Administration and Leadership, Operations

The new NFFF Initiative 13 Works to Change Traumatic Incident Response Stigma

Issue 7 and Volume 39.

Though not found in any official job description, the difficult nature of an emergency responder’s job has come to be expected. They’ll often witness or be part of traumatic events that can weigh on them physically, emotionally, spiritually and mentally. These events will take place throughout their career and, in many instances, stay with them long past the initial event.

These traumatic events aren’t experienced or witnessed the same way by each provider, and oftentimes they can leave an invisible mark that presents a multitude of challenges. This can make it difficult for a first responder—and their colleagues, family and friends—to manage their lives.

Although mental health for emergency responders has become a higher priority in EMS, it traditionally has been given inadequate attention. As a result, the industry has seen the use of standard practices that may lack empirical support and at times may even contraindicate studies and evidence. Substance abuse and suicide rates have underscored the significance of having proper research and interventions in place to correctly address important issues about provider wellbeing.

A New Approach
Critical incident stress debriefing (CISD) was created to combat the risks emergency responders face, and there’ve been other systems promulgated over the years to help struggling individuals deal with exposure to traumatic situations. However, evidence suggests that a different approach is needed.1

The National Fallen Firefighter’s Foundation (NFFF) held its Firefighter Life Safety Summit in March 2004 to address the many issues that converge on line-of-duty injuries and deaths. From this meeting, the program Everyone Goes Home was developed to oversee the 16 Firefighter Life Safety Initiatives. Initiative 13 concerns behavioral health: “Firefighters and their families must have access to counseling and psychological support.”

Behavioral health has remained an important issue since the summit. There’ve been two National Fire Service Research Agenda Symposiums conducted by the NFFF focusing on “producing documents that would help to identify and prioritize the areas where research efforts should be directed.” At these symposia, behavioral health was ratified as a legitimate and important fire service research concern.

Figure 1: The NFFF occupational stress exposure recommended protocol

The NFFF occupational stress exposure recommended protocol

As Initiative 13 has been studied and evolved, new programs have been deployed by the NFFF to assist first responders and their families. Initiative 13 suggests that firefighters and EMS professionals, along with their families, need to have access to resources capable of assisting them to properly cope with the various complications that can arise in their ordinary lives (such as parenting issues, marital problems, substance abuse or even financial strains) coupled with the particular stressors associated with first-responder duties. A driving difference in the new trauma model is to determine if people need behavioral support in the first place, and to match the needs of the individual with the proper resources. It seeks a balance between needs and resources.

“What drove the need to reexamine how firefighters and EMS professionals are offered behavioral health care was our recognition that a behavioral health stress injury is just as serious as physical injury—both can take a firefighter or EMS professional out of his or her job, or contribute to compromised performance,” explains JoEllen L. Kelly, PhD, a project manager for the Everyone Goes Home program. “If a first responder has a blown knee or becomes injured, they will go and get it taken care of. A stress injury is different because these injuries can be hidden by the individual who may feel stigmatized for coming forward. In the past, also, many felt that the challenges of coping with a traumatic event would eventually pass if they just waited.”

Kelly explains this is true in the vast majority of cases, but in some responders, untreated mental stress can lead to tragic outcomes. To make sure all cases are assessed properly, the NFFF created a new screening method.

Trauma Screening
At the heart of the NFFF model is an understanding that firefighters and EMTs don’t all respond the same to a potentially traumatic event (PTE). The NFFF model attempts to determine who’s impacted and who may need assistance with the Trauma Screen Questionnaire (TSQ)—a tool for self-assessment that aids in determining if the individual is in need of behavioral assistance.

According to the NFFF, this model reflects best practices based on current research and can be easily added into the operations and support systems most fire departments currently have in place. The main components to the model focus on the following:

Determination of a PTE: Each responder will react to a situation differently and at different times. What may be traumatic for one individual may have no apparent impact on another. The key factor is that an individual’s reaction to a traumatic event is subjective and driven by a variety of influences on that individual responder. If a responder has been exposed to a PTE, the NFFF model suggests they should be observed through the hot wash (discussed next), asked if they require assistance, and evaluated utilizing tools such as the TSQ. In some cases, the expression of support may actually be all that’s needed.

