OT’s Role in Firefighter Mental Health

Alyssa M. Garcia, OTD, OTR/L

Firefighters are regularly exposed to traumatic events on calls which results in their decreased mental health; and associated decreased participation in meaningful occupations, routines, and roles (Edgelow & Cramm, 2020; Edgelow et al., 2021; Wittwer et al., 2021). In 2017, firefighting was named the second most stressful job in the nation behind serving in the military (Isaac & Buchanan, 2021); however, the rate of suicide attempts among firefighters is two to three times higher than those of civilians and military personnel (Henderson, 2022). Because of this and the stressful work environment, firefighters are 10% more likely to have poor mental health and related behaviors (Substance Abuse and Mental Health Services Administration, 2018). Specifically, firefighters are at a high risk of:

• Posttraumatic stress
• Anxiety 
• Depression 
• Suicidality 
• Substance abuse 
• Burnout 

(Bing-Canar et al., 2019; Teoh et al., 2019)

As an occupational therapy student and a daughter of a firefighter, I felt there was more occupational therapy could do for this surprisingly vulnerable population. I dug into the research and found there was a role of occupational therapy in this niche, specifically in their interrupted occupations, routines, and roles. The three occupations most frequently interrupted are sleep, work, and social participation (Edgelow et al., 2019). With routines, regular exercise, sufficient sleep, healthy nutrition, quiet hobbies, social participation, outdoor recreation, and volunteering are the most frequently interrupted (Torchalla et al., 2019). Lastly, with roles, there is often an over-identification with the firefighter role and culture that leads to an inability to properly process the trauma in a healthy way (Hom et al., 2018; Torchalla et al., 2019). 

Additionally, gaps in current mental health services for firefighters were just begging for occupational therapy’s holistic, client-centered approach to make an impact. The three gaps in services are preemptive psychoeducation, practical support that can be integrated into the firefighters’ daily lives, and an understanding of the fire culture (Kim et al., 2021). To address these needs, I created a capstone to conduct research to learn more about firefighters from an occupational therapy perspective and to deliver a program to help firefighters cope with trauma. 

I created an original quantitative assessment to understand how firefighter demographics interact with interrupted occupations, routines, and roles and at what frequency when faced with work-related psychological trauma and stress (Edgelow et al., 2021; Gulliver et al., 2021; Pennington et al., 2022). My findings revealed that…

• After 3 to 6 years in the fire service, the functional impact of work-related trauma and stress begins to appear. 
• There is a sweet spot in the early and midcareer during which functional participation is withing normal limits.
• There is a decline in functional participation from 11-14 years up to 19-22 years when the firefighters retire.
• Single firefighters have better functional outcomes than those who are in a relationship and/or divorced.
• Married firefighters had significantly better functional outcomes than those in a relationship but not married. 

(Garcia et al., 2023)

With my program, I made a 30-minute workshop tailored to firefighters with guided self-reflection and education on re-engaging in interrupted occupations, routines, and roles. The feedback from the program participants was overwhelmingly positive:

• 100% found it interesting, useful, clear, engaging, and beneficial to co-workers
• 96% reported it was new information 
• 98% would implement these strategies 
• 93% already implement these strategies and felt it improved their abilities to cope 
• Additional feedback: mental health statistics were shocking and eye-opening 

(Garcia et al., 2023)

            Future recommendations to further this much needed work are to expand the research to different ranks as well as marital and familial status, see how trauma processing changes with switching from the rescue to the engine truck, conduct a longitudinal study after a potentially traumatic event, and conduct a qualitative or mixed methods study to further analyze the nuances in this population. Furthermore, the program should be conducted at every level of the department, to fire/paramedic students, loved ones of firefighters, and to the fire department administration and local council members in charge of policy and funding for mental health services. To the next passionate occupational therapist, the cultural shift towards self-care and mental illness awareness in the fire department and society as a whole has primed the way for strong mental health resources to be implemented and to better the lives of firefighters and those around them.

