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Welcome to the Behind the Shield podcast.
As always, my name is James Gearing and this week it is my absolute honor to welcome back
onto the show together two of my previous guests who are both some of the most respected
psychologists when it comes to working with first responders.
So both Dr. Brooke Bartler and Dr. Jenna Casas have been on the show before independently,
but this time they came on together and we unpack all things first responder mental health.
From the psychological testing of recruits, the efficacy of some of the choices used,
access to mental health practitioners, the education requirements of each of the mental
health practitioner labels, the EAP program, the financial barrier to entry, what counseling
should look like, red flags when it comes to finding help and so much more.
Now before we get to this amazing conversation, as I say every week, please just take a moment.
Go to whichever app you listen to this on, subscribe to the show, leave feedback and
leave a rating.
Every single five star rating truly does elevate this podcast, therefore making it easier for
others to find.
And this is a free library of almost 1000 episodes now.
So all I ask in return is that you help share these incredible men and women stories so
I can get them to every single person on planet earth who needs to hear them.
So that being said, I welcome back onto the show Dr. Brooke Bartler and Dr. Jenna Casas.
Enjoy.
Well Brooke and Jenna, I want to start by saying welcome back to the Behind the Shield
podcast.
A lot of you have been on once or a couple of times in Brooke's case, but never on together.
So I want to welcome you first both to the Behind the Shield podcast.
Thanks for having us.
Yay, super excited.
So each of your episodes, obviously we went from your early life, your journeys into the
world of psychology, your work with first responders.
So this time, you guys have come up with some pretty amazing kind of topics for us to hit.
So I want to dive into those rather than kind of go back.
Just so that people know who they're listening to though, I'll just go to each of you and
just going to give an overview of your qualifications and who you work with today.
So Jenna, let's start with you.
Yeah.
So I'm Dr. Jenna Casas.
I'm a licensed clinical psychologist and I practice in police and public safety psychology.
So that means that I primarily see people in fire, police, EMS, healthcare professionals,
as well as their spouses.
And I have a private practice where I see people across Northern Nevada and I'm licensed
through an inter-jurisdictional compact as well.
So I see people in states that are part of that compact called SIPACT.
Beautiful.
And Brooke.
So I'm also a licensed clinical psychologist.
I specialize in working with first responders and military.
I also have a private practice where I provide therapy almost exclusively to first responders
and military, but also do a lot of mental wellness programming for agencies and departments
across the country.
Things like building peer support programs, educational seminars and trainings and so
on and so forth.
Beautiful.
I want to start with the first question, the psychologist's eyes when you first entered
our profession and just some of the things that were glaring when you first kind of entered
working with people in uniform.
And then obviously we'll get to how to find a good counselor, what that looks like.
So Brooke, you came through the educational route as far as psychology.
What was some of the biggest aha moment or surprises when you started working with the
first responder professions?
Yeah.
First thing that comes to mind is I went, wow, they're very similar to the military folks
that I've been working with for many years.
So I started off, as you know, if you listen to my past episodes, doing research at the
National Center for PTSD at the VA and specifically being trained to work with military.
And when I started to work with first responders, I realized that the overlap was very similar.
And those similarities were not only in terms of what I saw similar patterns of what first
responders struggled with, but also just kind of the culture, the camaraderie, how tight
knit the first responder community is, how much pride there is in the first responder
community and how important it is to establish trust and rapport and to really be able to
connect on a different level with them than it is kind of with the civilian population.
Staying with you for a second.
What's the military population and the first responder?
Obviously, there are a lot of parallels.
What were the differences that you started seeing?
I'd say one of the biggest differences would be in the nature of the job in terms of your
first responders are on off, on off, on off, on off.
So they're having to kind of manage seamlessly.
Of course, it's not that easy, but they're having to manage switching from I'm on shift,
I'm captain, I'm lieutenant, I'm on shift for one, two, three, four days.
And then I'm off shift and I go back to being mom, dad, partner, sister, whoever it is,
right?
And having to manage these roles and expectations.
My military, it was a lot more stop and go, meaning like they're gone for long periods
of time, right?
They're gone for six months to 12 months if they're going on deployment.
And that is a it's similar, but also very different in terms of how you prepare for
that and the things that they experience when they come back because it really kind of came
down to, it really kind of comes down to expectations.
I've had a lot of my first responders be like when I was in the military, when I was deployed,
it was known that I was gone.
I wasn't really expected.
I didn't have these roles and expectations of being at home.
For the first responder, it's very much like it's very hard to switch back and forth to
having the expectations in my role in public safety and then having the expectations of
being at home.
There's not much space between those two.
So Jenna, back to you.
The first part of that question, when you went through his educational role through
psychology, you start working with first responders.
What was some of the aha moments or surprises that you kind of encountered as you entered
those professions?
I had a lot of really similar experiences to what Brooke was talking about where I was
able to make comparisons between military populations and then our domestic first responders.
Again, a lot of my training was looking at military first, so then making that switch
over.
I think it's just easy to draw those comparisons.
But for me, one of the biggest pieces was just getting embedded in those cultures and
realizing that it wasn't exactly what I expected it to be based on movies, TV shows, maybe
conversations with friends or family.
It was a bit different than I expected.
The other part that's interesting, and I don't know how much this generalizes to other areas,
but specifically with the people I've worked with in Nevada, it tends to be a multi-generational
thing or an inter-family thing where you will work with an agency and you could have siblings,
you could have parent and child, you could have spouses all within the same agency or
even working within the same community.
So when we talk about drawing that parallel between military and first responders here
domestically, when they're on shift, they could be on the same shift as their spouse
or the same shift as their brother or sister and experiencing the same incidents.
So I think that was something very unique and unexpected for me is if you're managing
one problem, one incident, one event with one person, the impact of that to impact that
family or that community is even greater because of how embedded they are.
One thing I've had people say to me recently is we used to have multi-generational element
to the fire service, to law enforcement, but this young generation now coming up with them
being a lot more in touch with emotions in general because we're having this conversation,
but also the devolution of the work environment that's created mandatory over time and organizational
stress and some of these things that are being witnessed by these young children is you're
getting that less and less, that fewer children of first responders are wanting to go in our
profession now.
I hear that a lot.
A lot of people that I work with will say, I have my kids and I'm coaching them in football
or I'm going to their cheer practices and I'm encouraging them to stay in school and
I want them to do anything but police, fire, EMS.
And it's really sad.
Absolutely.
Brooke, anything to add before we move on?
Yeah, no, I agree.
I've come across that a lot as well.
This idea of someone who's currently in the service, not really wanting their kids to
do it just because of all the potential roadblocks and obstacles that can come with it.
I also think there's a sense, I've also come across it almost on the opposite end where
I've worked with a lot of first responders who almost felt pressured to become a first
responder by their family.
Almost like you hear about it or like, oh, my parents expected me to be a doctor, medical
doctor, a dentist or whatever it was and that they really felt like they would be dishonoring
their family in some way if they did not actually join up and become a first responder.
So I've also come across that a lot, which comes with its own unique aspects.
That reminds me of a few conversations I've had.
One of them was with Angela Lee, who was an MMA champion under one championship.
She had a suicide attempt and then she lost her younger sister to suicide very recently.
And obviously she was just absolutely devastated and she's become a voice now for mental health,
but they are both of Chinese heritage.
And in some of these Asian households, that bar is very high.
Now, more often than not, you think of it academically.
In this particular household, it was in martial arts and kind of living vicariously through
your children as a lot of people do.
Either you're going to be a doctor or a lawyer or you're going to be in the NFL, the NHL.
I don't think there's that conversation or that conversation isn't loud enough yet of
the damage that can do mentally to a young boy or girl.
Yeah, absolutely.
Yeah.
It's pretty prevalent too.
I mean, like you're saying, it happens in a lot of different areas.
I know in the sports world too, that happens a lot.
But yeah, definitely is rather prevalent in the first responder world.
Absolutely.
Well, Jenna, let's go to the actual, I don't know if hierarchy is even the right word,
the different specialties within the mental health professions.
Because obviously you've got everything from a counselor through to psychologists, licensed
psychologists, clinical psychologists, psychiatrists.
So between the two of you, I'd love to kind of unpack that so people listening even understand
what that title is and how much education that person has had.
Yeah.
So I often like to start out by describing to people something visual.
I think it's easier to think about it this way.
Imagine a Venn diagram and you have all these different circles around the outside and these
are the different titles of the mental health field.
You have psychologists, psychiatrists, licensed clinical social worker, marriage and family
therapist, licensed professional counselor.
And by state, there can be even more names and titles included in these bubbles.
But what they all share, that middle part that overlaps in the Venn diagram is therapy.
So I think that's helpful for people to be thinking about there's all these different
titles and the one thing they share is therapy, but there's a lot of other parts that don't
overlap and that create differences within these different fields.
Psychologists being a doctoral level mental health professional that has knowledge and
skills to do therapy, but also to be able to intervene in problems, assess problems,
diagnose problems related to emotions, cognitions, behavior, and group processes.
It's like a super broad definition of psychologists.
We can go through psychiatrist, social worker, marriage and family therapist and talk about
the differences, but it really has to do with the way that they view problems and then from
that view how they approach and treat them.
Psychiatrists being mainly someone with an MD that will look at a biological or a medical
basis of behavior and typically does medication management.
Again, they can do therapy.
There's other modalities they can use, but the main one that people think about is the
medication route.
Social workers, same thing.
They can do therapy, but they often will look at a client from a more holistic lens, that
social lens, and think about doing case management, maybe advocacy or connecting them to different
practical supports in the community to help reduce barriers, social barriers, socioeconomic
barriers.
And then marriage and family therapists, licensed professional counselors.
The licensed professional counselor I'm not going to go into because that one does vary
state by state and I don't know enough about it to speak intelligently about it, but what
I will say about marriage and family therapists is they look at things from a relational lens,
a systems lens.
So they'll be able to look at a problem and think about family dynamics, the relationship,
the couple piece of it.
So again, therapy is that common thread throughout all of these, but the lens that's used to
be able to craft a treatment plan is very different.
Right.
Yeah, that was well put.
Wow.
Thank you.
Yeah.
So yeah, Jenna worded that really well.
And then outside of the therapy, I'll comment on just kind of the difference between psychologists
and those other titles is, you know, what goes into being a psychologist.
And I think I've talked about this a little bit on our past episodes, James, but, you
know, typically it takes anywhere from five to eight years to actually become a licensed
psychologist.
That's not including undergraduate.
And a lot of times for the PhD, which both Jenna and I have, you either have to go get
a master's degree before you start that five to eight years, or you have to do, you know,
anywhere from one to three years of a full time research position so that you can actually
get accepted into a lab for a PhD and start that PhD.
So for me from start to finish from, if I'm including undergrad, it took about 11 years.
And I actually finished kind of fast in my PhD.
I finished the PhD portion four years, I did a one year predoctoral internship, and then
I did a one year fellowship.
So I finished mine in six years.
But like I said, it could take anywhere people, you know, sometimes up to eight, maybe even
nine years to do that.
So there's a lot of not only education, yes, you're in school that whole time, going to
classes, doing didactics, things like that.
But I think what really differentiates the psychologist is that we have very comprehensive
training, not only clinically, which means like the therapy side of things, but PhDs
psychologists have a very heavy research background.
So not only are we learning in a specialized way how to treat specific areas of mental
health, but we typically are also conducting research.
And again, depending on what your specialty is, me and Jenna's both being in the first
responder military trauma area.
But that means we're writing grants, we're publishing scientific papers, we're collecting
data, all these things while going to school.
I also had to teach two to three classes at the university that I was getting my PhD at.
So I was a professor.
So you learn how to teach, you learn how to consult, you learn how to do all these things.
So you come out and not only are you specialized in providing therapy, but you have a lot of,
you know, the parts that also inform one another.
My research makes me a better clinician.
And my, you know, in the field clinical experiences inform the research side of things as well.
When I speak to so many members of the military that have been on here, it's like a broken
record the response.
Well, they prescribe me meds.
And it kind of makes me think my wife's just about to graduate in May from a doctor of
optometry.
Now, the optometrist is the person that you actually go to get your eyes tested.
You know, what's better one, two, and all the glaucoma testing and all those things.
And if they find something that's, you know, bad that you're going to need surgery or expertise,
a specialist, then the ophthalmologist is who you go and see.
But ophthalmologists are not usually doing eye tests and prescribing lenses and glasses.
Why is it in the world of the VA that it always seems to be the psychiatrist that our military
members are seeing rather than some of these specialties that maybe wouldn't be going to
med straight away?
I have three theories.
