Mental Health Care in the Fire Service: It’s Acceptable, But Is It Accessible?

A firefighter on a ladder with a hoseline and flames in the background
Photo by Rita Reith, IFD.

By Lee Look

Remember when no one on the department would talk about depression? Or anxiety? Or post-traumatic stress disorder (PTSD)? Remember when the “culture of the firehouse” had no space for mental healthcare?

And remember when the Employee Assistance Program (EAP) would come in once a year and tell everyone all the resources they could access, knowing full-well that no one would, and the EAP would pocket the retainer, providing no services for the money?

I remember.

So why did we never access the services?

We have heard all the reasons.

  • It’s the job.
  • The culture of the (fire/police/EMS) won’t use mental health services.
  • I won’t get promoted if people think I’m soft.
  • Counselors don’t understand what we do. I’ll have to spend hours just explaining the job.

These reasons kind of make sense. I would love to say that none of those items are true. But they are. Or they were.

We have come a long way. “Mental Health” is no longer a forbidden topic. Fire conferences have sessions on PTSD, and burnout, and anxiety. There are mental health teams that go to disaster areas to work with survivors. When we lose a member of our community, mental healthcare for survivors has become a priority.

Chaplains, traditionally the “counselors of the firehouse,” are now able to stay within their areas of expertise, deferring other issues to mental health counselors.

This momentum was encouraging. It still is.

There were problems, however. Yes, mental health was an acceptable topic, at least on paper. But it wasn’t accessible. Just like most people, firefighters’ “off” days are often filled with second jobs, childcare, or 24 hours of overtime. Scheduling appointments is challenging. The first call to a counselor is the hardest step in the counseling journey. The guts it took to call and make the appointment may not still be there by time the appointment comes around. That fortitude may have instead been replaced by skepticism and anxiety. When someone calls a counselor, it is often a time of acute need. An opening that fits both the counselor’s and client’s schedules is usually weeks away. The time that care was needed has passed. Clients may not bother to show up, opting to “deal with it” on their own. Often, this “self-care” is unhealthy, and can exacerbate the problem.

And now, the coronavirus pandemic.

As if accessing mental healthcare wasn’t challenging enough. We can no longer be in a room with someone without a mask. Facial expressions, the non-verbal signals of mental status, are hidden from the counselor and client. Virtual appointments, while an option, are a challenge. No one wants to have a counseling session at the kitchen table of their home while kids are trying to do homework. Strong Internet signals have become the “comfortable couch” of the counseling business. Without a strong signal, or a comfortable couch, neither client nor counselor can focus.

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The pandemic stress is universal and yet very specific to this job. The general public has some discretion as to the amount of risk/exposure they want to take on. First responders do not have that option, thus accounting for the stress and fear. We may take it home to our loved ones/support systems. We may bring it back to the firehouse or the ambulance. We live every shift as a “mission,” dealing in “operational periods,” and working through the “incident command system.”

How does this manifest on the floor?

  • After a rough shift, first responders could typically count on returning home and having a support system to help process. Now members of the support systems are scared and the first responder doesn’t want to make it worse.
  • We may experience disinfection burnout. We are tired of mopping, spraying, and sanitizing every surface. Eventually we will revert to our normal level of “alert.”
  • We may be re-thinking interventions on serious patients. Best practices during a pandemic are slightly different. Any intervention that aerosolizes fluids will be weighed against the chances of success. This is an increased burden on the backs of the responders and not a decision that anyone wants to make.

Unlike other disasters, there is no end in sight: No end to the increased personal protective equipment needs; no end to the increased call volume; no end to the “mission” mindset. For better or worse, this stress has become routine.

Our loved ones are experiencing the same amount of stress. Our families, our friends—all are in the same place. Everyone’s capacity for supporting others is stretched thin. If ever there was a need for formal mental health support, it is now.

What can be done? What to do, when first responder mental health is arguably strained to a breaking point, and counselors can’t readily access the first responders? What happens when the two groups do connect and it’s virtual, creating yet another barrier between counselor and client?

I contend this is an opportunity. This is a chance to take these constraints and use them to build a new model. This model considers both the world we live in and the world we communicate in. The solution I propose is, a combination of two concepts: embedded counselors and narrative therapy.

