Consensus Approach to Firefighter Behavioral Health

By JoEllen Kelly, PhD, Project Manager, NFFF Everyone Goes Home programs
Reprinted from the NVFC’s Helpletter

The National Fallen Firefighters Foundation’s (NFFF) Firefighter Life Safety Initiative 13 focuses on the behavioral health of emergency responders and their families. However, evidence from current research indicates that the way firefighters have been offered psychological support in the past has not always been practical or effective. As a result, the NFFF has released a new model based on a consensus approach derived from the best scientific data from military medicine, community psychology, health and wellness experts, and fire service subject matter experts who have attended to the behavioral needs of firefighters and EMS professionals over many decades.

The underpinning of this new approach is to meet each firefighter where they are in terms of stress, and to offer appropriate levels of care. A preponderance of evidence has concluded that a one-size-fits-all approach to stress injuries or life events does not always work effectively at identifying problems and helping firefighters.

The model, called Occupational Stress Exposure to Potentially Traumatic Events, consists of a series of protocols to help identify who may be having a stress injury. The actions recommended in the model reflect best practices based on current research, and should fit easily into the operations and support systems that most fire departments have in place. The model itself begins with the question: Who is injured and how can we help? The key elements of the Occupational Stress Exposure to Potentially Traumatic Events model are as follows.

Determination of a Potentially Traumatic Event (PTE): A trauma for one responder may be a routine event for another. Reaction to a trauma is subjective, driven by an individual’s experience, sensibilities, and personal situation. After exposure to a PTE, members should be asked if they require assistance. If so, what type? If not, an expression of support may be all that is required. If we think of the flowchart as a series of types of assistance, we would move through the following types of help.

Time out/hot wash: This concept is borrowed from the military as an element of After Action Review (AAR). It is a mechanism that allows those affected by an event to review what happened, what was successful, what could have gone better, and how they might improve the next time they respond to a similar situation. This post-incident assessment will often help firefighters put the event into perspective. After a brief “time out,” the vast majority of fire and EMS professionals may elect to
return to service with no further assistance needed.

TSQ screening: The Trauma Screening Questionnaire (TSQ), available at, is a straightforward and easily-scored instrument to identify who is progressing well, and who may need additional help down the road. Used 3-4 weeks after the PTE, it consists of 10 simple questions about recent symptoms. More than six positive responses suggest that a more complete screening by a competent behavioral health professional may be warranted. The NFFF strongly recommends that any and all mental health clinicians who treat firefighters take the Help Heroes® online training offered by the NFFF and the Medical University of South Carolina.

Complete assessment: This can typically be accomplished by a referral to a department or jurisdiction’s Behavioral Health Assistance Program (BHAP, or EAP) or other competent behavioral health professional. BHAP counselors can often help with managing specific symptoms and dealing with other nonevent related stressors of daily living (such as marital problems, financial issues, etc.) that might be interfering with a member’s recovery from exposure to a traumatic event.

Treatment by specialty clinician: If more intensive care is needed, it should be provided by a specialist (psychiatrist, doctoral-level psychologist, licensed clinical social worker, or licensed professional counselor) with advanced training and supervised clinical experience in specific evidence-based treatment for PTSD, anxiety disorders, and depression.

There are many levels of assistance the NFFF has developed to help both individuals and departments improve their knowledge of the best ways to help firefighters and EMS professionals in the realm of behavioral health. In most cases these materials are free. Please visit the Initiative 13 web site and consider it your portal to resources and training regarding behavioral health in the fire service. All of the materials mentioned in this article are available on the Initiative 13 web site at

If you would like to discuss bringing training to your department, please contact Amy Tippett, NFFF Behavioral Health Training coordinator, at