One, I think it's human nature that we want a quick fix.
And people view medication as a quick fix.
And in some cases, and unfortunately, the more destructive cases it is, right, you're
getting prescribed benzodiazepines because you have post-traumatic stress or high anxiety.
That's a pretty short-term quick fix.
You just pop a benzo and you feel better, right?
So I think quick fix.
I also think that, I don't know what you think about this, Jenna, but in my experience, you
know, I think that the MD behind the psychiatrist's name, people, you know, that's a doctor, so
I'm going to go see them.
Not really knowing that, again, as Jenna was saying, some psychiatrists have some training
in therapy, but like really theirs is on the medical side and medication management.
So I think that sometimes we can get a little bit looked over in that sense, and people
are more likely to go to that because a lot of people don't even know what a psychologist
is, right?
Like, what does that even really mean?
So that would be, I said three theories, but I'd say those are my top two theories, the
first being quick fixes.
I agree, and I also think that when you look at a system like the VA, because it's multidisciplinary,
they tend to have their own processes and procedures for how a client enters on the
doors, where they want them to go, and what it looks like when they exit.
And so it might just be, and I haven't worked in the VA, so I can't speak specifically
to this process, it might just be that they start there and there isn't a clinical rhyme
or reason why that's the first thing they do.
What I can say, at least from my training, is that there often is that co-management
piece where medication plus psychotherapy can be effective.
So if you combine what we know on that end with maybe a process and procedure for a large
organization like the VA, my guess is they can see a lot more people, psychiatrists can,
and they just start getting people in the system through the works, and medication is
the first way to go.
And then while you're on a wait list for a psychologist, which could be days, weeks,
months, I don't know, it depends, then you can get that ball rolling.
That's my best guess.
I'd agree with that too.
I worked in several VAs in my pre-doctoral and post-doctoral training, and it's a very
large organization, which has its pros and definitely has its cons.
In the clinics that I worked in, that I trained in, sometimes we had wait lists up to three
to six months.
I mean, just absolutely absurd.
So yeah, they'd get sent somewhere where they can just, hey, here's someone you can have.
And as Jenna was saying, most psychiatrists, you just meet with 15, 10, 15, 20, maybe 30
minutes, right?
You just talk to them about what you're experiencing, and they might provide you medication.
So I do agree that sometimes it definitely was my case at the VA where when someone would
finally get to me, they'd be so angry, understandably, they deserved to be angry because they had
been sent around for four months to this person, to that clinic, to this, to that, and then
they landed in the PTSD clinic to see me.
So it definitely, I think there is sometimes no rhyme or reason to it, but I agree with
Jenna where it's like, okay, if we can just get that person in to see that person, we
can get that ball rolling.
Yeah, it's interesting.
I mean, obviously the whole point is to reverse engineer and figure out what we're doing wrong,
how we can be proactive and reduce the number of people so we're not straining the system.
And I talk about this a lot.
The NHS in England, I love, the one in Britain, but Britain's again fatter and sicker.
So that's starting to collapse because they haven't done the proactive side to make British
people healthy.
They've followed the American model and here we are.
When it comes to the snobbery as well, I've seen this because even my wife's profession
was attacked and they have to word their doctorate a certain way because some people are like,
oh, you're not a real doctor, air quotes.
The irony is how many real doctors prescribe meds to very overweight people and never talk
about sleep, nutrition or exercise.
You know what I mean?
So I think that even evaluating the weight of an MD and empowering some of the other
professions that support them, and I was one of them.
I was working under a medical director's license, a doctor's license, and we were out in the
field cutting holes in people's throats and sticking tubes down their necks because you
have to trust the people beneath you and allow us to use our skill sets.
And it feels like that's the same in the psychology world.
We need to kind of cut those apron strings, allow the psychiatrist to be there for the
specialties when you're talking about a medication being needed in that case, but empower the
other professions and trust them to work with these people because more often than not,
it's the other modalities that actually seem to work.
Yeah, I agree.
I do think there's a massive disconnect between psychiatrists and psychologists.
There's one psychiatrist I worked in all my years of training when I was working in an
inpatient unit with combat veterans in Houston.
I will never forget her, she was such a fantastic psychiatrist and her motto was skills before
pills.
She was, of course, providing medication appropriately when needed, but was very much wanting to
be on a team with the psychologist, which is how it should be.
But I feel like that's pretty rare.
I didn't have an experience like that again in any of my training in any of the hospitals
I worked in.
It's obviously harder to comment on in the private sector, in the private practice world,
but I do think there is like more often than not, they're not working together in tandem
thinking about like we're doing this as a multidisciplinary approach to helping this
person.
Jen, anything to add before we move on?
I was just having flashbacks to a clinic that I worked at on my postdoc year and this clinic
was absolutely phenomenal.
It was a rural clinic and it was multidisciplinary.
We had one psychiatrist and this is not a dig at them because there were good reasons
why they weren't able to attend these meetings, but they were the only individual out of the
entire clinic that didn't attend our weekly staff meetings.
I thought that was a huge issue because we would talk about cases, we would staff, we
would figure out if people were making progress and they were absent in that.
One thing that I did, knowing that they weren't able to make that meeting again for their
own good reasons, was make sure that if they were the psychiatrist on any of the cases
that I had, that I made sure that I was in regular contact with them.
Because I think what Brooke had said is true, it's pretty rare for at least psychology and
psychiatry to be on the same game plan with clients where they're in regular communication
and we are so much stronger when we're together on the same team and we can say, hey, you
just up their medication and here's what I'm seeing.
Is this normal?
Is it just a phase?
Is there any way that we can reduce the side effects while increasing the things that they
want to be happening?
If we're not talking about that and you're just relying on the client's self-report,
sometimes they'll miss things because they're not an expert in the way that the medication
could impact their whole physiology.
They're just an expert in their experience and there could be misses there.
Absolutely.
Well, I want to go next to testing for a fire slash PCMS agency or corrections.
My personal experience for fire departments, that's three polygraphs that I lied through
and four MMPIs, correct me if I'm wrong, Minnesota Multiphasic Personality Interview.
Have I got that right?
Okay, brilliant.
In my opinion, and then you sat down with a psychologist and hilariously enough, the
people that I sat down with usually were more crazy than any of the people that I ran on
in uniform.
When I look back now and people talking about the funds to, for example, hire a full-time
physical health practitioner in a department, I look at the seemingly wasted money on these
box checking elements of hiring a young recruit.
You've got a physical test, you've got a written test.
Obviously, you've got an intense background check on us to make sure that we're not the
kind of people that shouldn't be in uniform.
Then you have a year probation as well to filter out anyone that shouldn't be there.
I would love to unpack, firstly, and I know we've talked about this and both of you individually,
but I think it's worth revisiting the ability to select a fire or police recruit with the
MMPI on its own.
Then what should, if anything, a psychological testing look like for a fire department?
At the moment, if we're doing these two that seem not to be effective because the polygraph
is a smoke and mirrors magic show that you confess to, then to me, the money is better
served investing and giving these young new firefighters counseling right from the front
door.
I'll revisit that question because I just monologue for a second.
Talk to me firstly about the ability of the MMPI on its own to successfully filter out
fire and police recruits.
Short answer, it can't.
Short answer on the psychological aspect, you shouldn't.
Then in terms of a full pre-employment assessment evaluation, there's a lot of things that should
be incorporated in that if you're going to do it by best practices in the field.
Again, if you are practicing in police and public safety psychology and this is one of
your areas, the International Association of Chiefs of Police has guidelines for how
to conduct these things.
You should be getting regular supervision and consultation around it.
You should understand what instruments are well validated to answer the questions at
hand, how to work with agencies, convey results, understand what the referral question is.
There's a lot that goes into that process.
But the MMPI to RF on its own, no.
Never use one data point that's not acceptable.
If you know what you're doing, you wouldn't do that.
It's not going to give you anything.
On its own, it's just a personality inventory that's going to tell you a little bit about
a person's personological characteristics.
It's going to tell you, are they maybe a little bit more labile in their mood?
Are they a bit impulsive in their behavior?
It's not going to give you, is this person suitable for the job at hand?
100%, everything that Jenna just said.
100%.
I agree.
I mean, it's like that with a lot of things in this field, but like she said, it's one
data point and it can be a helpful data point in conjunction with a lot of other means.
But on its own, yeah, it's not going to tell you whether or not someone's fit to join public
safety.
So, this is my point is when people say, oh, we don't have the funding for a mental health
practitioner, well, if you get rid of the polygraph and the MMPI, ideally, like you
said, put something else in place.
But if you're not, then now this new person could come in and let's say have five sessions
in their probationary year or in the first six months and have a mental health conversation
from the door, have zero barrier to entry because you're not looking at EAPs and copays
and all these things, and give them a chance to offload some of the stuff they brought
into the job because every single one of us, more of us than the average civilian, have
things that send us into uniform.
Yeah, I've definitely followed a lot of, I know you're a huge advocate for that, James,
and I agree with you.
I think that it's a delicate situation because understandably, you want to make sure you
do some form of testing when someone's trying to enter the service to make sure that there
aren't any glaring reasons or issues or problems why someone wouldn't be fit to serve.
At the same time, as I'm sure we all know, is a lot of these fitness for duty evaluations
and assessments aren't necessarily looking at or promoting or sending the right message
of what kind of characteristics we are looking for.
Or even, I look at it from the standpoint too, of what it is we want to build in that
person.
What makes someone good in public safety?
We're talking about certain characteristics, social characteristics and psychological characteristics
and styles of thinking and not the expectation that you're coming into this field tip top
perfect.
You have to be so perfect and all that stuff that's happened to you before, you just need
to be a robot and a machine and operate through this.
Because what I also think it does is in the long term, it also sends this message that
perpetuates the culture and public safety of, I can't have any flaws or weaknesses lest
I lose my job, lose my promotion or be ostracized or looked upon negatively in some way.
I think that sometimes that precedence gets set at the very beginning when someone is
just joining the job.
Jenna.
Yeah, I often think about the message that some of this testing sends too.
I think when you're doing the pre-employment evaluation, it can look like it's an impediment
to somebody's goal.
This is my dream, I want to do this thing and you're the person standing in the way.
That's not a really great spot for a psychologist to be in if that's the perspective that they
have.
Then if they're on the job and they're getting in trouble, they're not meeting those essential
job functions, a supervisor writes it up, puts it into a fitness for duty evaluation,
requests that and then an evaluation is conducted.
Again, it's like I was doing the thing that I wanted to do and you don't think I'm doing
a good enough job.
Again, you're the person standing in the way.
I think in some ways that perspective is true.
There has to be an objective person on the outside saying that this is acceptable, this
is a cutoff or not.
On the other hand though, I think it gets a bad rap and that we do have to have standards.
These professions, they place themselves as well as the community in difficult positions
and you have to be able to make sure that somebody can handle that.
I look at pre-employment as a baseline standard.
Can you meet these requirements today?
Knowing that on the job, these experiences are going to change you and you might have
some bumps in the road.
Then I look at fitness for duty as an opportunity, not a punishment.
It's an opportunity for people to be able to think critically about what's causing them
problems, come up with a rehabilitation plan and come back better than they were before.
It's also a recognition on everybody's part.
Hey, this is not working for us.
Now, is it always used that way?
No.
In theory, this is how it's supposed to look.
In practice, it depends on who you're hiring, what the goals are, lots of other things.
I love the fact that you just said better than when you were before because this is
I think the message that is so needed in the mental health conversation and this applies
to a brand new recruit that again, you've done some evaluation, realized all right,
there's something that needs to be worked through all the way through to obviously our
10, 20 plus year people that really start to struggle if it hasn't reared its head early
in our career.
The resilience that appears to be forged from hundreds and hundreds of conversations I've
had on here that when you find that toolbox that works for you, that mental health toolbox
and you do the work and you come out the other end, we talk about resilience and we put firefighters
through mazes and play loud noise and bang on the walls.
I don't think that's it.
Of course, that's overcoming fear and that's a skill in itself.
To me, resilience of the struggles that we had that were buried down, pulling them out
into the light, working through them and that becomes that badge of honor then, that scar
that you're proud of, the gold ink in the Japanese metaphor or the gold glue, excuse
me.
So talk to me about that concept because we don't really hear it discussed very often
but through your eyes, I'm not wanting to load the question, but the ability for someone
to be even better than they were prior to struggling, the hope that is forged from post
traumatic growth.
Yeah.