Time out/hot wash: This is a concept borrowed from the military and works similarly to the after-action review (AAR). This component allows individuals who may have been affected by an event to review what occurred. Individuals can discuss which parts of the event worked well, and what could have been changed to make it more successful. The AAR can help the crew leaders determine who may be having difficulties.

TSQ: The TSQ is a free, straight-forward assessment tool that makes it easy to identify who’s progressing well and who may require additional assistance down the road. This component is typically used 3–4 weeks after the PTE and consists of 10 simple-to-answer questions about ongoing symptoms. If more than six positive responses are answered on the questionnaire, a more complete screening will be recommended and a competent behavioral health professional may be needed for further care.

Complete assessment: For further assistance, a complete assessment is done by a behavioral health assistance program (BHAP) counselor. Typically this is accomplished through a referral because BHAP counselors are able to assist in the management of more specific symptoms, as well as coping with other stressors of daily life. These components, such as marital problems, financial issues, etc., can interfere with an individual’s overall recovery. If a department doesn’t have its own employee assistance program or BHAP, a community resource will need to be identified.

Know the Difference
The new model has the support of mental health experts from across the spectrum. Although it’s different from the current model, it still completely supports the same ethos to help first responders recover from stress injuries. However, it may be helpful to review the differences between the two.

The central concept behind the standard CISD model is a seven-phase structured group discussion that’s provided 1–10 days following a crisis.2 It’s purported to help mitigate acute symptoms, assess the potential need for follow-up and, when possible, help give a sense of psychological closure in the post-crisis state.

“The level of impact on an individual’s emotional, behavioral, physical and psychological state from a traumatic event will mostly stem from the degree in which they were involved with the event,” explained professor, author and researcher Joseph A. Davis, PhD, from the California State University system. “Re-exposure and re-arousal to the traumatic event can create further acute or possible long-term side effects due to reintroducing the trauma.” He states that there’s real concern in the mental health community about the harmful effects of the application of current models on emergency service workers.

The National Fallen Firefighter's Foundation new Initiative 13 focuses on behavioral health of emergency responders.

The National Fallen Firefighter’s Foundation new Initiative 13 focuses on behavioral health of emergency responders.

“The real concern essentially rests with mandated CISD vs. elective CISD,” continued Davis. “Proponents of the Mitchell model indicate there are certain incidents which, by virtue of their involvement, suggest all emergency personnel go through CISD and some suggest that it be elective. Also, some suggest that a peer might be a more effective debriefer than a mental health professional. This is an ongoing debate.”

Critical incident stress management (CISM) specialist and Director of Robert Douglass and Associates Robert Intveld states that as a first responder model, CISM is a form of crisis intervention. If delivered to a willing, homogeneous party led by a highly skilled professional and featuring peer support, it can be effective.

“A challenge with the CISM model and more specifically CISD, is its flexibility to use with a wide range of reactions and among diverse populations. If research is telling us that the most prevalent response to a critical incident is one of resilience (this without formal intervention) then we are likely to have resilient group members who are in no need of services but nonetheless are subjected to them via the CISM process.”

According to Intveld, controversial matters raise the liability risk. “If there is a chance of a harmful outcome, the method is not likely to be supported. At the end of the day we need to feel confident in our approach and utilize the best practices
out there.”

The NFFF behavioral health model was developed to help give tools to the individual and their families and help keep their lives on track. According to Kelly, it’s developed to identify who and what kind of support is needed.

“We started with a commitment to have the best people in the country find a solution,” he said. “We scoured the fields of military medicine, community psychology, EAP and fire service leadership—to determine the best-stepped care protocols for firefighters and EMS professionals.”

For more information about the NFFF model and the 16 Firefighter Life Safety Initiatives, visit

More Provider Wellness from

1. Turkington D, McKenna PJ. Is cognitive-behavioural therapy a worthwhile treatment for psychosis? Br J Psychiatry. 2003;182:477–479.
2. Mitchell JT, Everly GS: Critical incident stress debriefing: An operations manual. Chevron: Ellicott City, Md., 1996.