A brief descriptive analysis of a pilot study of peer support training and supervision for Texas firefighters

Abstract

Background

Peer support has been shown to reduce the incidence and severity of mental health disorders among firefighters. This pilot project had two aims: (1) to assess training satisfaction and knowledge, self-efficacy, and skills development of Texas firefighters participating in the International Association of Fire Fighters (IAFF) Peer Support Training, and (2) to determine if newly trained peer support specialists would use monthly phone supervision.

Methods

The study included 14 Texas firefighters who enrolled in the IAFF Peer Support Training. Pre- and post-tests were administered to evaluate training satisfaction, skills development, self-efficacy, and behavioral health knowledge of participants. Use of phone supervision over 6 months following the training was also recorded.

Results

Overall, participants reported high satisfaction with the training provided. While self-efficacy regarding detection of mental health issues and therapeutic empathy skills significantly improved following the training, participants did not show a significant improvement in knowledge regarding mental health. Attendance of participants to supervision calls was less than expected, although 71% attended at least one supervision call.

Conclusions

This project was successful in increasing firefighters’ self-efficacy and therapeutic empathy skills, and participants were highly satisfied with the training. However, further research on follow-up supervision of peer support trainees is needed.

Peer support services and programs have many advantages when used in conjunction with standard clinical care. These programs use individuals with lived, similar experiences, who are not professional clinicians, to provide behavioral health support to those in need. Peer support can eliminate standard barriers to behavioral health care such as transportation, cost, and scheduling, which expands access to behavioral health care. It can also help reduce stigma associated with using behavioral health services, as trained peer supporters often share their lived experience in a manner that reduces shame.¹

Peer support has been utilized among a variety of populations, including firefighters.^2,3 Firefighters are exposed to high levels of potentially traumatic occupational stress, which can be a factor in developing behavioral and physical health conditions.^4–9 This exposure elevates firefighters’ risk for development of depression,^10–13 posttraumatic stress disorder,^10,11,14,15 and suicidality.^16,17 Currently within fire service, 13% to 16% of firefighters are at risk for depression,^14,18 between 8% and 26% of firefighters endure posttraumatic stress symptoms,^6,19–21 and 30% show evidence of addiction.²² Despite the knowledge that stress load is very high in fire service, stigma remains a significant barrier to evidence-based care.^23,24 In one study, 23% of firefighters indicated that stigma would prevent them from using behavioral health services, and 29% indicated that using behavioral health services might damage their reputation.²³ Peer support may be used to alleviate stigma and bridge the gap between firefighters’ behavioral health needs and access to professional services.

The International Association of Fire Fighters (IAFF) currently offers a standardized peer support training to its members and departments across the United States and Canada. The IAFF Peer Support Training is a 2-day program in which trainees gain the skills necessary to provide peer support, such as an understanding of common mental health issues in fire service and an understanding of how to connect firefighters to formal behavioral health treatment from clinicians. The IAFF considers peer-led support programs the cornerstone of any fire service behavioral health program.²⁵ However, in Texas, behavioral health programs are not widely established among fire departments, and to our knowledge, at the time of this project, no standardized peer support training had been disseminated within Texas, despite the fact that 54,778 Texas firefighters provide emergency services for the second largest American state.²⁶

To date, there is a paucity of research regarding the collaboration of peer supporters and professionals to provide client-centered care for firefighters. Thus, this pilot project had two primary aims: first, to assess training satisfaction, behavioral health knowledge, self-efficacy, and skills development of the Central Texas firefighters participating in the IAFF Peer Support Training, and second, to determine if newly trained peer support specialists would use monthly phone supervision.