I think that this aspect goes under looked a lot, overlooked a lot with respect to, I
mean, my approach from the work that I do is very much that proactive approach where
we're setting someone up to be able to not only keep themselves healthy if they're feeling
pretty good mentally and physically, but so that they're also equipped with the tools
to learn, bounce back and intervene, whether it's through themselves, using tools and skills
themselves to intervene when they're noticing things aren't going great for them or that
they have support resources that they can utilize and reach out to at that time to prevent
the snowball from continuing to roll and getting to that, what I call the third line, which
is the crisis part.
So post-traumatic growth, there's a plethora of scientific research on something, on a
topic like post-traumatic growth, which really kind of goes in line with resilience.
I feel like resilience has become like a super hot topic, resilience, resilience, I'm a resilience
this, I'm a resilience coach, I'm a resilience that, but what actually is resilience?
And I feel like sometimes when people hear the word resilience, they think that I'm going
to get the information, tools, whatever it is to protect me from ever having any problems
so that nothing ever affects me.
And that's actually not what resilience is.
I like to utilize the analogy of if I was working with a professional athlete at the
very beginning of their career and I said, let me tell you what you need to do and you
will never have an injury, you will never be sore, you will never have anything like
that because you're going to be so resilient.
You'd look at me like I was a snake oil salesman, which I would be, right?
And it's the same when we're talking about mental health and resiliency.
And so something like post-traumatic growth is being able to have the information, tools
and resources to experience what it is that you've experienced, hardship, trauma, and
be able to use that and take that to build upon who you already were and enhance skills
you already had and learn new skills to continue to forge through and live your life in a way
that is best for you.
So it's not, I'm protecting myself from ever being touched.
I'll never get touched by any of this stuff on the job ever because I'm so resilient.
It's actually having the tools and the resources to be able to, despite the aspects that you
might be experiencing on the job and off the job, that you are able to then learn and grow
and adapt from that.
Jenna.
Yeah, everything you just said, totally agree with.
And I think the one part that I'd add is, when you think about what trauma does for
a person, typically it affects their belief system, their beliefs about themselves, the
world or other people.
And we tend to think about it in the post-traumatic stress way where it changes those beliefs
to be maladaptive.
It makes people afraid.
It's that fear system that's triggered.
When you're looking at something like post-traumatic growth, you're really flipping it on its head
asking what purpose and meaning does this provide for your life now that you've gotten
through this thing?
And then focusing there.
So it's really about perspective, in my opinion, and being able to put effort in something
that I believe is changeable.
So the event happened, that trauma is in the past.
And if you can focus on who you are today because of it, what you want to do today because
of it, or in addition to it, that allows you to put your effort in something that you have
control over.
And that tends to be pretty powerful and motivating for people.
What I've seen so often is that when people have come out the other end, they become a
beacon of light for others.
And people come out the shadows and say, you know, I've been going through it too.
And the irony is that they were looking at each other and both of them thought they were
fine because this bloody mask that we wear so well in our profession.
But I was just thinking when you were both talking, a good analogy is when we learn extrication,
they say never get your body between the tool and the vehicle.
Because as you try and spread a car, it tends to turn and you literally will get crushed.
So you know, the resilience piece is the experienced firefighters teaching an academy.
They know they've been taught and most of us have been pinched at least once and we
remember then.
So that trauma isn't forgotten.
You're not scared of the hydraulic tools anymore.
You've just learned in a way to use it in a different way.
And your vulnerability of like, let me tell you when I was an idiot and I almost got crushed
by one of these now becomes a lesson for someone else.
So I think that it's owning that but using it in a positive way, whether it's beckoning
people from their own struggles to be vulnerable enough to talk to them about yours or like
I said, parallel with an extrication tool in your hand.
Yeah, not to go too far down a rabbit hole, but when we're talking about post-traumatic
stress in particular, what leads to the development of severe post-traumatic stress injury or
a diagnosis of post-traumatic stress disorder would be what we call avoidance.
And typically that comes with I'm not talking to anyone.
I'm going into autopilot.
You know, it can lead to severe isolation, but typically it's just keeping my mouth shut,
putting the mask on.
I'm good.
I'm good until the levy breaks.
So like you're saying, James, when I give trainings and presentations on trauma and
stress and I'm talking about the tips in my tips section, the first thing I talk about
is talking to other people.
You know, these aren't like groundbreaking things that I'm going to tell you.
Like this is exactly how you manage it or how you prevent it.
But talking is scientifically proven to not only help resolve post-traumatic stress if
you're in utilizing an evidence-based treatment, but it's actually a very, very massive protective
factor.
And so I have found, like you're saying, James, I've worked with several first responders
over the years who are in a leadership position, a higher ranking position who start in treatment
and then they become empowered to kind of share their story with their crews and other
people.
And it's just, it never ceases to amaze me the domino effect that starts to happen.
And then they're telling me that, you know, other people in their crew are now kind of
speaking up about certain things or willing to talk about how something bothered them
or whatever it was.
So talking is massive.
It's really a massive tool at our disposal, of course, talking to people that we trust,
but it's scientifically proven to be helpful.
Anything to add, Gemma?
Yeah, I think what's really funny about what Hugh just said is that most people think it
needs to be more complicated than that, or more sexy than that.
And I think people don't value that it could be something as simple as talking with somebody
who's qualified to be able to navigate you through something like that.
So then we have this host of other things, and I'm sure we'll get to it in other parts
of this podcast that people are drawn to, to try to solve the problem because in their
eyes it needs to be more complicated.
What built up to create this problem was complicated and long standing.
So the solution has to be complicated.
It has to take a lot of time.
It needs to be difficult.
And that's just not necessarily the case.
Well, I want to explore the elements that contribute to our challenges.
And then obviously we'll get to how to find the right solutions as well as highlighting
the wrong solutions.
But without loading the question, I've discussed it many, many times.
I'm just going to give you guys the mic.
What are the multitude of contributing factors that together lead to someone struggling mentally
in our profession?
You want me to go?
I'll go.
Yeah.
Multitude of factors that lead to someone struggling in your profession.
All right, so let's talk about, I like the Venn diagram aspect.
Sometimes I'll put this on a screen when I'm giving presentations on this.
One thing, one point I want to get across.
It's never one thing.
Even if there was one specific thing that you can point to that that's when my problem
started, it's never one thing.
Okay.
It is a combination, like you said, James, the multitude of factors that leads to someone
struggling.
So we obviously can talk about experiences and events.
And what I also want to really, really highlight is it's not always the job.
Not always.
Meaning I can tell you anecdotally, at least 50% of the first responders who come to work
with me have childhood trauma, ranging from sexual abuse, physical abuse, neglect, and
everything that falls underneath those.
Trauma is cumulative.
So when we grow up in environments like that, and then we join a profession where we're
exposed to a lot of trauma and just high stress, all these things accumulate.
So of course the events, those things can add up and accumulate and lead to someone
struggling.
But what really in the first responder profession, other factors that I see contributing to someone
struggling is what we were actually just talking about.
One being very much of put the mask on, keeping my mouth shut in terms of, you know, I'm good,
I'm fine.
I use the example of driving your car when the check light is on.
Okay?
We all have a check engine light on our car.
When the check engine light goes off, doesn't mean there's something terribly wrong.
Just means, hey, you check in on this.
Could be something as minuscule as change your oil.
Right?
But you can still drive your car for a long time with the check engine light on.
Long time.
You know how I know?
Because I've done it.
And six months later, my transmission blew out.
And I was left with a very costly repair and, you know, that set in motion a lot of other
things with my car.
That being said, when we're driving our car with our check engine light on for months,
years on end, at some point, that transmission is likely going to blow out and cause a lot
more issues, you know, and have a lot more of a significant impact on our life.
So I'd say the multitude of factors that go into someone struggling, particularly in the
first responder world, are just autopilot, you know, not talking to other people, at
least not about things that we're experiencing or going through.
Using vices.
You know, instead of talking to people, I'm just going to have a couple more drinks or
I'm going to watch more pornography.
Next thing you know, I'm watching more porn.
I'm going to keep myself so busy or I'm going to keep getting those adrenaline hits outside
of the job.
So I notice that I need to just keep going and going and going.
And when I have to be stagnant, something's not right, right?
I don't feel great.
So that is a long winded answer of like, broadly speaking of what I think leads to someone
in the first responder world developing like more significant issues is that check engine
light is on and we are still going forward without actually looking at doing any maintenance,
looking at why the check engine light is on and we just keep driving the car for hundreds,
thousands of miles.
Yeah.
And I think it's pretty easy.
Everything you said, I agree with.
And I'm just adding that it's pretty easy for people, especially in these roles and
with how understaffed agencies are right now for them to just say, I'll take care of myself
later.
So I'll just put myself on the back burner because the job's got to get done today and
I'll take care of myself tomorrow.
I'll take care of myself next week, next month, next shift, bid, whatever it is.
And that day never comes.
So a lot of the people that come to me, it's a mixture of disconnection from self, disconnection
from others, and then disconnection from their, like their, their community.
So others more broadly, where they're not investing in passions or hobbies or any self
care activities at all.
They're not connected to their spirituality, if that's important to them.
They're not connected to their family, if they have, if they have one.
They're not seeing their friends anymore.
They're doing the job, but they're not getting any source of satisfaction from it at all.
They don't understand why they're still doing it.
It's just money in the bank type of deal.
And then where they are putting their effort tends to be in things that are quick, convenient,
and easily pleasurable.
So like Dr. Brooke was saying, they're using pornography, they're engaging in maybe affairs
with other people at work or otherwise.
They're reckless driving.
They're getting drunk on the weekends with family or friends, but they're taking it a
little too far.
It's this kind of stuff that they're doing.
So, but it's a slow roll.
So it's not just, you know, one day I was okay in the job and I was really getting a
lot of satisfaction from it.
And then next Sunday, it's totally flipped the script on me.
It's gradual.
It's that grind.
So when I see people in my practice, I often ask them, draw out for me what the last week
looked like for you from 7 a.m. to 7 p.m. or whatever your hours of being awake are,
draw out for me how you spent your time.
And in this week, tell me how on average, if this is regular for you or if this is something
totally off base, it was just a weird week.
And what I end up seeing is that they're almost doing nothing for themselves that would lead
to being an adaptive behavior.
Their nutrition's out of whack, their exercise is non-existent, they're not spending any
time with friends or family.
They're just working themselves into a puddle.
And so I would just ask would anybody have good mental health if they were doing that,
regardless of first responder occupation or not?
No.
One area that's just hands down getting worse and worse and worse is our recruitment crisis.
You know, I've been very vocal about the ridiculous nature of our even basic work week, but then
you add the mandatory overtime into that or the voluntary overtime, which I would argue
is another unhealthy coping mechanism.
I think work is the unspoken one.
You have responders working insane hours.
My goal is to make it a 42-hour work week nationally, 24, 72 standard shift cycle.
And that would then attract young people back into our profession and therefore resolve
most of the staffing problems as well.
That way people will be back in their homes, in their beds with their families.
Talk to me about the impact of sleep deprivation when it comes to the mental health side.
How much time do you have?
All the time in the world, Brooke.
Well spoiler alert, sleep is very important.
And it just, I think, including myself, I was guilty of this in the past, you know,
yeah, yeah, yeah, yeah, yeah, sleep is important, sleep is important, sleep is important.
But when we actually like learn about what sleep does, quite literally what it does both
for our physical and our mental health, and physical and mental health are, you know,
tied together, right?
It's really, really, really fascinating.
On the mental side of things, when we're sleeping, our memories are being consolidated and stored
properly.
Our emotions are actually processing while we're sleeping.
All very important things, right, on the physical side of things, we repair, our body is repairing
our muscle tissues, it's regenerating cells, it's doing all these things to make sure we're
healthy.
Here's kind of the way I explain it now, is that our sleep prepares us to be as optimized
as possible when we're awake.
Meaning it's not, I need to be as productive and optimal when I'm awake and then I have
to sleep.
Your sleep actually sets the precedence for how productive and optimal your health, mental
and physical health are going to be when you're awake.
That is quite literally what it is for.
So when we're not sleeping, when we have chronic sleep deprivation or chronic sleep issues,
it takes a massive toll on our mental and physical health.
They typically tend to plummet.
In very important aspects, if we're talking about the requirements of a job in public
safety, things like decision making, snap decision making, logical reasoning, memory,
all these things that our research has shown that things like reaction time, snap decision
making, all of those things plummeted for first responders when they were chronically
sleep deprived.
These things affect the first responder, not only on the individual level, but what I really
try and get across the leadership is it has a macro impact on the organization.
It can lead to more sick time.
It can lead to more line of duty injuries or God forbid line of duty deaths.
It can lead to more turnover because people are just tired of it.
It's not manageable, right?