 References

Bing-Canar, H., Ranney, R. M., McNett, S., Tran, J. K., Berenz, E. C., & Vujanovic, A. A. (2019). Alcohol use problems, posttraumatic stress disorder, and suicide risk among trauma-exposed firefighters. The Journal of Nervous and Mental Disease, 207(3), 192-198. https://doi.org/10.1097/NMD.0000000000000947

Edgelow, M., & Cramm, H. (2020). Developing an occupation-centred framework for trauma intervention. Occupational Therapy in Mental Health, 36(3), 270-290. https://doi.org/10.1080/0164212X.2020.1808148

Edgelow, M., Lewis, M., Toope, M., & Cramm, H. (2021). Environmental scan of return to work programs for trauma-related mental health conditions. Occupational Therapy in Mental Health, 37(3), 264-277. https://doi.org/10.1080/0164212X.2021.1923430

Edgelow, M. M., MacPherson, M. M., Arnaly, F., Tam-Seto, L., & Cramm, H. A. (2019). Occupational therapy and posttraumatic stress disorder: A scoping review. Canadian Journal of Occupational Therapy, 86(2), 148-157. https://doi.org/10.1177/0008417419831438

Garcia, A., Kasyan-Howe, P., Domville, K., & Llaca, K. (2023). Analysis of firefighters’ psychological trauma and interrupted domains. [Doctoral project, University of St  Augustine for Health Sciences]. SOAR @ USA: Student Capstone Papers Collection. https://doi.org/10.46409/sr.OKQD7764 

Gulliver, S. B., Zimering, R. T., Knight, J., Morissete, S. B., Kamholz, B. W., Pennington, M. L., Dobani, F., Carpenter, T. P., Kimbrel, N. A., Keane, T. M., & Meyer, E. C. (2021). A prospective study of firefighters’ PTSD and depressive symptoms: The first 3 years of service. Psychological Trauma: Theory, Research, Practice, and Policy, 13(1), 44-55. https://doi.org/10.1037/tra0000980

Henderson, E. (2022). Conceptualizing suicide prevention in firefighters through the lens of the Interpersonal-Psychological Theory of Suicide: A narrative review. Archives of Suicide Research, 26(1), 28-43. https://doi.org/10.1080/13811118.2020.1779152

Hom, M. A., Stanley, I. H., Spencer-Thomas, S., & Joiner, T. E. (2018). Mental health service use and help-seeking among women firefighters with a career history of suicidality. Psychological Services, 15(3), 316–324. https://doi.org/10.1037/ser0000202

Isaac, G. M., & Buchanan, M. J. (2021). Extinguishing stigma among firefighters: An examination of stress, social support, and help-seeking attitudes. Psychology, 12(3), 349-373. https://doi.org/10.4236/psych.2021.123023  

Kim, J., Aggarwal, A., Maloney, S., & Tibbits, M. (2021). Organizational assessment to implement trauma-informed care for first responders, child welfare providers, and healthcare professionals. Professional Psychology: Research and Practice, 52(6), 569-578. https://doi.org/10.1037/pro0000408

Pennington, M. L., Cardenas, M., Nesbitt, K., Coe, E., Kimbrel, N. A., Zimering, R. T., & Gulliver, S. B. (2022). Career versus volunteer firefighters: Differences in perceived availability and barriers to behavioral health care. Psychological Services, 19(3), 502-507. https://doi.org/10.1037/ser0000559

Substance Abuse and Mental Health Services Administration. (2018). First responders: Behavioral health concerns, emergency response, and trauma. Disaster Technical Assistance Center Supplemental Research Bulletin, 4(1), 1-15. https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf

Teoh, K. R. H., Lima, E., Vasconcelos, A., Nascimento, E., & Cox, T. (2019). Trauma and work factors as predictors of firefighters’ psychiatric distress. Occupational Medicine, 69(8-9), 598-603. https://doi.org/10.1093/occmed/kqz168

Torchalla, I., Killoran, J., Fisher D., & Bahen, M. (2019). Trauma-focused treatment for individuals with posttraumatic stress disorder: The role of occupational therapy. Occupational Therapy in Mental Health, 35(4), 386-406. https://doi.org/10.1080/0164212X.2018.1510800

Wittwer, M., Ramella, K., & Gupta, J. (2021). Perceived benefits of counseling provided to first responders through the Officer Craig Tiger Act. The American Journal of Occupational Therapy, 75(Suppl. 2), 7512505123p1. https://doi.org/10.5014/ajot.2021.75S2-PO123