“Chaplain, follow me into the fire scene,” the incident commander ordered. As we entered the burnt-out room of a high-rise apartment building, a charred body was sitting grotesquely in his electric wheel chair. “I went to high school with him,” the commander said as the color drained from his face.

At the time, it seemed like my colleague was simply facing up to his own mortality. In reality, however, the veteran fire officer had nightmares of this scene long after. Throughout the night he would roll out of bed to wash his hands over and over again. The stench, the sight, the touch of his old school acquaintance etched a dark stain on his memory.

Trauma in emergency services has given rise to an entire industry of Critical Incident Stress Management. However, the matter is much larger and more complicated than CISM. One debriefing in the fire station can't possibly deal with the complex issues fire service personnel experience.

Chaplains function as triage officers for fire service personnel. Most chaplains thrive on this role and relish being needed. Sometimes, however, if they are slow to refer personnel for specialized help, triage becomes treatment, limiting their effectiveness.

Time to refer

Referral conveys to some chaplains a sense of failure. If we refer to another specialist, we are admitting our limitations. The truth, of course, is that everyone has limits imposed by experience, understanding and training.

Chaplains need to build a network of caregivers. (See the Referral Matrix, page 96.) Often referral is misconstrued to be abandonment. We perceive it as passing the firefighter's problem on to someone else. In reality, referral is as essential as follow-up is after a referral.

“What happened?” I asked two firefighters checking an upstairs landing for hot spots.

“The old guy didn't make it,” said one, machismo masking the misery. I could barely make out the victim's charred body under a pile of blackened blankets. After checking to see how each of the firefighters was coping, I left the firefighters to their chief.

This was really abandonment. As a chaplain, I was good at responding but followed up poorly. The secret of effective referral is proactive referral. So when it is time to make a referral?

Three guidelines can assist in determining the correct time for referral. Referral is usually necessary when:

The problem exceeds the chaplain's skills

Perhaps the firefighter exhibits self-destructive tendencies or there is evidence of addictive behavior. There may even be deeper mental health issues, such as obsessive-compulsive disorder. Perhaps the issues may require legal advice, which only an attorney can give. Very often the employee assistance program becomes the best ally for the chaplain in such referrals.

Crisis counseling is not enough

The chaplain's main role on the fire scene is presence; he or she is there to listen. As chaplain and professor Henri Nouwen put it, “The friend [or chaplain] who cares makes it clear that whatever happens in the outside world being present to [or for] each other is really what matters.” But the dynamics of first response dictate that there is little time and less privacy for in-depth counseling.

For instance, after a plane crash, it took two days to recover all the bodies. There were no survivors. A chaplain encountered a worker from the medical examiner's office toting a biological waste bag.

“Body parts?” the chaplain asked.

“You got it,” she replied grimly as she rushed to clean up the scene. No follow-up was given, as the ME's office has little or no crisis assistance.

Needs go beyond the time available

The chaplain's role is emotional, mental and sometimes spiritual first aid, sort of an EMT of the soul and the spirit. As dedicated as we are, often needs go far beyond our skills and time.

For instance, firefighters were recovering from a child's particularly disturbing death. At the end of a CISM session, a rookie exploded. “We lost a ton of guys at the World Trade Center,” he blurted out, “and this kid died on us, too.” Pressure and stress is cumulative, and this young firefighter had reached his limit.

Referral network

The chaplain is simply an emergency counselor; the main task is to find further care for firefighters. Here are some of the referral partners for fire chaplains. A more complete catalog is found in the matrix.

Mental health facilities

These psychiatric emergency rooms can quickly assess presenting symptoms and decide on the best course of care. This is appropriate when a firefighter might hurt himself or others. It also holds true when there's an attempted suicide or threat of such action. Sometimes a particularly traumatic experience demands immediate intervention by mental health professionals.

While serving in England, I encountered a police officer who was shot during a robbery and seriously wounded in the face. At first, his strong spiritual resources and tight circle of colleagues and family supported him. However, that support was not enough, and ultimately he was forced to take a medical retirement from the force. Proper referral may have prevented that.