And then you have to spend more money to recruit and train.
But sleep is extremely important and I do a lot of sleep trainings.
I have my on demand sleep course now because I feel like if we're talking about, if an
organization wants to bring me in, they're like, we don't even know where to start.
What should we just, what's the first thing we should focus on?
I always say sleep because I'm like, this is something we can all relate to because
it's all something we have to do, right?
And it's something that is at the foundation of physical and mental health.
Yeah, sleep is absolutely fundamental.
We have to be focusing on it.
And I think the work that I do with a lot of organizations, it starts at sleep too.
I'm thinking about the annual wellness visits that I do for staff.
I hand everybody an educational packet and I was smiling as Dr. Brooke was talking because
the first page of my packet is sleep education.
And it gives them information about how many hours when you're awake, what it's related
to as blood alcohol content.
To be able to give them a comparison of if you are awake for 24 hours at a time, there's
significant detrimental effects to that.
And not only for you as the person that's experiencing it, but in your job, if it is
to be interacting with the community in some capacity and maybe you have the opportunity
to use lethal force if necessary, that's a huge decision to be making.
You don't want to be making that decision sleep deprived.
I think the really difficult part for me is we are working with the individual level factor.
How sleep deprived is this person or how much sleep are they getting?
But the actual intervention point is within something outside of that person.
It's within the organization.
So a lot of the work that you're doing, James, talking about wanting to shift the focus at
the organizational level is huge because if we don't have the ability to impact change
there, talking to a person about what they can do individually is only going to get us
so far because we're always going to be constrained by what those organizational demands are.
And I've run into that where I'll be talking to supervisors about, hey, a lot of your people
are requesting time off and it seems like they're not able to get that.
And they'll say things like, I know, literally my hands are tied, there's nothing I can do.
And that creates its own issues on the supervisory level where they feel like they are harming
their own people because they're between a rock and a hard place with the organizational
demand and what they know is best for their employees.
So it's really a huge problem.
Absolutely.
Two things.
Firstly, the blood alcohol element, the sleep medicine world has talked about that.
But I think what's interesting is if you think about how most research studies are done,
a lot of times it's college kids.
You get 50 bucks and you come do the study and then you can go buy beer the next day.
So you've got people that I would argue are usually in their beds every night, maybe not
Friday, Saturday night, but most of the time they are.
So these studies are probably on well-slept people that didn't sleep for 24 hours.
So what is actually the cognitive parallel of blood alcohol for a firefighter that's
worked for 20 years every third day plus mandatory overtime?
Probably way past point one.
It's probably much higher than that.
So I think that's a big issue.
The other thing as well with this conversation, and I'm always fair, even with the obesity
element in uniform, when you look at the environment we work in, it sets these responders up for
failure.
You are far more likely to be overweight, have your testosterone in the toilet, all
these things working the way we work.
So ownership is absolutely part of it.
What do you eat?
Are you moving?
Are you trying to sleep?
But the environment is the other part.
And it's the same with this.
And to put it on us, if we forge a work week that is healthy, then we as a responder have
to own our sleep hygiene when we're home.
We have to not take overnight shifts to the ER or an ambulance company.
But we can absolutely, and this is what drives me crazy, oh, they'll work anyway.
Well, yeah, but they'll hang drywall, do landscaping, personal train.
They'll be tired and they'll sleep next to their husband or wife and wake up next to
their kids in the morning.
So I think that this is the thing.
It's not one or the other.
Again, it's both.
But if the organization is turning their back and just saying they need to sleep better
when they're at home, you're missing, I would argue, two thirds of the conversation.
Yeah, I agree.
And like what Dr. Jenner was saying, I've run into this a lot too, where I'm working
with an agency that at the organizational level is not necessarily being run in a way
that's optimal for sleep.
But another reason why I like to come in and do these sleep trainings is because it's one
of the few aspects that I feel like I can empower first responders with and be like,
okay, I understand that you're really pissed off at leadership and the way things have
been running and you're running 10 calls a night and having to do so much manatee over
time and that's impacting your sleep.
But let me at least give you scientific ways, show you based on scientific evidence how
you can prioritize and manage and behaviorally habitually operate outside of the job so that
you can optimize your sleep off the job, which then ends up actually diminishing the effects
that the sleep deprivation can have on the job.
And it's called sleep banking and it's been studied by sleep neuroscientists.
But basically the idea of can we make up for lost sleep?
No, we can't say I haven't slept for two weeks, but I got a night or two good sleep, which
means that didn't matter anymore.
But what we can do is we can optimize our sleep leading into times like when we know
we're going on shift for a few days so that the effects of that sleep deprivation on shift
are slightly diminished, that the negative effects of that sleep deprivation are slightly
diminished.
And that's where we come in where the important message is then it's up to you, right?
Meaning like how much do you actually prioritize this because if you're not actually prioritizing
your sleep when you have when it's in your control and you have the opportunity to, you
know, then you're getting it on both ends.
Right.
And I also wanted to comment on it made me think James, because when you ask this, like
the multitude of factors that go into someone in service having issues, sleep is a big one.
Right.
Sleep is massive and I talk about this a lot too, is that there is a plethora of scientific
research studies that show that sleep deprivation is associated with higher risk of developing
every major psychiatric problem, post-traumatic stress disorder, major depression, anxiety
disorders.
Right.
And it's a risk factor for suicide.
And the way I explain this is doesn't mean that because I'm not sleeping, that means
I'm just all of a sudden going to be taken over and attempt suicide.
That's not what that means, but it's one factor of many, because let's talk about review.
What we just talked about with what sleep does is it's optimal for our physical and
mental health.
So when we're chronically sleep deprived, we're not thinking straight.
We're exhausted.
We're grumpy.
We're irritable.
We're snapping at our family members or our family relationships start to go down.
We don't have the energy to socialize or engage in hobbies or things we enjoy doing off the
job.
So that goes downhill.
Then we're on the job and we're just a zombie and we're going through all these things build
up and make way for problems like post-traumatic stress and anxiety and depression and alcoholism,
which then increase the risk for suicide at some point.
If someone gets to the point where they're not getting the help they need and it just
continues to snowball.
So sleep is so important.
It's a huge prevention factor.
Jen, anything to add before we move on?
I think she covered it well said.
The other crazy thing that I've realized now is it's a money saver as well.
And sadly, I'm glad that this is the thing that's actually moving the conversation because
to me, the parallel I use is we used to send children up chimneys and work in factories
in Victorian times.
And then one day someone said, this isn't right and we stopped doing it.
Well this is where we're at in the mental health and physical health conversation in
the first responders.
But the good news is it saves money too.
It's an absolute false economy when you drive your responders into the ground.
And that's why we have a recruitment crisis and so many vacancies.
But if you look at the money that departments spend on new recruits that will walk out the
back door in a year or two and the overtime costs alone, there is more than enough money
to staff up a fourth shift, a D shift.
And then that excites young people to come to your department, filling all the holes
and now you're operating optimally.
So this is a beautiful thing is the solution not only saves first responders lives, which
is what I care about, it also saves cities and counties money, which then will put that
fourth person back on the engine, help put a gym in the stations, help hire a mental
health counselor and we start filling in all these other areas that we can address.
I quote you in some of my talks, James, from your first book where you talk about that.
And I quote you in when I'm really trying to get across the idea that, you know, ideally
leadership would want their workforce to be just healthier and happier in general.
But hey, if that's not really at the top of mind, then what about money?
How about saving money?
Right.
So I really tried to hit it from both sides.
Absolutely.
Well, thank you.
The second one's coming out next week.
So it's a story this time is fiction, but it's basically historical fiction.
It's all pretty much true.
But hopefully that, you know, my goal is to make that into a TV show because I want this
to be through the screens and people to really understand what our men and women do and the
costs of that and the multi-generational trauma story that's woven in as well.
So I'm hoping that most people that watch it and or read it will see themselves in one
of the characters in the story.
And we can put some compassion and empathy back in this mental and physical health conversation.
All right.
Well, they're moving on.
So the next topic I want to hit EAP is, you know, an acronym that doesn't mean that much
to most people.
But when you have a podcast like this and you've spoken to so many first responders
who were struggling, the EAP Russian roulette or EAP nightmare is something that I get a
lot.
Now, the framework obviously can be incredibly proactive and full of culturally competent
clinicians or it can be an absolute shit show of randomly selected low bid people that probably
are going to do more harm than good if a responder even manages to get an appointment with them.
So I'd love to just unpack, you know, what the the framework of the EAP is supposed to
be like.
And let's kind of paint the picture of what it should contain, the kind of providers that
people should be able to find in a good EAP program.
So EAP stands for Employee Assistance Program.
And broadly, it's supposed to be a resource that employees can access through their work
where it's paid for, it's confidential, and they can get in for an appointment relatively
quickly.
In practice, whether or not that happens is different and based on a lot of different
factors.
EAPs are staffed by providers that are available in that area.
So resources, the availability of mental health professionals to be able to join an EAP, the
willingness of them to do that, and then whichever company is contracted with that organization
that that can impact who you could get on the other end of the line when you're making
the phone call.
I think one thing I can say confidently is I don't believe that anybody gets into the
mental health field and wants to have bad intentions, wants to do harm, wants to do
a bad job doing therapy with people.
I think whether or not somebody is effective at their job is a culmination of their education,
training experiences, willingness to be humble, gain supervision and consultation, and have
an appropriate work-life balance.
I cannot speak for all the EAPs out there and say whether or not the providers that
are part of that have all of that together or not.
But in the organizations that I've worked with, when I've had phone calls with EAPs
and been able to talk about their process for making referrals, whether or not people
have choice in picking their providers, the ones in my area are fairly good in terms of
having immediate availability for someone, making sure that the payment process is not
a hassle, they're not worried about that, and if they weren't satisfied, being able
to be transferred to another provider.
I think there is a, maybe not a misconception, but I think that there's talk about EAPs being
like quote unquote garbage and therefore people don't want to go to them, and I don't think
that that's the case.
I think that there are people who have had bad experiences, and that is probably true,
and that's soured their taste.
And that's valid.
They're entitled to their opinion, their experience likely was what it was, but I don't think
that's a call to just throw the baby out with the bathwater.
Yeah.
My experiences with public safety and for responders and EAPs hasn't been as positive.
And I really think that I agree with Dr. Jen on the intention behind it, but I think that
having an EAP workforce, your clinicians that are available, making sure if we're talking
about working with public safety, putting in the measurements, and even if that means
a little bit of extra money or a little bit extra time at the front end to ensure that
you have providers that are well equipped to actually work with first responders.
They don't need to be the best, most highly specialized people ever or anything like that,
but just kind of has the foundational, knows the foundational aspects of the culture and
the ins and outs of that.
And so that also that the EAP providers are aware of whether or not this is actually a
population they want to work with.
I have come across EAP providers who are like, I learned that this is not healthy for me.
It's too difficult for me.
It's not a good fit.
So I think that comes at the macro level, like the organizational level and whatever
EAP company is to ensure that they're providing therapists to a public safety agency that are
actually culturally competent, but also on the agency's end to make sure that the EAP
that they're contracting with meet those just basic prerequisites.
And like Jenna was saying, on top of just the cultural competency, making sure it's very
clear how many sessions you get, what problems you can seek therapy for through the EAP.
Is there a process for if there's someone that I'm seeing or I have a session, it's
not a good fit for me and I want to find someone else.
What about confidentiality?
If I'm going to EAP, what am I going to do then?
If I tell them something, are they going to run with it and tell my command staff?
And so I think the responsibility is on both ends of the spectrum.
And I've definitely worked with public safety agencies that don't really look into it that
much.
They're just like, it's an EAP and look at that number is pretty low.
So let's go with that one.
And they do that.
And that's obviously super harmful as well.
I've also worked with organizations where I've asked them if they have any statistics,
that they look at what their EAP usage is.
So they even have a baseline of whether or not what they're paying for to provide that
service, if they're getting any return on the investment, where people are even feeling
comfortable to be able to go in and utilize it.
And a lot of organizations don't have any, they're not tracking any of that.
Now, depending on who they're contracting with, sometimes that data is available, like
a certain percentage of phone calls per month, per year, whatever it is.
In some organizations, they won't provide that.
So it really depends on who they're contracting with and what they have access to.
But I think that's a really important number to be tracking.
Is the service that we've decided we're going to spend money on even being utilized?
Because what I've watched happen in my area is a lot of organizations decide to embed
their own mental health provider for their people to use, which is a great resource,
but it is in a way double dipping a bit.
