Abstract
Military service members and first responders experience significant trauma exposure in the line of duty. Service members who transition to first-responder positions may be at an increased risk for developing PTSD due to the cumulative effects of trauma exposure. A common criticism of the standard delivery methods for most evidence-based treatments for PTSD is high dropout rates. Massed-prolonged exposure (Massed-PE) has been demonstrated to be efficacious and reduces dropouts by about 50%. This case study is the first of its kind to specifically assess the clinical utility of using Massed-PE to treat PTSD in two firefighters. Results from this case study indicate that both firefighters had significant reductions in their PTSD symptoms. Massed-PE may be an effective approach to treating PTSD in firefighters and may help overcome some of the barriers of conventional treatment delivery. Additional controlled research is needed to further evaluate this promising treatment approach in firefighter populations.
There are approximately 1,115,000 career and volunteer firefighters in the United States (Evarts & Stein, 2020). Through the provision of fire protection, emergency response, and first responder medical care, they serve a vital role in their respective communities. Their profession is distinguished by lifesaving actions, bravery, and self-reliance; however, it is also marked by significant trauma exposure in the line of duty. Whereas approximately 60% of the general population will be exposed to at least one trauma over the course of their lifetime (Bürgin et al., 2020; Kessler et al., 2005, 2017), firefighters and other first responders are repeatedly exposed to potentially traumatic experiences over the course of their professional tenures. More specifically, firefighters are exposed to life-threatening situations as well as the aftermath of motor vehicle accidents, suicides, and serious injuries or deaths. The accumulative effects of repeated trauma exposure increase the risk for physical and psychological health conditions including posttraumatic stress disorder (PTSD). Lifetime PTSD prevalence rates in firefighters (17%–22%, Klimley et al., 2018) are estimated to be significantly higher than those found in the general US population (3%–8%; Kessler et al., 2005, 2017).
PTSD, a psychological disorder that may develop after trauma exposure, negatively impacts behavioral, social, cognitive, emotional, and physical functioning (American Psychiatric Association [APA], 2013). Without effective treatment, PTSD persists over time and is associated with substantial individual and societal hardships. PTSD contributes to professional burnout, lower life satisfaction, interpersonal dysfunction, poor physical health, missed workdays, unemployment, substance misuse, and long-term psychological disability (Bastug et al., 2019; Crum-Cianflone et al., 2016; Klimley et al., 2018; Maynard et al., 2017; Milligan-Saville et al., 2017). PTSD exacerbates work and relationship stressors, which have been linked to both burnout and decreased work-related safety behaviors in firefighters (Smith et al., 2018). Importantly, PTSD significantly increases risk of suicide in firefighters (Bing-Canar et al., 2019; Boffa et al., 2018; Klimley et al., 2018).
In Fire Departments across the United States, PTSD and trauma-related conditions (i.e., depression, suicidality, substance misuse) are responsible for the loss of knowledgeable and experienced firefighters. There have been recent efforts to identify firefighters’ PTSD treatment preferences and detect barriers to them receiving care. Findings indicate that firefighters prefer to seek treatment from their personal support system or from a professional outside of their department (Gulliver et al., 2019). First responders also express a preference for evidence-based, trauma-focused cognitive protocols over psychopharmacology, less empirically supported psychotherapies, and Crisis Response Debriefings (Becker et al., 2009). Additional barriers to PTSD treatment for firefighters include perceptions of stigma, embarrassment, concerns about reputation, fears about confidentiality breaches, providers that lack cultural competence, prior negative treatment experiences, logistical obstacles, and inaccessibility of treatment (Gulliver et al., 2019; Johnson et al., 2020; Jones et al., 2020). Not surprisingly, treatment accessibility is particularly problematic for rural firefighters, volunteer versus career firefighters, and firefighters who work for smaller departments (Johnson et al., 2020; Stanley et al., 2017).
Prolonged exposure (PE), a gold-standard, trauma-focused, cognitive-behavioral protocol, has strong empirical support for its treatment of PTSD in civilians, military veterans, and active duty service members (Bisson et al., 2007; Blount et al., 2014; Cigrang et al., 2005, 2011, 2015; Foa et al., 2018; Peterson et al., 2011; Peterson, Blount et al., 2019; Peterson, Foa et al., 2019; Peterson et al., 2020; Powers et al., 2010). PE is typically delivered in-office through weekly 90-minute therapy sessions over the course of 2 to 5 months. The use of PE or CPT has not been evaluated specifically in first responders with PTSD. Case study reports support the use of trauma-focused cognitive-behavioral approaches to treating PTSD in first responders (Tolin & Foa, 1999), including firefighters (Gramlich & Neer, 2018). In a randomized clinical trial of 21 disaster workers who responded to the World Trade Center attack, a 12-week, virtual-reality exposure, trauma-focused cognitive-behavioral therapy (CBT) protocol resulted in significantly greater reductions in clinician-assessed PTSD symptoms than the treatment-as-usual control (Difede et al., 2007). In a more recent randomized clinical trial, Bryant et al. (2019) compared the efficacy of two 12-week, exposure-based, trauma-focused CBT protocols to a waitlist control in treating PTSD in 100 Australian emergency workers. The effect sizes for both trauma-focused CBT protocols were large, and both protocols significantly outperformed the waitlist control. While the trial included firefighters, most of the participants were police officers. Additional studies are needed to better understand how firefighters specifically respond to trauma-focused treatments and whether these treatments can be modified to address their barriers to care.