METHODS

Procedures

Fourteen firefighters from three professional Central Texas fire departments received IAFF Peer Support Training, hosted by Warriors Research Institute of Baylor Scott & White Health, as part of a project funded by the Hogg Foundation for Mental Health. The 14 attendees were firefighters of varying ranks, recruited to participate in the 2-day training by the IAFF union presidents or department leadership from their respective departments. The participants provided informed consent prior to the training and completed paper-and-pencil self-report assessments prior to and following the 2-day training. At training completion, all attendees were scheduled for once-monthly supervision phone calls with a senior firefighter, Captain Frank Leto, director of the New York Fire Department Counseling Service Unit, and a licensed clinical psychologist (Dr. Gulliver) for 6 months after the training. The Texas A&M University institutional review board and the Baylor Scott & White institutional review board approved all procedures.

Pretraining assessments evaluated firefighter levels of peer counseling skills, efficacy, and knowledge. The posttraining assessments included pretest measures in addition to a measure of training satisfaction and usefulness.

Measures

Demographic information

Basic demographic information (e.g., age, sex, race) and information related to fire service (e.g., current rank, years of service) was collected.

Training satisfaction and helpfulness

The Training Satisfaction and Helpfulness Questionnaire (TSHQ; Gulliver et al., unpublished measure) was adapted to assess participants’ satisfaction with their training. The original measure from which it was adapted (Patient Satisfaction/Condition module of the Longitudinal Interval Follow-Up Evaluation²⁷) is a quality assurance measure used to assess participants’ satisfaction with the group experience and their perception of the usefulness of different group components/modules.

Behavioral health knowledge

The Behavioral Health Quiz for Firefighters (BHQ-FF) is a 12-item test designed by Dr. Gulliver and team to assess behavioral health knowledge. The BHQ-FF consists of multiple-choice questions designed to assess knowledge of relevant behavioral health issues, including posttraumatic stress disorder, depression, alcohol use disorders, and suicide.

Behavioral health intervention self-efficacy

The Behavioral Health Intervention Self-Efficacy Questionnaire (BHISEQ) is a 9-item self-report measure designed by Dr. Gulliver and team to assess how confident firefighters are in their ability to identify and intervene in situations in which they believe someone is in need of behavioral health services. Sample items include “How sure are you that you could detect if a fellow firefighter was feeling depressed?” and “How sure are you that you could get a firefighter to behavioral health care if they needed it?” The measure employs a 5-point Likert scale (1 = unsure, 5 = sure) and is modeled after existing self-efficacy measures.

Therapeutic empathy

We adapted the Helpful Responses Questionnaire (HRQ)²⁸ for firefighters (HRQ-FF) from the traditional HRQ to assess development of therapeutic empathy skills. This measure provides five simulations of communications with individuals with specific concerns and asks participants to write down the next thing they would say if they wanted to be helpful in that situation. Participants’ responses were coded by two assessors on a 5-point scale designed to assess empathy and depth of reflective listening. Interrater reliability for the original six HRQ items ranges from 0.71 to 0.91, and reliability for the total scale is excellent (0.93).

Participants

Of the 14 professional firefighters, 93% were male, which is consistent with the fire service population across the United States.²⁹ The mean age of participants was 34.77, and they had completed an average of 1.36 years of post–high school education. Approximately 86% were firefighters and/or engineers, while 14% were officers. Of the sample, 72% reported that they did not have a behavioral health program in their department, and an additional 7% reported that they were unaware of a behavioral health program in their department.

RESULTS

Participants reported high satisfaction with the training: M = 49.54 (SD = 2.63), range = 44 to 53 (possible range 11 to 55). In general, all attendees reported they were “glad that I participated in this training” and “satisfied with my participation in the training.” Also, 100% reported that they were “confident that I can use the information presented to me today” and “learned skills today which will help me better handle situations in the fire station.” When asked how likely the students were to recommend the training to a friend, all endorsed likelihood, with a mean of 8.21 (SD = 1.23) out of a possible 9 for highly likely.