If you have this EAP program and nobody's using it, but you're spending money on it,
and now you're trying to argue we need somebody that's embedded because we get to see them
every day, we know who they are, we trust them, we know they're culturally competent,
then everything that Dr. Brooks said about ensuring on the EAP and that that's happening,
you're just doubling back and doing on the agency side.
So just some things for agencies to think about there.
Some of the horror stories that have been repeated over and over again were anything
from the phone number not even working, not be able to get an appointment for as you touched
on in the VA, you know, three, six months and you go to someone who's in crisis, the
the clinician breaking down in tears, the clinician telling them I can't help you get
out, you know, and I say this a lot.
These are the ones I heard.
How many will I never hear because that was the final nail in the coffin, you know, so
I think this is a really important conversation.
You can't make, you know, make it 100% the right fit, especially when you're doing it
blindly, but you can at least make sure, for example, I think Brooke and I, we spoke about
this before, how many of these clinicians list first responders amongst roller skating,
badger, you know, taming all the other expertise that they supposedly have, you know, I mean,
if you are a first responder and or military specialist, then that should be somewhat your
field.
It's an extremely broad group to work with.
So with that being said, let's talk about a culturally competent clinician.
What kind of, you know, person are we looking for?
Because as you said, it's a very diverse group, you know, working with everything from children
to marriages to all kinds of areas.
And that might be an expertise that you need for one part of your mental health journey.
But for an EAP, for a first responder, kind of first contact, what kind of professional
were we looking for and how do we the responder make sure that's at least in the parameters
when we're researching the people that we're trying to find?
So there's a lot that goes into being culturally competent, a lot of different factors.
Unfortunately, like you were saying, James, and we've talked about it before is there's
a lot of people, Jenna and I have talked about this a lot too, is that there's a lot of clinicians
that will operate outside of their scope.
And that will, you know, think that because they worked with one retired police officer
five years ago, that when they're being asked, can you, you know, be, you know, work embedded
in this, you know, AP and work with these people, they're like, oh, yeah, I have experience
doing that.
Right.
That's not culturally competent.
Having one, two or three cases spread out over years, that doesn't mean you're culturally
competent to work with that population.
Cultural competency comes from years of a multitude of things, direct experience, right?
Working with individuals.
It could be spending your own time off the job, let's say going on ride alongs, you know,
going to fundraisers, meeting up, spending time around the culture.
I mean, for me, I was fortunate enough to, you know, spend my, you know, my years of
doctoral training embedded in a department.
So I was doing much more than just therapy and crisis response with them.
Right.
I was showing up to the promotions.
I was showing up to the funerals.
I was showing up to their galas and their events.
Right.
Is just getting to know the culture, both on the therapy side and outside of the therapy
side.
Attending trainings by actual culturally competent specialists, you know, like Jenna or I, on
working with first responders.
Right.
Even supervision at the beginning when you're, when you're starting to work with first responders
from someone who's culturally competent so you can continue to refine your skills.
Reading books on working with first responders, reading books written by first responders.
Right.
All of these things go into becoming culturally competent, not just like one thing that I
did one time or that one book I read or I went on that one site and I took a 30 minute
online self paced little course and it gave me a little certificate that said I can work
with first responders now so I'm culturally competent.
There's a lot of factors that go into being culturally competent.
I'll also add here that broadly when you're thinking about cultural competence, you're
thinking about somebody's ability to understand a culture and then interact effectively with
them.
So having the awareness that it's even a culture with its own values, norms, traditions, schedules,
languages, uniforms, you know, colors, whatever it is, you have to be able to just have awareness
that that's a culture that you're even looking into at all.
Then you have to have the knowledge and the skills necessarily to look at what's going
on for that person and put it in context.
So a lot of times I'll work with people in first responder professions and I'll realize
that that first responder piece isn't even a huge piece for them for their life.
They don't identify strongly with that part.
It's a part of their life but it's not something that they themselves have identified being
a huge part in that culture.
So if I as the provider go in and I treat them as if, you know, they are this first
responder, that's their most salient identity, I'm going to do wrong by them.
So you have to be able to look at the person in front of you and figure out what are their
cultural elements.
How strong do they identify with them and then what can I do, you know, taking my clinical
training, taking my experiences and looking at them as the expert on them to be relevant
for them.
When you're talking about cultural competence around people in police or public safety professions,
you need to be able to understand how specific occupational factors are going to influence
their behavior.
That includes their stress response or mental health issues.
And we had a bit of a conversation about this earlier so I won't go into depth about that.
But this might include, you know, if you're looking for a provider and asking are they
going to get it, do they understand what shift you work and do they understand how the demand
of that shift is going to play into your family life?
Can they talk about how if they've read through your policies and procedures, some of those
policies might inadvertently punish people who are seeking treatment and therefore have
a cultural piece where there's stigma towards treatment seeking.
This is the difference between somebody who gets it and somebody who just thinks it's
fun to work with a first responder because it could be exciting or they could kind of
be a trauma tourist, right?
There's a big difference there.
Trauma tourist.
I like that.
I want to just add on because Jenna, she commented on this and I'm glad she did.
Another aspect of that is being able to knowing the culture and being confident that being
able to adapt that with your actual clinical training, meaning like how you actually, let's
say, implement an evidence-based treatment for post-traumatic stress, right?
So I'm going to give you an example.
So when you are using the gold standard to diagnostically assess for, let's say, PTSD,
it's called the CAHPS-5, the clinician-administered PTSD scale, okay?
You start off that diagnostic interview by saying pick one trauma, your worst trauma,
what is your one trauma that your symptoms are tied to?
That's like what the actual language is in it.
Now imagine saying that to a first responder.
Now once in a while, I have had first responders who come in and there's like one very particular
incident whether it be on the job or off the job, right, that is like very much tied to
when their symptoms started.
But nine out of 10 times, they're like, what do you mean pick one, right?
What are you talking about?
Pick one.
It's the same for evidence-based treatments.
We're talking about cognitive processing therapy for PTSD or prolonged exposure for PTSD.
It'll be like pick one, right?
Choose your worst one.
So understanding the culture and what goes into the job, the things you have to see,
the things you have to do, just again, the mindset towards it.
You know how to kind of adapt your language a little bit to even if you say, I'll still
say let's talk about, I know you've experienced a lot of different things and it could be
really hard to just pick one.
Is there one that pops in mind?
And if not, let's talk about, talk to me about a few that like really stick out to you, things
that really stick out to you that like the thoughts and the memories you have.
And then I'm going to ask you questions about those, right?
So you learn how to kind of adapt that.
So you're not just going, well, just tell me one and then I ask this and then I do that
and then I do that.
So that's also the aspect of cultural competency is being able to integrate those two things
together so that you can provide that effective individualized care.
I've never been asked this, but I know so many responders are, you know, what's the
worst thing you've ever seen.
And it's so funny because I actually wrote down, these are just the horrendous deaths,
not the hundreds and hundreds of deaths, you know, the passing asleep, the kind of pseudo
natural deaths.
And preparing for the first book, it was two sides of A4 paper, you know, thin lined A4
and I'm like, Jesus Christ.
So when people say that, it's like, we got to be more specific.
Do you want a baby?
Do you want a gangbanger?
Do you want, you know, a suicide?
I mean, you have to narrow it down a little bit, you know, and then obviously then they'd
be shocked.
But I mean, it is, it's a death by a thousand cuts.
If you were at the World Trade Center, like Wil Hemenno, who I'm about to rerelease his
episode this week and the WTC collapsed on you and one of your friends died next to you
and you almost died from crush injuries and you got out.
I'm thinking maybe that's one of the most traumatic things for Wil.
But for the, you know, the other 99.9% of first responders, it's so many of these, a
lot of times it's not even the thing.
It's the whales of the family from the death.
You know what I mean?
So it is, I mean, it's, you know, there isn't a thing.
This is what I've always observed too.
It's like when you take that multifaceted approach and then you add in early life and
the fact that, you know, you've just gone to your third death and then you get written
up for not wearing a traffic vest, backing up a fucking ambulance at a hospital.
You know, these are the small Lego bricks that make up someone's overall stresses.
Yeah.
And another, you know, common theme I've heard from my first responders in terms of, you
know, bad experiences they've had before with therapists who weren't culturally competent.
And I've directly, you know, seen therapists do this, but is kind of like assuming that
because they've seen this thing that I think is super traumatic, right?
That like that, that's no, let's talk about that.
No, we really need to break that apart and talk about that.
And they're like, I'm literally not fazed by that.
Like let's talk about more like about these things, right?
So kind of like assuming that, you know, because they've seen this or they tell you that that
must just like really be affecting them, right?
Because that's just for a civilian would probably be the worst day of their life, but it was
just one call on one shift of thousands of shifts for this first responder, right?
So that's another thing I come across a lot.
Absolutely.
I think a huge part of being in therapy and with a culturally competent provider is that
you will, it will feel like a good fit.
And the reason for that, and I know you can't really quantify feel, but I think the reason
why that's the case is you'll be able to experience non-judgment and that curious approach where
you're really the seen as the expert on you.
Like as a provider, my job is not to be entertained.
My job is to not get whatever answers to questions that I want answered.
It's to try to pave that way where the person in front of me can feel comfortable and safe
to be able to get what they need from the process.
When somebody is not culturally competent, they're not sensitive, meaning sort of what
you were talking about earlier, people asking the question, what's the worst thing you've
ever seen?
If you understand the culture, you would recognize that that's an insensitive question to ask
and you wouldn't make maneuvers like that.
So part of understanding a culture really well is being able to have that sense of what
are these different characteristics that make up this profession, these professions, who
are the types of people that work in those places?
How do I get the experience to be able to understand what it would feel like to be there
with them, to have gone through the same things, to see things through their eyes so that I
don't make missteps like that?
Not saying that the provider you work with is never going to make an expectation or an
assumption and that they can ask that with you, hey, did I get this right?
But if they get it wrong, another hallmark of a culturally competent therapist is humility,
saying, okay, I understand.
Thank you for teaching me.
Moving forward, now I understand it from your perspective.
It's not a place to be defensive or argumentative or I'm the expert.
Absolutely.
Well, on that theme, I want to go to paint the picture of what counseling should even
look like.
I think that was a great point that you brought up to talk about today.
But prior to that, red flags.
Let's get that out of the way.
What are some of the red flags that a responder looking for some sort of clinician should
be aware of that maybe will get them to avoid that experience in the first place or at least
acknowledge that that is not a healthy practice when they're sitting with a counselor?
You want to go back and forth on this one, Dr. Brooke?
Okay.
Dr. Drew and I talk about this a lot offline.
So, LinkedIn is a great place, but it's also a terrible place when you wake up and you
see some of the things on LinkedIn.
So yeah, you want to start?
Sure.
So, the first red flag for me that I'm looking for is whether or not a person is even qualified
to help you with the issue that you're experiencing, even though they're advertising that they
can.
Everybody, especially with social media, the internet, you can buy a website, you can talk
about what you want to do, you can advertise that you can help people, but whether or not
you have the backing through specific education, training, and experience, that's going to
give you credibility to know that that provider can help you with that.
It seems like a little bit of work, and it is, but investigate what the standard is for
the field.
So, in mental health, what are the standards?
We talked a lot about in the beginning with our Venn diagram, different labels and titles
that people hold in the mental health field.
That's the standard.
If you're going outside of that and you see people calling themselves like counselors
or clinicians, specialists, technicians, analysts, coaches, mentors, any other word like this,
do your due diligence to look into that person's education, training, certifications, whatever
their qualifications are to make sure that they can help you.
Just because somebody says they can doesn't mean that they can.
Yes.
Along those lines, I think I've seen a lot with the individuals who promote or advertise
to help people with mental health related issues and problems like trauma and alcohol
and whatever else it is that don't actually have the education, the licensure, the training
to do that, is that they'll cite their lived experience.
Now, lived experience can be a very beneficial aspect of helping someone who's struggling
with some kind of mental health issue, 100% or having someone who's a licensed clinician
who was also a first responder.
Massive advantage.
That's very helpful.
Lived experience on its own is not enough to help someone who's suffering from post-traumatic
stress.
Just because that person has suffered from post-traumatic stress doesn't mean that they
are then able to actually use evidence-based, scientifically supported means to actually
resolve that other person's traumatic stress.
Unfortunately, I see this a lot in the first responder world, someone being like, I have
lived experience with this.
So therefore, I'm trauma-informed is a nice word.
I'm trauma-informed so then I can help you when you're struggling.
It's not only inaccurate, but for me personally, it makes me really mad.
I think that most of these people are coming from a really good place of wanting to help.
