any of this. It's been taboo”—and he wants to see that change.

“It's always been, at least in my perception of my career, you take that case; we don't show emotions, and then onto the next case,” he said. “For me it's kids. And when I had kids, it made it sensitive. And, so, you go to that dead baby call, you take the report, give it to the detectives and on to the next call—and that's kind of the expectation.

What I've tried to do is talk about it and say, ‘We know it affects you. It affects me. It affects everybody, and it's OK to cry.' … It's trying to create that encouraging environment where it's OK to cry. … If you find yourself overwhelmed, it's OK. That's part of the human recovery process.”

Teaming up

At the Reno Police Department, there had been an unofficial peer support team for years that's manifested in one form or another since the first official support effort fell by the wayside during the Great Recession. Last December, the department officially restarted the team, and, in early August, they appointed a uniquely qualified officer as team leader.

Brandon Cassinelli has a master's degree in marriage and family therapy. He's the RPD's new embedded resource officer for its peer support team, which he said he's working to ensure is comprised of officers and employees of every rank.

“I think we have four at the dispatch level, 12 at the officer level, and at least two supervisors now,” he said. “It helps to have a good spread, demographic-wise—because somebody at your tenure you might feel more normalized speaking with, or your age group or gender. It may go along a whole bunch of lines, as far as trust goes.”

Tasheeka Clairborne, a patrol officer on the peer support team, agrees with him.

“From a lower tenure perspective, and being on patrol, I think actually instituting it and having supervisors that have a lot of tenure on the team—it's normalizing it,” she said. “It's to where, even when we're on patrol … if something happens, and I happen to be on the call with [another officer], and we'll be sitting car by car, and they'll tell me how they were feeling or what they thought while the scene happened. It's kind of like an emotional debriefing, without it being so formal. And I think just having the title we have here, ‘peer support,' makes it way easier for officers to feel even OK talking about it in the first place.”

She also believes the department's Mobile Outreach Safety Team, which pairs clinicians with police officers to respond to mental health crises in the community, is beneficial—because it gives officers the opportunity to be around a mental health professional and talk in an informal environment. Both Cassinelli and Clairborne agree that peer support is normalizing discussions about mental health issues among their ranks. Cassinelli believes a culture change is happening outside of RPD, too.

“At least in the valley, I know it's changing,” Cassinelli said. “I can speak directly to that. Sheriff Balaam and Chief [Jason] Soto are very vocal about wanting to take care of their people, so that their people are able to take care of other people and take care of the community they're in.”

For Reno Fire Department Captain John Mandell, who's that agency's peer support team coordinator. Understanding emergency responders are a part of the community—and getting them to do the same for themselves—has been critical.

“We serve our community,” Mandell said. “In responding to emergencies, we serve our community directly. By taking home the trauma from helping the community, it hurts our families—and that, in turn, hurts our community. So it's kind of a cycle, like, if we can't be present and helpful and positive in our family lives, that has a negative affect on our families, which are also a part of the community. So we're kind of taking this community approach to it.”

As a part of this approach, Mandell said, an important aspect of the RFD's 21-person peer support team's work is to provide similar services to firefighters' families. While many firefighters or other first responders will shield their families from what they experience—and while the team isn't there to “spill the beans,” he said—talking to the families as well let's them “know what the firefighter is going through and what to expect, just to kind of keep them clued in on the process so that they don't feel so abandoned or left out.”

“Our mission statement is to provide emotional health and well being for firefighters and their families,” Mandell said. “So, really, it's hard to describe what it looks like, but it could be anything—any type of support a firefighter needs, whether it's work-related stress or home-related stress, dealing with a critical incident, dealing with disappointment from not getting promoted, just dealing with the burnout from working. … Or we can help them with their personal life—marriage, financial, children issues.”

Mandell also sees the culture surrounding emergency response work changing.

“I know people are reaching out for help, and that' s another indicator,” he said. “We've had 41—what we call contacts—we've had 41 contacts since April of this year from Reno firefighters reaching out to our team for some form of assistance. So the team is getting used. … And, just this morning, we were talking about counseling and talking about counselors. And that's something you just didn't talk about. If you went to marriage counseling, maybe you'd tell one or two people that you're real close with and felt secure with. But, now, four of us were sitting around talking about counseling and our experiences with counseling this morning. Conversations like that didn't used to happen.”

Still, people like Mandell, and his counterparts on other peer support teams around the valley, say there's more work to be done to protect the psyches of first responders—from finding the right counselors to talk with them to making sure their out-of-pocket costs for care aren't astronomical.

Finding solutions

According to both fire and police peer support team members, finding clinicians who are willing and prepared to talk with first responders can be a challenge.

“What we do is we go and seek out counselors that are willing to understand the fire culture and even be willing to do ride-alongs,” said TMFPD's Reid. “That way they can understand the job. They can understand the camaraderie that goes on within the station. We are normal people, but we are massively exposed to trauma. Every day we come to work, it could be a dead elderly person or a baby. It could be a heinous car accident. It could be a fire where people get burned, or just the fire in itself can be traumatic because our own lives are on the line when we go into a house and we can't see anything. We feel heat, and all we have is the senses of being able to feel where we are. … We're a unique group, but we are normal people.”

At the sheriff's office, they also vet clinicians to see who should be talking with their officers.

“We started a few years ago, we would look at the ones that like [Employee Assistance Program] and our insurance uses and refers us to,” Vawters explained. “We had a set of questions we would ask, and that became very time consuming—because there's a significant list. So, then we started going off referrals from people who had utilized EAP or various insurance services for mental health, and saying, ‘Hey, this person really worked for me. This person really didn't work for me.' So, it's really been word of mouth. And we do a lot of collaboration with other teams to see who've they've vetted.”

At RFD, Mandell said he's pleased with the list of “six or seven clinicians that are trauma trained, trauma experienced and can handle that stuff and handle talking to a firefighter” that his department has put together. Something the agencies have also been working on is ensuring insurance or worker's compensation payments when emergency responders need care after a traumatic event—which hasn't been entirely easy.

“They're used to seeing injuries—broken legs, broken arms,” Balaam said. “This was mental health, and so we had to pull in the county because [officers] had to start paying for some of those sessions by themselves. And so that's a learning curve for peer support. We're having to say to the county, ‘When we come to you with individuals who don't have obvious physical injuries, it's because it's mental … And just like if you broke your arm, we're going to provide those services to you.' So, the county has been very good, and peer support has been awesome at creating that environment where, ‘I know if I come forward it's not coming out of my pocket.'”

On Oct. 15, agencies across the valley—including the sheriff's office, RPD, RFD, TMFPD, the coroner's office and others—met to share some of their insights during a four-hour peer support workshop. Going forward, Balaam wants to see this type of cross-agency cooperation continue.

“This is a critical need,” he said. “And it's not just the sheriff's office. It's all of us pooling together, and that's something we're dedicated to—changing the culture.”