Working with first responders and firefighters in therapy

I had recently started working with first responders. And I was attending my first meet and greet with firefighters at a fire department that had just contracted with my group practice, Redemption Counseling Center, for emergency service personnel therapy and mental health services. 

“How do I know you won’t be like the last therapist I had?” he said. “The one who threw up in her trash can when I told her about the two year old who got run over when his dad was backing out of the driveway.” 

The firefighter was sincere and asked his question legitimately. 

Everyone in the room was skeptical, rightly so, about whether or not I, and my team, could handle the content they would share if they showed up in our office. 

“I can’t eat scrambled eggs anymore,” another one told me. “You know, scrambled eggs and brain matter splattered on the highway, they look the same.” 

These firefighters had seen and lived through more years of trauma than many people who have fought in combat, and their hypervigilance showed it. 

They needed a therapist who didn’t require rescuing when they talked about the worst parts of their jobs.

They needed to make sure that if they opened up, they wouldn’t have to be the one taking care of their therapist. 

Working with first responders and firefighters in therapy is so important.

In light of the recent fires that have ravaged California, New Jersey, and other states across the country, there is no better time for therapists to be considering how they can best provide emergency service personnel therapy in the midst of the tireless work they do to keep our communities and homes safe. 

Firefighters and other first responders work long hours and many long shifts. 

They often sleep on floors and eat food from gas stations, and are at high risk for cancer, back injuries, severe chronic pain, and line of duty death. 

According to the Ruderman Foundation, firefighters and first responders are more likely to die by suicide then from workplace injury. 

Firefighters in particular have a suicide rate approximately 38.5% higher than the general population. (For police officers, the number is significantly greater.) 

Vicarious trauma and post-traumatic stress disorder (PTSD) are significant problems within the first responder community—and many therapists are not familiar or aware of the unique needs and problems that first responders face. 

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Emergency service personnel therapy: How to build trust

So, when providing therapy to emergency service personnel, how to build trust is an essential question. 

Where might a therapist start off when working with first responders and firefighters? 

Firefighters and first responders have a unique and embedded subculture that most therapists do not understand. 

Many firefighters are wary of opening up to someone who isn’t a part of, or who doesn’t understand, their subculture. 

Ask them questions about their jobs—what they love and hate

“Get them to open up by talking about their careers,” says Christina Curry, LPC, lead counselor of first responders at Redemption Counseling Center. 

As to how therapists can start building rapport when working with first responders, she said, “What are their goals? What do they love, what do they hate? Get them talking about why they went into the field.”

This will not only help the first responder open up, it will also help the therapist learn about the client, their work, and subculture. 

For many first responders, there is often a lot of stigma associated with seeking mental health treatment. 

Providing applicable psychoeducation about how they can better do their job and show up in their personal lives is a vital first step for therapists working with first responders. 

Introduce grounding, mindfulness, and breathwork techniques

Many therapists want to start emergency service personnel therapy sessions off by getting a client out of a state of hyperarousal and hypervigilance. 

While this is important, when working with first responders, this creates a challenge because emergency service personnel may argue that they need to stay in a state of hypervigilance to do their job, which is not untrue. 

Therefore, therapists need to think critically about how to help. 

First responders live in a state of vigilance when they are on the job and need to save a home, a community, or a life. 

Being in a state of hypervigilance allows them to fight when they need to fight, and push through things that no one should have to push through. 

It is not intuitive to run towards a burning home, but firefighters are trained to do this in order to keep our communities safe. 

Therapists need to help first responders understand that while vigilance can be important for their jobs, staying in that hypervigilant state all the time can be detrimental. 

Teaching emergency service personnel therapy techniques and tools like the Window of Tolerance, grounding techniques, mindfulness, and breathwork can be essential in helping them function more optimally both in and outside of work.

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What protocols work best? 

For therapists working with first responders and firefighters who are wondering what protocols work best, consider IFS and EMDR.

Internal family systems (IFS) and eye movement desensitization and reprocessing (EMDR) therapy are both approaches that have had incredible efficacy with first responders. 

Therapists should make sure that the modality they are using has evidence to support it being effective in working with first responders. 

It is also vital to inform firefighters and other first responders that they have multiple options, and that if the first treatment approach or modality doesn’t work for them, it does not mean they are too broken to heal.

Take a practical, whole-person approach

Due to the type of work firefighters do, practically fixing (or fighting) the problem is a huge focus. Most first responders are seeking a practical fix when it comes to their own mental and emotional health. 

Additionally, due to the nature of their jobs, it is essential that they are able to quickly get back into the line of duty and do things that the average person is unable to do. 

This can be challenging for therapists who are well-aware that there are no quick fixes. 

However, that said, therapists should consider practical approaches for the whole person, including assessments and tools targeted towards sleep hygiene, nutrition, physical health, and communication. 

For most first responders coming to therapy for possibly the first time, there are usually other areas in their life where they are experiencing problems. It’s not solely their mental health. Often work, physical health, relationships, and family are all suffering.

A few years ago when a wildfire burned through multiple neighborhoods in Flagstaff, Arizona, I asked the fire crews what their biggest struggle was in the aftermath. 

At the time, I had been working with first responders and firefighters for a number of years, but I was still surprised by the answer they gave me. 

It wasn’t the grueling days or the physical labor that had gotten to them. 

It was that they had not been able to save all the homes in the area. 

The guilt and shame and failure they felt was overwhelming, causing them to have nightmares and days riddled with self doubt.

They felt ashamed even to say it, because it meant admitting their failure out loud. 

The firefighters told me that people living in the area had assured them that they were “doing enough,” that they did “all they could have done,” but what they needed was somewhere to process their own shame and sense of failure that the general public didn’t understand. 

They told me that each house they lost was a personal failure that they carried with them. 

Even after years of working with them, I had more to learn. 

More to get curious about. 

Therapists working with first responders can provide significant benefit, but ultimately, as with all of our clients, the most important thing we can do is get curious and show up authentically without judgement. 

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