  • Embedded counselors
    • Following the model of ‘embedded journalists: Embedding can benefit both sides, military and media, and help to improve their historically troublesome relationship.(1)
    • The regular contacts between the two (soldiers and journalists) build trust and reduce the common suspicion that normally exists between the two parties. Both informal and formal settings that develop during the embedment period can result in great transparency because the government and the armed forces will find it easy to pass information freely.(2)
  • Narrative therapy
    • Online Calming Effect: many people find online interactions less stressful than face-to-face interactions. (3)
    • Maybe you live in a small town or rural area. Or you might have trouble leaving home, whether that’s because of mobility challenges, physical illness, or mental health symptoms that make it difficult to leave the house…Text therapy provides another option. (4)
    • Online clients and therapists rated their session impacts and alliances as equally strong or stronger than had previously clients in face-to-face therapy. (5)

The traditional counseling model is not viable in this environment. Childcare is scarcer. Work schedules are less traditional. Most counselors don’t understand the unique nature of this work. Therapy may be considered an indulgence, unlike more typical doctors’ appointments, and indulgences amid a pandemic and economic collapse are often forgone.

The two-pronged approach outlined above will eliminate many of the obstacles of traditional therapy. Why do we share more of our thoughts at 10 p.m. to a bartender rather than at 3 p.m. in a counselor’s office? Why are we processing our fears at 2 a.m. staring at the ceiling in our bedrooms rather than at 4 p.m. in a counselor’s office?

The answer: because therapy requires both participants to be open and engaged, not just one. And if the client is worried about childcare, getting back to work, being seen entering or leaving the counselor’s office, or frustrated because the counselor keeps asking fire department jargon means, then the client is not ready to do the work.

And therapy is work.

Part 1

  • Engage the services of a counseling company.
  • This company should be able to commit enough resources to have one consistent counselor committed to one crew, for at least four hours per week.
  • This counselor would do “ride time,” namely being with the crew through their day, doing whatever the crew is doing: chores, hydrant testing, inspections, training, and responses. This would be done consistently on a weekly basis.
  • This builds relationships with the firefighters in a natural manner. Meeting someone for the first time sitting in an office is often uncomfortable and forced. Mopping floors with someone builds bonds.
  • It also allows the counselors to understand much more clearly the job of a firefighter/police officer/medic. It’s hard for a client, at times, to convey the trauma of an event (CPR, automobile accident, structure fire, etc.) and how that event lives in the brain of an emergency worker. The goal of the embedment is for the counselor to witness the beginning, the middle, and the end of an incident so that the client doesn’t need to explain it.

Part 2

  • Do a thorough “intake” of the client. Just as everyone is not suited for every therapist or every therapeutic orientation, not all situations are best served in this style of therapy.
  • Provide a HIPAA-compliant platform through which client and counselor can communicate.
  • Establish reasonable expectations for the number of interactions per day/week.
  • Establish reasonable expectations for turnaround time for a response (for example, if client writes to counselor at 2 a.m., can client expect a response by 2 p.m.?)
  • The time between approach and response allows the counselor to craft a more thoughtful, productive response. It allows time for research and it allows time to gather resources that the client can use.
  • During the time between in-person sessions, the client often becomes less specific about a feeling or situation. Additionally, the counselor may need to be reminded of the most recent conversations.

We did a version of this many years ago in our 40-member department. We had counselors spending time at the firehouse, riding on the truck during responses, and providing training for us on topics ranging from substance use to relationships. In general, it received a lukewarm reception, but we were getting to know each other. We were comfortable with each other, and eventually they became “one of us.”

At one point, we had a member of our department die by suicide. We were lost. We knew we needed help. And because of the relationships we had built with our counselors, we knew exactly who to call. We knew who would show up. And we weren’t bringing in “outsiders.” Best of all, the counselors knew us. They knew our personalities. They knew our faults. They knew our culture.

That’s the key.

Just like a firetruck. We put tools on the truck we are certain we will never need, but we put them on there anyway. Because we are always ready for the unknown. Just in case.

This model is an investment of resources, of course. More importantly, it’s an investment in the future. Something tragic will happen to every department. Let’s be ready. Just in case.

Lee Look, Ph.D. is a company officer with St. Matthews Fire & Rescue in Louisville, Kentucky. He is also a licensed psychological practitioner and a licensed long-term care administrator.


1. Brandenburg, Heinz. Security at the Source: Embedding Journalists as a Superior Strategy to Military Censorship. Taylor & Francis Online. 2007. Pgs. 948-963.

2. BohatALA. The Pros and Cons of Embedded Journalism. October 26, 2019.

3. Raypole, Crystal. (Medically reviewed by Timothy J. Legg, Ph.D. What’s the Deal with Text Therapy. May 22, 2020.

4. Ibid.

5. Reynolds, D’Arcy J. William B. Stiles, A. John Bailer, and Michael R. Hughes. Cyperpsychology, Behavior, and Social Networking. National Center for Biotechnology Information. May, 2013. Pgs. 370-377.

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