In terms of knowledge acquisition regarding general mental health, no detectable change occurred (paired sample t = 0.000, P = 1.0; Cohen’s d = 0.000). The mean total knowledge score at pretest was 9.77 (SD = 1.36), and a similar mean was found at posttreatment assessment (X = 10.17, SD = 0.937). However, self-efficacy in detection of mental health issues in fellow firefighters improved following the training (t = −4.54, P < 0.001; Cohen’s d = −1.21), with a mean of 33.36 (SD = 4.43) at pretraining and a mean of 38.50 (SD = 4.20) at posttreatment. Therapeutic empathy skills improved (t = −10.21, P < 0.001; Cohen’s d = −2.73), with a mean total score of 6.79 preceding training (SD = 1.62) compared to a posttraining mean of 13.57 (SD = 1.74).

Attendance to supervision calls was meaningfully less than expected. The first month following training had the greatest attendance, with 57% (8) of participants calling in for supervision with a senior peer firefighter and the clinician. The last 2 months showed the lowest participation, with only 14% (2) attending for each month. No one participant attended every supervision session, although 71% (10) attended at least one session and 29% (4) attended four or more sessions.

DISCUSSION

The current study aimed to assess training satisfaction and knowledge, self-efficacy, and therapeutic empathy skills development of Texas firefighters participating in the IAFF Peer Support Training and to determine if newly trained peer support specialists would use monthly phone supervision. The results of our study showed that participants were highly satisfied with the training. Additionally, self-efficacy regarding firefighters’ ability to identify mental health issues increased significantly following the training, as did therapeutic empathy skills. However, participants did not show a significant improvement in knowledge regarding mental health. Attendance at supervision calls was less than expected, with 57% of participants attending in month 1, decreasing to only 14% attending in month 6. However, 71% of participants attended at least one supervision call.

Increasing self-efficacy of identifying mental health issues among fellow firefighters is important because it may lead to early treatment following potentially traumatic events. Similarly, increasing skills of therapeutic empathy may help to decrease stigma concerns among firefighters who are hesitant to seek help. Stigma remains a significant barrier to evidence-based care in fire service due to the “tough guy” mentality.³⁰ Peer support provided by a trusted firefighter may be used to alleviate stigma and bridge the gap between firefighters’ behavioral health needs and access to professional services. It is concerning that knowledge of behavioral health did not change meaningfully from pretraining to posttraining, but it should be noted that there was a relatively high level of correct answers to the quiz at baseline (a ceiling effect), so there was not much room on the measure for improvement.

Monthly supervision calls with a senior firefighter and licensed clinical psychologist were not attended as frequently as expected. However, decreasing attendance at the monthly calls may be due to increasing confidence in abilities and skills over time following the training, as the majority of firefighters trained attended the call the first month following the initial training. Furthermore, 71% of participants attended at least one supervision call, so it is possible that trainees only used supervision on an as-needed basis as issues occurred during their work as peer supporters. Although ongoing supervision after Peer Support Training is appealing, to date, no empirical evidence exists to argue either for or against inclusion of supervision. As peer support specialists are unlicensed and unregulated volunteers, there are fewer contingencies on peer supervision, and it seems prudent to offer the support of licensed professionals.³¹

Although this descriptive project contributed to evaluating the IAFF Peer Support Training, some weaknesses must be noted. First, recruitment for the 2-day IAFF Peer Support Training was handled solely by union and department leadership and thus was not random. The only guidance provided by this team regarding attendees was to include members who were active-duty fire service personnel. A more comprehensive recruitment strategy may have yielded additional students; however, this is the typical recruitment strategy used nationally for selecting peer support specialists. Second, this was the first evaluation of the training intervention, and more data are in order. Finally, the supervision calls likely deserved additional advertising and promotion. Nonetheless, as a first step, this study demonstrated that firefighters found the IAFF Peer Support Training highly satisfactory, and most firefighters availed themselves of at least one supervision session.

Funding Statement

This research was supported by a grant from the Hogg Foundation for Mental Health [RRU-004; PI: Gulliver]. The authors report no conflicts of interest.