Psychiatrist

An otherwise very well-adjusted firefighter confided he was privately struggling. The chaplain discovered a history of mental illness in his family, some ending in suicide. Prompt referral to a psychiatrist revealed a bipolar disorder, and medication brought the firefighter years of healthy living.

In another instance, a health care professional manifested indications of disorientation. The chaplain referred this patient to an emergency center. The alert physicians discovered a chemical imbalance, which responded immediately to intravenous therapy.

A referral to a psychiatrist or a medical professional is necessary if someone:

• Attempts to hurt the counselor.
• Displays delusions of grandeur.
• Displays abrupt change in behavior.
• Hears voices.
• Expresses rigid or bizarre ideas.
• Displays obsessive/compulsive behavior.
• Is disoriented.
• Is clinically depressed.
• Is withdrawn.

Emergency room

The chaplain must refer someone to the emergency room in instances of drug overdose (or suspected overdose), or attempted suicide of a firefighter or significant other. Also, in cases of work-related injuries, the chaplain can accompany the firefighter, releasing a line officer to stay at the scene.

A young firefighter struggled to clear a hydraulic line. When the line finally cleared, it sprayed hydraulic fluid in his face and eyes. The chaplain was able to accompany him to the emergency room. This released the incident commander to oversee the extrication. The chaplain's presence eased the firefighter through this crisis.

Psychologist

Our union local makes an excellent licensed psychologist available to its members as part of its employee assistance program. A psychologist is particularly helpful in cases of persistent depression. The incidence of clinical depression has increased since Sept. 11, 2001, in many fire departments, not only in New York.

Anxiety neuroses also can respond well to psychological counsel. The line-of-duty death of a firefighter can trigger such neuroses among his or her colleagues.

Referral Matrix

	Presenting Symptoms	Therapeutic Process	Desired Outcome
Mental Health	Attempted suicide or bodily injury Violent or dangerous behavior	Stabilize the patient Refer for further treatment Hold for protective care	Amelioration of crisis situation
Social Services	Threat to hurt self or others Suspected child or spouse abuse Unsuitable living conditions	Protection of at-risk minors Protection of at-risk spouse Protection of mentally incompetent person	Provide legal and physical protection for at-risk parties
Emergency Room	Drug overdose Attempted suicide Injury	Provide immediate life-saving care Refer the patient for further treatment if needed.	Relief from immediate physical condition
Psychiatrist	Mental illness which presents as psychotic behavior, such as schizophrenic, paranoid, bipolar and hysteric behavior	Professional diagnoses Testing when required Prescription of needed medication.	Alleviation of immediate symptoms Achievement of biological balance Oversight of maintenance
Psychologist	Family issues Anxiety neuroses Dependency issues Sexual dysfunction	Testing as needed Counseling over several sessions Rehabilitation as required	Achievement of proper psychological and family balance through behavior modification
Sociologist	Interpersonal conflict Antisocial behavior	Testing as required Counseling over several sessions Connecting with available services	The achievement of proper socialization and balance.
Financial Counselor	Uncontrolled debt Bankruptcy Family conflict over finances	Analysis of spending and income patterns Development of budget Oversight of compliance	The achievement of financial viability for the family unit or individual
Attorney	Problems of legal conflict Risk of financial or custody loss	Assessment of legal position Legal action as required	Achievement of equilibrium before the court
Clergy/Chaplain	Usually the clergy-person is involved at the time of trauma	Often the task is triage to others Sometimes there is direct spiritual counseling	Proper and immediate and empathetic care of the presenting need as well as referral for further counseling
Fire chaplains can use this catalog of referral partners for mental health and social services based on symptoms present and desired outcome.

Dependence issues, even to simple over-the-counter drugs, can respond well to psychological counsel. An alert chaplain can steer endangered firefighters in the direction of such help.

Social services

Sometimes, a distressed firefighter needs not only help from mental health professionals, but from social support services as well.