If you want to be a peer supporter, meaning I want to support this person, and then I
can help steer you or motivate you to get in the direction of seeing a licensed therapist
who's specialized in treating this, awesome.
I've seen a lot of people who advertise, I save lives.
Come to me because I can help you with your trauma because I am trauma-informed when they
don't actually have any of the education or really the training or the licensure to do
that.
It's dangerous.
That's the bottom line.
It's very, very, very dangerous because when you are not actually equipped to truly address
mental health issues, it can put that other person in the position where their mental
health issue is not only worsen, but it can lead to potentially catastrophic outcomes.
So the thing I get most upset about when I see that is I just see it and I'm like, this
is dangerous.
It's so, so dangerous and I think that it might be more appealing to some first responders
because therapy is icky and that means they're weak and this and that.
I don't want to go to a shrink because there might be some culturally incompetent shrinks,
but this person used to be a first responder and they're saying they can help me, so I'm
going to go to them.
So that is, I think, one of the top red flags to look out for and to have understanding
of everything that Dr. Gena was saying is do the due diligence and do some research
on what is the standard of this and how does this look.
I never understood the term life coach.
I'm hopefully only 50% through mine and I don't feel like I'm an expert in anything.
So how other people can tell you how to live your life, I find an intriguing philosophy.
I have seen every name word in the gamut now in front of the word coach.
I'm a life coach.
I'm a resiliency coach.
I'm a trauma coach.
I'm a relationship coach.
I started keeping a list.
I don't have it in front of me, but I've seen some very wild ones where I'm like you literally
just use an adjective and put the name coach after it.
So yeah, there can be a time and place for coaching if we're talking about someone who
has been a public safety provider and they're coaching.
I think of it as consulting.
I think coaching is the wrong word for it.
If you're saying that you offer consulting on how best to prepare for the entry exam
into the police academy, great, consult on that.
You have the experience to do that, right?
But when we're talking about like I'm going to coach you through your mental health problems,
is that healthy?
Absolutely.
Yeah, I think it's a huge problem and I'll just say one more piece on it before I move
on to a second red flag that I have.
But I agree what you said, Dr. Brooke about first responders potentially thinking it's
more appealing to go to this safer perceived middle ground of a peer where they're like,
I'm not quite invested in the idea of therapy yet.
I don't know what I think about that field.
Maybe I don't know how to reach out or who to reach out to.
It seems complicated, but there's this guy or gal at my agency that I know has been through
something similar with me or a guy or gal at an agency, you know, one state over.
They say that they've been through the same thing.
I'm going to talk to them, feel it out, see if that's helpful and then I'll make a decision.
I think it can be helpful as long as you understand what you're getting into and you recognize
the limitations of that.
If you think that talking to a peer supporter is the same as going to therapy, that would
be an incorrect conclusion and you're going to set yourself up for failure.
You're also going to set up the peer supporter to practice out of scope, which again is a
huge problem.
If you can see it for what it is, peer support, this person just talking to me about what
I've been through and helping me navigate to get to more appropriate resources, I think
it's totally fine.
In terms of a second red flag, I think it's a red flag when you look at people's advertising,
whether it's psychology today, good therapy, whatever the directory is that they're using
and they specialize in everything.
So if they just have a laundry list of 120 different things that they specialize in,
that's a problem.
And the reason for that is if you think about the earlier part of the conversation where
Dr. Brooke was talking about how much time it takes for psychologists to get through
school and how through that process, it's like a funnel where you start really broad
and then you narrow yourself all the way into a specialty.
Unless you're funneling, you're also taking stuff and you're throwing it out of being
out of your area of expertise.
So by the end of the time that you're getting through your education and training and your
license, you should have fewer things on the list that you can treat competently than you
started with.
You might be interested in everything in psychology.
I know I am for sure, but I'm not competent to treat every diagnostic issue in the book
as well as not being able to competently and culturally competently provide care to every
population that exists under the sun.
So it's a red flag if they have a huge laundry list, but it's also something where if you
really jive with that person's profile and you're interested to determine whether or
not they would be a good fit for you and you're willing to look past that, call them and make
sure that they fit with your characteristics.
Do they actually have the education, training, and experience to work with whatever it is
that you're managing and who you think you are?
If they can answer those questions well, then it doesn't really matter if they can treat
the 119 other things because you're coming to them for the one thing that you've determined
they can treat you with.
Love it.
What did you say earlier, James?
You said like they list like honey badger hunting or something.
Yeah, badger taming and roller skating.
Badger taming, yeah.
Yeah, the listing, a lot of different things typically is a red flag that that person probably
actually isn't like well equipped or specialized to treat whatever it is or address whatever
it is that you're coming in for.
It's possible that they can, but like Dr. Geno was saying, giving them a call and asking
them and I love, I'm so glad you explained that Dr. Geno too because it's very true.
Like we start off here and then over the years, at least for the psychologists, we become
very specialized and that doesn't mean we only treat one very thing, one specific thing,
but like specializing in trauma and anxiety, those are the umbrellas and there's common
things that fall underneath those umbrellas.
But like she was saying, through my years of training, I have done therapy and clinical
work with a lot of different presenting problems.
I mean, my second year of my PhD, I treated someone for bulimia.
I treated someone for binge eating disorder.
I treated someone for body dysmorphia and you're in training, right?
So this is okay.
You're a student, they're well aware, they sign consent forms for this, like you're getting
supervision and you're learning.
But as I go on and I specialize, yeah, I just had someone reach out to me the other day
or clinician being like, hey, I have someone with pretty severe post-traumatic stress and
they also have pretty bad disordered eating.
And I referred them out and I'm like, I can target that, but I'm not, yeah, I've seen
cases in the past where I've addressed that, but I'm not competent enough to do that.
So knowing your scope of practice is pretty important and then it's a red flag when someone
is not necessarily very clear on what their scope of practice is.
Beautiful.
Well, before we move on to what counseling should look like, are there any more red flags?
I think one of the most important ones that has become very prevalent, I think, to me
in recent years, especially with social media, is when clinicians or providers, I should
say, excessively self-disclose and there's not a clinical reason for it.
And it's looking like me and Dr. Berger on the same page.
That's the one I was going to go for next.
Two thumbs up.
So self-disclosure is a tool and self-disclosure is exactly what it sounds like.
It's the provider centering themselves in the therapy space, making it about them for
a moment.
And there's lots of good reasons to do it.
If you need to be more relatable to the client, if you need to be more transparent to the
client, depending on the population that you work with, my first responders being one,
they're typically not super cool with walking in the room and knowing nothing about me.
They don't want that blank slate.
They want to know basic things.
But when I go into the therapy room, I make sure that I have a set amount of information
that I'm comfortable sharing and that there's a clinical reason for doing so.
If you're looking for a provider and they have social media or they have profiles or
websites or whatever presence where you have the opportunity to learn more about them and
the self-disclosure is excessive, I would ask myself whether or not that person is appropriate
to treat me because the more that you disclose, the more potential there is for you to feel
judged and misunderstood as a client, the more the opportunities there are for breaches
of privacy or confidentiality for clients, and the more that you learn about them, the
more that can shift the power dynamic in the therapy.
And there's a lot I could say about that, but the short of it is in therapy, it should
be a collaboration and the therapy should be about you.
I had a clinical trainer that said one time, you should not be the most interesting thing
in the room to us as trainees.
And I thought that that was a really beautiful way of saying it.
It's not that I can't show up in the room.
I obviously have my stuff.
I have my experiences.
I have my preferences.
All of that is true, but it's not about me in that moment.
And so just take a look at that and figure out would I feel comfortable with this person
providing care for me based on how they show up in their own life.
Beautiful.
Yep.
I second all that.
And Jenna and I have talked about this before, but particularly when you're getting a doctorate,
you spend seven years just being scared shitless.
They train you to be so afraid of crossing ethical boundaries and doing all that.
So you come out as a licensed psychologist and you're just so terrified of everything.
But once you work out the kinks there, part of that is they're like, you just keep that
boundary between you and the client and no self-disclosure at all.
And I don't think that that's appropriate either.
As Jenna is saying, it's important and I think especially important in working with first
responders, I'm a human too and I want them to know who I am at the foundational level
and my characteristics and my personality.
And I'll self-disclose things, particularly when I'm in training.
So if I'm doing a sleep training, I talk about how I struggle with sleep my whole life.
I've done CBTI.
Share that I see my own psychologist and I go to therapy, but there is a limit to what
I share about my personal life.
And so on top of what Dr. Jenna said is another thing that I, why I would be very cautious
about working, having a therapist who really overshares is I really question their ethical,
their understanding of ethics in general, because it's actually very important when
we're talking about therapy and effective therapy and things like maintaining, like
Jenna was saying, privacy and whatnot.
So if there's someone who is just letting you know everything about their life on social
media and honestly, some things that I've seen therapists share things where I'm like,
I would never even share that on my personal social media platform.
Like, oh my God, but knowing that about your therapist, what do I want my client to know
about me when they come into the room?
That's really kind of like what it boils down to.
It's like, what am I comfortable with my client knowing about me when they come into the room?
So I would really see it as a red flag for kind of like their understanding of ethical
boundaries and guidelines.
Brilliant.
Yeah.
It's, I mean, every time I even see with the sploomin' TikTok and all that stuff, if I'm
going to anyone and they're out there dancing, I'm going somewhere else.
I'm sorry.
Like you're a dentist.
You're a fucking ballerina.
Just focus on teeth.
All right.
Well, moving on, I digress.
So let's talk about what people can actually expect in counseling, because that's one of
the things you had on here and it was such an interesting point.
And we talk all about the philosophy of mental health and counseling, but not actually what
to expect for the first, you know, the person who's never done it before.
What will that look like?
So I'll kind of again, give you the microphone.
Go ahead, Jen.
Okay.
So starting out, let's say that you've done all of the groundwork.
You've vetted your person.
You've decided that they're culturally competent.
You've landed that they're the person that you're going to go see.
You're going to start off with a phone call or emailing them through their website to
be able to put that inquiry in and ask whether or not you can consult with them and determine
if they're accepting new clients.
So let's say you've gone through that process.
They're like, yep, I'm accepting new clients.
You're getting ready.
Here's your appointment date.
It's tomorrow at 9 a.m.
You should be ready to just bring yourself to that appointment.
You don't have to have anything prepared.
You don't have to do anything other than make sure that you had a good breakfast and an
okay night's sleep.
And when you show up at that office, either waiting in their waiting room for them to
call you back or immediately walking in and being greeted at the door by them.
For me, I've I've put a lot of thought and consideration into my practice and how that
feels for people where I did everything from choosing the building to make sure that there
was parking directly out front, having a waiting room that was mixed with other specialties
like physical therapy attorneys, that there's some privacy in the waiting room.
People don't know necessarily who you're going back to see.
And that creates a bit more comfort for people.
And then I show up in that waiting room and I am there at their appointment time.
So they're not waiting for more than half a second.
I know for a lot of my first responders, every opportunity they have between the phone call
and the appointment, they're thinking about using that out.
So if they can't find parking, if they have to wait in the waiting room, if they have
any seconds to second guess themselves, we'll often talk about it in the meeting.
They do.
So I've made that process very seamless.
So you can expect to do something similar when you see your provider waiting at the
waiting room, getting called back to their office.
Once you start that process, you're it varies a little bit.
But generally, the first meeting is a meet and greet.
They want to get to know you.
You get to know them.
It's a conversation about what therapy is, what confidentiality is, as well as getting
to know the reason for your visit that day.
Why today are you coming in?
How can I help?
From there, the therapy, the provider is going to use that information to develop a treatment
plan that you're a part of in that collaboration of that process creating.
And then you get to sign on for the treatment or not.
Depending on what your provider's theoretical orientation is, the way that they think about
symptoms, there can be some some variance here.
Some might have you fill out questionnaires about signs and symptoms.
Other ones might ask you to invite people close to you into the therapy session, whether
that's a family member, you know, or other people close to you in your life.
And then they determine how often they want to see you.
Is it is it a serious problem that requires quick intervention and and it needs to be
a bit more of a dose of therapy?
You might see them weekly.
If it's anything less than that, maybe they'll collaborate with you and do it every
other week, every month, something like that.
But in general, you can expect show up to the appointment.
Just bring yourself fill out a little bit of paperwork or discuss it.
If you filled it out beforehand, have a conversation about you.
You're the expert on you.
Those questions should be pretty easy and then potentially discuss where you're going
in the therapy.
I love it.
It's funny the the character in my new book, some of my personal experiences, and it's
exactly the opposite of what you said.
You know, that first impression can be so detrimental for someone who's finally got
the courage to try and get some help.