Sociologist

Some counselors hold a master's of social work. They often specialize in addiction and can ease a firefighter into a 12-step program. From Alcoholics Anonymous to Higher Ground, this type of counseling is peer-based and promotes accountability.

Financial counselor

Unwise credit card use or post-divorce financial management can result in the specter of bankruptcy, the first symptom of financial distress. I often refer firefighters in need of financial first-aid to Consumer Credit Counselors, private financial counselors, or the faith-based Crown Financial Ministries.

Attorney

Impending divorce is a frequent stressor for firefighters. A related and even more stressful matter is child custody. Advising him or her concerning appropriate legal advice can be helpful.

“I don't know what's wrong with my husband,” a perplexed woman lamented. “He's never home. When he is, he seems so distant from me and our small son.” In fact, he had set off on a business trip that very morning with a female colleague.

I eased into the question: “Do you think he might be having an affair?”

Her response was as emphatic as it was negative, “No, he'd never do that.”

She later learned he was having an affair. My first referral was to a particularly skillful divorce attorney, who clarified the issue and protected her and her son's interests.

Peer counselors

In their Critical Incident Stress Management model, Jeffrey T. Mitchell and George S. Everly Jr. introduced the value of peer counseling. Since Sept. 11, however, many crisis counselors and chaplains are moving beyond this model to a more flexible approach to post-traumatic stress management. I'm currently assisting Richard Gist and S. Joseph Woodall, Ph.D.s, in preparing a textbook, Managing Post-Incident Trauma for the Fire Service.

Peer counseling may work best on an informal basis. Often the best “counselors” for stressed firefighters are members of their own fire company. Sometimes, though seldom, this may lead to a formal debriefing.

Following the plane crash and the prolonged recovery of bodies, the firefighter support team (including chaplains and psychologists) sent the companies back to their stations with this advice: “Talk freely to each other. Share what you are going through.” Subsequent follow-up revealed a remarkable lack of post-traumatic stress symptoms.

Chaplain

In many ways, the chaplain can be the point person in directing personnel to various employee assistance options. This brings us back full circle to the role of the chaplain or team of chaplains.

The chaplain has a distinctive role in leading ceremonial events. This is especially true in funeral services. The Bureau of Justice Assistance and National Fallen Firefighters Foundation provide a manual for funeral services. For more information, e-mail: firehero@erols.com or visit www.firehero.org.

The first role of the chaplain is triage. He or she passes on the firefighter to other counselors or caregivers. Sometimes the chaplain enters into prolonged spiritual counseling. But everyone has limits imposed by experience, understanding and training. If a chaplain can't provide sufficient help, refer outside the department to someone who can.

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Wayne Detzler is the chaplain for the Charlotte (N.C.) Fire Department.

CARE Model

For quick reference, chaplains and firefighter support teams can use the CARE model to increase effectiveness in helping fire service personnel. CARE stands for:

Care

You have to be there to show that you care. The chaplain's best tool is listening — active listening. Be alert for the nuances.

At a plane wreck the FBI chaplain and I spent two days mainly observing body recovery. We positioned ourselves outside the perimeter fence near the decontamination tents, where the mangled bodies were decontaminated, one by one, from aviation fuel. This waiting watch enabled us to identify with the firefighters who extricated the victims and the FBI agents who shared the gruesome task of collecting evidence.

Assess

Based on what you learned in the caring stage, quickly assess the situation. If the caring stage moves slowly, the assessing stage is lightning fast. It's important to assess the need and presenting symptoms and to procure immediate help.

Refer

After assessing needs, move to referral, if necessary. Similar to the emergency physician, your job is to assess injury, relieve pain and pass the patient on to a specialist.

Evaluate

Following a traumatic incident, the chaplain or firefighter support team needs to follow up on personnel touched by the incident. In some cases, this will require a disciplined regime to visit all companies involved.

To quote the wise Catholic chaplain and professor Henri Nouwen: “In the long run, cure without care is more harmful than helpful.”