And you know, let's say using an example, they can't park or they sit in the waiting
room for 20 minutes while the person and the counselor is doing whatever the hell they're
doing and you go in and the room is chaos, you know, and they have to move.
This is actually happened to me move piles of paper off the couch so you can even sit
down.
So again, we're talking about red flags.
You know, if you've got the opposite of that might be a good time to just turn around and
go find another one.
Yeah.
So I'll talk a little bit more.
So I do right now I do fully telehealth.
And so I think all those factors that Dr. Jenna mentioned and the in person are so important,
you know, very similar process.
So I'll go back to say someone hears about me or, you know, finds me online and they
email me, hey, I'm looking for therapy.
I'll email them back typically within 24 hours or less and tell them that I like to set up
a free 15 minute phone call with them.
And I emphasize that this phone call is not only so that I can hear what they're looking
for and make sure that I'm competent and it's within my scope of practice to address, but
almost more importantly, it's an opportunity for them to talk to me to get a feel for me.
And of course, you don't know, get a full feel for me in 15 minutes, but you can get enough
of a feel.
And so you can ask questions and I can answer them.
And this is the opportunity for everyone out there who's listening.
You got to shop around for a provider that's a good fit for you.
And it can be really frustrating.
And I'll disclose, like I said, I get my own therapy and throughout my years of doctoral
training and everything, I've lived all over the country, which means every single time
I moved to a new state, I'd have to find a new provider and it'd be really, really frustrating.
But you need to shop around for your provider and make sure that not only are they competent
and trained in the scope of what it is you want addressed, but that you feel good with
them.
You could have the most highly trained star psychologist in the world.
And if you don't really like jive with them just on a personality level, not a good fit,
it's very, very important to just feel like you can connect with that person in some way.
So that 15 minute phone consult is just a brief way for you to talk to me and see if
I might be a good fit.
And then we do a lot of what Dr. Jenna was saying.
If you schedule an appointment, I use a system called simple practice.
And basically that's where you schedule your appointments.
Where I send you the intake paperwork, which is mostly electronic signing, electronically
signing things like consent forms and whatnot.
And then you schedule our appointment and we see each other through a secure video platform.
So we're looking at each other.
Once in a while, someone might need to request a phone session if the circumstances are such,
but otherwise, we're visually seeing each other and we're working through that secure
platform.
First session, like Dr. Jenna said, is really about getting to know you a little bit better,
meaning the bigger scope of what's bringing you in and background and the factors that
might be contributing to this thing.
And then collaboratively developing treatment goals that we use as goalposts to assess how
you're progressing.
And then a treatment plan and what that might look like moving forward.
So it should always feel very collaborative.
It should always feel like you can connect in some way to this provider and that they're
genuinely trying to connect with you as opposed to you're just another person on the couch
and they're taking notes and they forget what your kid's name was and if you've told them
10 times and you're just another person there.
It should feel personal in that sense that they are truly there for you and they are
wanting to develop a treatment plan specifically for you.
Let's talk about confidentiality because you touched on that, especially in the first responder
professions if you're in an AAP provider or the one that works for the agency.
What are some of the myths around confidentiality?
What are some of the justified fears?
And then what is the ideal model to make sure that our responders feel comfortable about
being open without fearing losing their jobs?
Okay, so I'm going to address maybe like one question, one of those questions.
Well, first, let's talk about what confidentiality is when we're talking about therapy.
That means that I'm not only ethically obligated to keep what we talk about in sessions private
and I'm not allowed to talk about that outside of the session, but I'm legally obligated
to that too.
I could be legally reprimanded in some way if I break that confidentiality.
So that means I can't share your name.
I can't share the information we talk.
Any type of protected health information or what we talk about, things like that.
Now I can potentially consult, let's say, with Dr. Jenna on a case that I'm working
on that I need some consultation because it's important to do that if you're kind of stuck
on something and you need to kind of reach out to someone.
But again, I'm not giving your name away.
I'm not giving specific identifying information away.
I'm more so saying, Jenna, I have this case where someone came in and they're struggling
with significant guilt, but they've recently started using some narcotics.
And what's your experience of the best way to address this in a way that we're addressing
both aspects, right?
So it's very broad-based and I'm not giving any specific information away.
So confidentiality is something that's extremely imperative that clinicians and providers follow
in the therapy room.
But there are four exceptions we call limitations to confidentiality.
We are mandated reporters and you're probably aware of what that is, James, right?
Educate me, please.
I think I understand the concept, but let's not ask my opinion of it.
So there are a few circumstances in which I'm legally obligated to actually break that
confidentiality that I just talked about.
One would be if I suspected that my client was in imminent danger of harming themselves,
imminent danger of suicide.
And when I'm talking to my first responders, I make it very clear when I say imminent for
me as a clinician is much more specific.
I work with first responders with varying levels of suicidality to people who have chronic
thoughts of wanting to kill themselves and maybe even like they've started to drive by
bridges and they've engaged in some behavior, even that in and of itself wouldn't necessarily
lead for me to break that confidentiality and call 911.
For me, examples of imminent would be if someone says I've made up my mind, I made up my mind,
I'm going to do it.
Something like that, for example, I would break confidentiality for that.
I would consider that imminent.
Or if there is a multitude of pieces of information present that indicate, that lead me to believe
with the information I have that it's quite possible that this person might attempt suicide
when they leave the session, soon after they leave the session.
So I like to make that very clear because I've had first responders say that they're
worried that if they tell me that they've attempted suicide recently or that they've
been thinking about it, that then I'm going to go tell someone about it.
In most cases, that is not the case, but there are certain circumstances where that would
be the case.
Do you have anything to add to that one, Dr. Jena?
I love that you went into detail more specifically about it because I think when we're talking
about first responders, one of the biggest challenges for clinicians is a lot of them
have access to lethal means.
So that can feel kind of spooky, right?
There's a group of people who are highly trauma exposed that have a lot of those risk factors
for suicide.
They have access to lethal means, which we know it can be a problem.
How do we keep them safe?
But remember the goal in therapy, if you're suicidal and you're coming to a therapist
and you're asking them to help you is that you want to live.
So I look at my role as have we done everything that we can to get you there, right?
Including but not limited to can you voluntarily choose other methods to keep yourself safe
at this time?
So the last option for me, and again, it has to be the imminent threat is let me call somebody
else and do this thing with you.
Let's involuntarily take you somewhere maybe where you don't want to go.
I'm willing to exhaust all options with somebody.
And in fact, we as providers are the perfect people to talk about suicidal thoughts with
because we're well equipped to be able to their suicide trained, well equipped to be
able to manage those problems.
So that's one circumstance.
So that's one of the limits of confidentiality.
And I should also comment that this very much varies confidentiality, whether you're in
a private practice like me and Dr. Jenna are, whether you work for an EAP, whether you're
an embedded psychologist in an agency.
This can all look very different.
So I'm commenting from the perspective of someone who's in a private practice, which
means that your agency, your captain, they have nothing to do with you and I's work together.
Nothing.
I've had so many first responders call me.
They'll sometimes not give me their name.
They'll be like, I'm not giving you my name yet.
And we'll do the 15 minute consult.
I'm like, that's fine.
You know, because they want to feel me out and talk to me.
But unfortunately they think that, let's say, especially if I work with an agency, like
I come in and I do trainings there, that they'll think that if something's wrong with them,
then I'm going to go tell their leadership or even in the instance of imminent suicide
that I'm calling their agency or their leadership about that.
As Dr. Jenna said, if all options are exhausted and someone I believe is an imminent risk
of taking their own life, I'm not calling their agency, right?
I'm calling an emergency service so that we can get them the help that they need at that
time.
So I think that that's very important when we're talking about practitioners like me
and Dr. Jenna in private practice is you're only working with us.
None of those other factors have any, any, any handle on the care we do together to the
point.
You know how strict confidentiality is in private practice.
If your supervisor calls me, say you tell your supervisor, you openly tell them, I've
been seeing Dr. Brooks, she's been great, blah, blah, blah, blah.
And your supervisor calls me and says, John Smith said that he's been seeing you and I
want to see you.
You know, so, you know, do you think that John's care has been helpful for him?
And can you provide me the same care as John?
I don't know, John.
I don't even say, listen, I can't give you that information, specific information about
John, but he's been great to work with and let's talk about how that looks with you.
I don't even know John.
He doesn't exist.
I'm sorry.
I can't comment on whoever it is that you're talking about under my care, but, you know,
I'm not sure I can, you know, identify anyone that you're talking about.
So that's how strict confidentiality is in private practice is that it's just you and
me.
No one else has access to those things.
So I wanted to make that very clear to you because I feel like that's probably like one
of the most common concerns that I have with first responders who reach out and for a consult
is they're like, you know, I see you all the time.
I see four times a year giving trainings here.
Are you going to talk to my leadership?
What if I tell you something really bad?
Then are you going to tell them?
Right.
So no contact.
There is no conversation.
They have no access to the records.
So that's super important.
I want to highlight that.
Yeah, I think it's really helpful to let people know that there is a difference between privacy
and confidentiality.
So what Dr. Brooke is talking about is privacy.
You have the right to control the disclosure of your own personal information.
If you want to go and tell the whole world that you're seeing Dr. Brooke and she's doing
an amazing job, that is up to you.
You get to say that you choose who, what, when, where, and why you're disclosing that
information.
Privacy is the provider's vehicle by which they uphold that on their end of the deal.
So if even if you've told everybody in the world, you've written books about it, you've
advertised about it, Dr. Brooke's therapy is the best.
If you, if anybody was to call or inquire about that, again, I can't confirm or deny
that this person is a client.
What are you looking for?
How can I help you?
Right.
I think a lot of my people, the sticky situation to sort of segue into this piece of the conversation
is when agencies call and consult saying that they have, they want to support an employee.
They don't want to go the fitness for duty route, but they want to support an employee
by paying for some therapy.
And this is very provider specific and I encourage anybody doing this to get consultation around
it and contact their liability insurance and make sure they're going about it the right
way.
But what I've done with some agencies has said, if the client calls me on their own
volition and decides that they want to enter into therapy, what I will do with them is
explain the limits to confidentiality and I will have them sign a release of information
for the billing information so that you can cover the end of the billing.
It does not give you access to anything other than how much money you owe me.
You don't get to have access to their records.
I don't get to make any formal opinions about their performance or whether or not they're
fit to come to work, stay at work, do anything different, go to any other duty status.
If you want to support the employee in that way, I'm willing to do that as long as both
of you are aware that I can't even if you were to call me outside of that, confirm if
they're attending.
Again, different providers have different comfort levels, but I think that's helpful
for people to know because when we're talking about this confidentiality piece, it applies
to voluntary therapy.
If somebody is being mandated to some other type of service, like a fitness for duty evaluation
or a pre-employment evaluation, audience members that have gone through something like this
might remember you sign releases that say that you don't get access to some of the results
in your agency does.
That is a limitation to confidentiality.
All of this information about how services are being provided should be outlined in informed
consent with your provider.
If you have any questions about that, it should be directly outlined and discussed in that
first meeting and that should answer any questions people have.
What about the other side of that before we go to the other elements?
Where has this fear come from?
Have there been history of agencies providing what their employees thought was simple mental
health resources, but then that confidentiality wasn't honored in that particular case?
Sure, there have been.
I've heard of cases.
There's two sides of this.
I've heard of horror stories.
What I think are horror stories of clinicians not knowing ethical guidelines and boundaries,
oversharing things.
I've heard of it on that side and I've heard all too often organizations that are able
to get access to previous therapy records or to find out that one of their personnel
has gone to therapy in some way.
Not if you're going to a private paper rider though, we'll talk about that.
But this is typically if someone went through insurance-based means of some sort and they're
able to find out that they went to therapy and then they're like, oh, now we need to
evaluate you on all these factors because we found out that you went to therapy for
depression.
Yikes.
Five years ago.
So we got to make sure you're not crazy.
So let's go ahead and put you through the wringer and make sure because you did the
right thing and got help five years ago.
So I've had people call me.
I've had people in aviation specifically, it's bringing to mind most recently, call
me.
It was like 10 years ago they went to therapy.
They were struggling with depression.
They went to therapy.
They've been doing pretty well, but their agency found out and they were making them
do this whole reevaluation to make sure that they're mentally stable.
Otherwise they were going to not let them fly anymore.
So that's a real sight.
I always tell my first responders, your fears around these things are, they're there for
a reason.
Like I'm not going to sit here and tell you, you got nothing to worry about because there's
a lot of that that's going on.
Maybe the pilot could do an MMPI and a polygraph and then it'd be sweet.
It'd be golden after that.
Yeah, and they're good.
Yeah, exactly.
Well, you mentioned four elements when it came to when you have to disclose.
What were the other three?
Yeah, another one would be if I suspect any harm or abuse to anyone under the age of 18,
anyone from a protected population, someone with disabilities of any kind or anyone over
the age of 65.
That's what they constitute as elderly.
So that would be like if someone comes to my session and they're bawling their eyes
out and they're like, I feel so guilty.
My anger got the best of me and I hit my kid and they have a bruise.
Unfortunately, I have to report that, make a call CPS and file a report in that.
I'm legally obligated to do that and for psychologists, at least in the state of California, and
I'm sure it is in most places, not only can we lose our license if we don't do that, but
we could actually receive a pretty hefty fine and face jail time.
So in those cases, very few and far between, particularly in my private practice world,
but in those cases, it's not like, oh my God, I can't believe you told me that and then
I got to end the session, I'm going to go do this.
I very much reiterate, so I told you about the limits of confidentiality and I can see
that you're very upset about this and I want to work with you through this.
However, this is something that I'm legally obligated to call CPS on, is are you willing
to be there on the phone with me?
I'd really like you to be there on the phone with me to do that.
So I see if they're willing to do that.
We call CPS.
I only give the minimal amount of information necessary.
So that's another really important part, which means I don't say, well, John Smith here,
he's a firefighter, he came in, he's been cheating on his wife for a bunch of years
and he's just had so much anger and blah, blah, and last night he did this.
I just say, my client here, do you want to tell them what happened?
Sometimes I ask them if they want to, but they're able to disclose that or just the
details surrounding the hitting of the child, they struck their child, they report that
there's a bruise.
CPS gets to do whatever they want with that.
I have no decision of what goes with that, but that's another example of a limit to confidentiality
that we're legally required to report.
Do you have anything to add to that, Jenna, that I missed anything?
No, I do.
I go about the process the same way.
And I think for some people, they can be upset about the consequences of that action, right?
But if they can be a part of the solution, it tends to be a bit better.
So I also will sit down with people, have them call CPS, walk through that process,
and then there is a lot of transparency there, which I think is helpful.
A lot of people will think, oh, you're going to call and tell my whole life story.
But when they can be there present for the information that's being given, they realize
that, like you said, only the minimum amount of information is given.
They were in control of that.
Maybe they even were the ones to share it.
And so it makes them part of that process.
And that tends to be better.
You mentioned children, special needs population, the elderly.
Is that the fourth one?
If there's imminent harm to someone else, if someone says, I'm going to go and shoot
Brian Smith, my brother, as soon as I leave here.
Yeah.
So there's an I'm is it just in California, the Terrace off?
Or do you have Terrace off too?
You have Terrace off.
Yeah.
So the Terrace off also.
Yeah.
There's imminent danger to someone else with an identifiable target.
It has to be an identifiable target.
And what that means by that is if you just said, I want to go kill someone.
I actually can't break that confidentiality.
I'd probably ask a lot more questions and say, what do you mean?
Who?
What are you talking about?
Is there anyone you have in mind?
Right.
But if someone says my neighbor, John Smith, he's seen his last day and I'm going to make
sure of that.
I'd have to legally report that or that post office over on the corner of GenC and Point
Loma.
I'm going to blow it up tomorrow.
Or like I, you know, I want to make sure I have some fun with that tomorrow.
I got, I went and got a bunch of fireworks in Tijuana and I want to make sure I have
some fun with that.
I'd have to report that because that's an identifiable, an identifiable target.
Believe it or not, confidentiality is so strict in the private practice world and such that
if someone told me they've killed five people, they've killed five people.
I'm not legally allowed to tell anyone about that.
I can't call 911.
I can't make a report.
I'm not condoning you coming to me after killing people.
But my point is, is that it needs to be danger, imminent future danger to someone.
If someone's done really bad things in the past or let's even get into the weeds a little
bit more.
If someone discloses that they've done some other not so great things in the past, whether
it be with children or things like that, like they've hit children in the past or anything
like that, our job is to assess what's their access to children now, if they have children
in the house now.
It gets a little bit more complicated there, but really that imminent future dangers to
oneself or to others with an identifiable target are the ones that we are clearly required
to report.
Anything to add, Jenna, before we go to one last area?
Nope.
I think she covered it.
All right.
Well, the very last one, then we'll make sure everyone knows where to find you guys.
What about the financial element?
I think this has actually become quite a big barrier to entry to departments where they
just don't have a lot of support.
An EAP, for example, it might only cover five sessions and then you're on your own.
Talk to me about the different methods of payment or being in a network, the user's
insurance or doesn't, and then what have you seen as far as the best dynamics or philosophies
to enable first responders?
Arguably a lot of them in crisis are probably not doing well financially and it seems like
everything falls apart when it does.
Kind of trying to reduce those barriers to entry to get our first responders to good
culturally competent clinicians.
Generally speaking, there's sort of two ways into the field of psychology payment wise,
private payer insurance.
I think there's a third middle ground where we're seeing kind of an increase of that of
nonprofits that are something that providers can contract with and then have that party
pay, but essentially it ends up being some private payer or insurance.
Most of the time, and I'm private pay, so just speaking from my own experience and reasoning
for me choosing it, but also I know reasons for other people going to that route.
I'm aware that my first responders are not the richest people in the world and that there
is a barrier to care.
They already have insurance and that paying for something out of cost, out of pocket can
be difficult, but my rationale for choosing private pay over insurance are kind of three
main ones.
Number one, I like to be in control of my patient's care.
I want to be able to make the decisions about whether or not they meet criteria for a diagnosis
and what I think essential care is for them.
When you work with an insurance company, not only are you working with them deciding what
they are going to reimburse you for the session, what that should cost as opposed to what you
think the session costs.
Not only is there administrative burden associated with filling out all of the paperwork continuously
to continue to get authorization for the services, but you have to be able to determine by their
standards that the care is essential.
I'm the provider.
My job is to determine what care this person needs and then articulate to that person that
this is what the game plan is and here's how we're going to move forward.
When you talk about cultural competency like we did earlier, some of that means adapting
things to fit the context and the person in front of you.
It's not always the case that that care will be covered by an insurance company.
Those are kind of my reasons for private pay.
What about you, Dr. Brooke?
All those, and on top of that, they typically require you to diagnose someone.
They require, like she was saying, you need to prove why this person actually needs this
care and the best way to do that is to diagnose them.
Now, there's schools of thought that are like, let's just get rid of diagnoses completely.
I'm not from that school of thought.
I think that they are very important.
We're talking about assessment and learning what someone's needs are and being able to
provide them the treatment that they need.
However, there are a lot of people that actually don't have a diagnosis.
They don't meet criteria for a diagnosis.
There's no reason to assign them a diagnosis, but a lot of insurance companies require that
you give them a diagnosis regardless so that you can prove why it is that they need that
care.
I'd add that on too, like she was saying, is that insurance companies are the ones who
determine what they think you need and what your treatment looks like.
In addition to that, a reason why I'm also private pay is that confidentiality aspect.
When you go through insurance, they have access to everything, everything.
They can do what's called clawbacks, which is when they're like, we don't actually think
we need to pay you, Dr. Jennifer, that appointment that you just have with that person because
we don't actually think they need this care.
Give us all their records so you can prove to us why they actually need that care.
They have full access to all that stuff.
That's an important thing to consider when going through insurance is there's a possibility
that your records are not as protected as they would be in private pay where Dr. Jenna
and I are the ones who are in control of everything.
You're working directly with us.
No one else has access to any of your information or records unless you quite literally sign
a release of information willingly and voluntarily because you want me to provide these records
to someone else.
That's another major factor for also why I do not take insurance in private pay.
I had Greg from the Overwatch Collective on.
That's one organization though that helps fund counseling for first responders.
Seeing all the things that you said and realizing that obviously the private model is a great
model for a number of reasons, have you seen any departments that have something in place
where they will fund for that first responder to go and find a counselor of their own?
Yeah, I contract with, I guess it's not technically a contract, but I work with two organizations
right now who have a policy and a procedure in place that if an employee wants to utilize
anybody else's services, all they have to do is have that provider send them a de-identified
bill at the end of the month.
They aggregate it to the month.
It just says number of appointments and a dollar amount and the agency will pay for
that.
It doesn't go back to anybody in particular.
That's the most progressive of the agencies that I've seen so far in terms of the agency
owning it.
Again, they can pick whatever provider they want, which again gives them a bit more autonomy
to pick that culturally competent person.
I work with an agency that does that as well.
It's really fantastic that they do that.
Now they do set a limit on, which is still within my normal fee, but the chief had told
me at one point they found out that one of their people was seeing someone who was charging
like $700 for one session, like something insane, obviously just completely abusing
and taking advantage of that person.
But anyways, yeah, they pay your full fee given that it's within a reasonable, the average
for a psychologist.
You just send in a de-identified bill and you assign a number to that firefighter, like
a five digit number, and then you send them a bill and they send the money to you.
That's definitely one of the more progressive routes.
There's other aspects, like I've contracted with departments where we decide on a number
in advance.
Basically, they pay for six sessions a month.
Say this is a smaller department or something, they cover six sessions a month.
They pay upfront for it and whether or not someone utilizes those, they've still paid
upfront for it.
But first responders, they get set up with me just like it's in private practice.
I'm not working for the agency and then they can utilize those sessions if need be.
I've even worked with agencies that are like, if you go over, then let us know and we'll
cover those as well.
But again, it's completely de-identified.
They just like to see the data of how many people are actually utilizing the services,
but without any de-identified, without any specific information that can give away the
person that's going to therapy.
That's also a route to go.
Beautiful.
With that model, does that somewhat eliminate the need for an EAP if you've just got practitioners
that you're doing that with?
I believe so.
Again, this is me.
An advantage of doing that for the agencies, I typically give a significant discount because
it's upfront and they're paying me for that, whether or not people use them, meaning I'm
not charging my full fee for those six sessions.
I give a pretty significant discount on those.
That's one way to go about it.
But yeah, I think that that could be a really good way to go if an agency doesn't have access
to an EAP that they think is effective, is to maybe do that with multiple, depending
on the size of the agency.
I operate on my own in my private practice and I do a lot of consulting too, so it's
not like I'm spending all my time doing therapy.
I've actually gotten brought into agencies to actually train other providers to be culturally
competent so that then they can use those providers as well.
There's a lot of different ways to go about it.
It might involve a little bit more work on the upfront for them and maybe a little bit
more money on the upfront, but I think that the benefits of it in the long term are super,
super valuable and important.
Brilliant.
All right.
Well, we have been talking for over two hours now, so I want to be mindful of your time.
So Jenna, for people listening, where can they find you online and any kind of courses
or services that you want to talk about?
Yeah.
So you can find out about me and all the services that I offer at my website, www.theregnvlikenevada.com.
You can also follow me on my professional social media.
I post a lot of psychoeducational topics.
A lot of the stuff that we talk about today, there's little informational posts about that.
Every once in a while, I'll post something interesting that I'm doing.
You can find me at doc.jena.
And just as a broad overview, I provide consultation, therapy, assessment, the works.
So learn more on my website.
Do you have any dances on TikTok?
Because I'm not interested if you do.
Zero TikTok dances.
It would be embarrassing if I did because I am a terrible dancer.
I don't even have TikTok on my phone or anything like that.
So you can find me at my website, www.centertas.com.
I'm also on Instagram.
It's Dr. Brooke PhD.
I post a lot of...
I'm not going to over post.
Don't worry.
I'm not going to learn too much about me.
But I do a lot of...
Share a lot of the things I've been doing lately, whether it be podcasts or if I'm offering
new courses or webinars, things like that, and just some psychoeducation as well.
And as I mentioned earlier that like Dr. Jenna, I do a lot of different things, including
therapy, but also a lot of wellness programming for agencies across the country.
I do a lot of educational trainings, get brought in to give presentations to agencies on mental
wellness topics and peer support programming.
So yeah, feel free to reach out.
Beautiful.
Sorry about my distraction.
My son just came home as a thunderstorm in Florida.
He came home drenched and then my dog just pushed away into my office.
Well, I want to thank you so, so much.
I mean, obviously we've had great conversations just individually on some of the previous
episodes and I'll put those on the intro to this so people know where they are.
But this dynamic of the two of you together has been phenomenal.
And I think I hope it's really brought a lot of kind of understanding to areas that I know
I've touched on, but we've, we've glossed over.
So I want to thank you both so, so much for being so generous with your time and coming
on the Behind the Shield podcast today.
Thanks for having me on again, James.
Yeah, me too.