Most standard outpatient CBT protocols adopt a similar schedule of weekly sessions. While there are benefits to this format, weekly sessions can reduce treatment accessibility for firefighters experiencing PTSD. The format can prove particularly problematic for firefighters who do not live near a PE provider, who have difficulty traveling the distance needed to obtain services, and/or who do not have the time to attend weekly therapy sessions for several months. One way to resolve the obstacles associated with once-per-week treatment sessions is to adapt PE to a massed or daily treatment format. By compressing PE into a 2- to 3-week-long protocol, Massed-PE increases the feasibility of traveling for care. This framework extends existing treatment catchment areas and offsets the current lack of expert PTSD providers within the United States. Additionally, the compressed format diminishes opportunities for PTSD-related avoidance to interfere with firefighters receiving the full dose of treatment and has the added benefit of promoting quicker recovery.
In a randomized clinical trial of 370 active duty soldiers with combat-related PTSD, Foa et al. (2018) demonstrated that a compressed PE protocol (10 sessions over 2 weeks) was superior to a minimal-contact control condition and non-inferior to Spaced-PE (10 weekly sessions). Moreover, compressed PE had a lower drop-out rate than that of Spaced-PE (13.6% vs. 24.8%, respectively; Foa et al., 2018). The treatment efficacy of a compressed PE format was further evaluated in a sample of 234 post-9/11 active duty service members and veterans (Peterson et al., 2018; Peterson, Blount et al., 2019). A 3-week Massed-PE protocol was associated with statistically significant posttreatment reductions in clinician-assessed and self-reported PTSD symptoms. Over 80% of the participants reported a clinically meaningful improvement in their self-reported PTSD symptoms, and more than half lost their PTSD diagnoses. In conjunction with PTSD improvements, notable posttreatment reductions in disability and functional impairment were also observed. Notably, research has demonstrated that trauma-focused cognitive behavioral treatments such as PE significantly reduce suicidality in adults with PTSD (Brown et al., 2019).
Military service members/veterans and first responders share many cultural values and face similar treatment barriers for trauma-related care. Therefore, Massed-PE may prove a valuable treatment option for firefighters with PTSD. This case series focuses on the treatment of PTSD with two veteran firefighters using a 2-week Massed-PE protocol. This is the first study of its kind to specifically assess the clinical utility of using a Massed-PE approach to treat PTSD in firefighters. The aim of this case series is to present details of two military veteran firefighters treated with a Massed-PE protocol, and to highlight components of the intervention that may be helpful in treating firefighters in the future. Specific strengths and challenges of Massed-PE with this population are also discussed.
Method
Baseline and Outcome Assessments
The Clinician Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake et al., 2013) is a structured diagnostic interview used to assess PTSD symptoms. Symptoms in the past month are rated on a 5-point ordinal scale, determined by symptom frequency and intensity. Total scores range from 0 to 80, with higher scores indicating more severe symptoms. The CAPS-5 has demonstrated high internal consistency (α = .88), as well as good test-retest and inter-rater reliability and convergent and discriminant validity (Weathers et al., 2018). The CAPS-5 was administered to firefighters at baseline and follow-up.
The PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz et al., 2013) is a 20-item, self-report measure used to assess PTSD symptoms. Items are scored from 0 (not at all) to 4 (extremely) to indicate how bothered the patient has been by the symptom over the last month or last week. Higher scores indicate more severe symptoms. The PCL-5 has demonstrated high internal consistency (α = .91–.96), good test-retest reliability, and convergent and discriminant validity (Blevins et al., 2015; Bovin et al., 2016; Wortmann et al., 2016). The PCL-5 monthly version was administered to firefighters at baseline and follow-up, and the weekly version was administered twice during treatment.
The Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) is a 9-item, self-report measure used to assess depressive symptoms. Patients report the frequency they have been bothered by each symptom from 0 (not at all) to 3 (nearly every day) over the course of the previous 1- or 2-weeks. Higher scores indicate more severe symptoms. The PHQ-9 has demonstrated higher internal consistency (α = .83–.92; Cameron et al., 2008) and convergent validity (Kroenke et al., 2001). The PHQ-9 2-week version was administered to firefighters at baseline and at one-month follow-up, and the weekly version was administered twice during treatment.
The Depressive Symptom Inventory-Suicidality Subscale (DSI-SS; Metalsky & Joiner, 1997) is a 4-item, self-report measure of suicidal ideation. Patients are asked about ideation, plans, perceived control over ideation, and impulses for suicide over the past 1- or 2-weeks. Scores on each item range from 0 to 3, with higher scores indicating more severe suicidal ideation. The DSI-SS has high internal consistency (α = .90) and concurrent validity (Batterham et al., 2015; Joiner et al., 2002). The DSI-SS 2-week version was administered to firefighters at baseline and at one-month follow-up, and the weekly version was administered twice during treatment.
Massed Prolonged Exposure
Prolonged Exposure (PE; Foa et al., 2019) is a gold-standard treatment for PTSD in both civilian and military populations (Steenkamp et al., 2015). PE promotes the emotional processing of traumatic experiences through psychoeducation, in vivo exposure, and imaginal exposure. In vivo exposure involves approaching previously avoided situations, people, places, and/or objects that are realistically safe. Imaginal exposure involves revisiting the trauma memory to promote emotional processing of trauma-related thoughts and feelings. A Subjective Units of Distress Scale (SUDS) is used in both in vivo exposure and imaginal exposure in which patients rate their overall subjective level of distress on a scale from 0 (no distress) to 100 (high distress).
Both firefighters were treated with ten 90-minute sessions of Massed-PE over the course of 2 to 3 weeks. Each of the 10 days of treatment adhered to a similar structure. The firefighters participated in a daily 90-minute PE session with the provider. Outside of session, the firefighters were asked to listen to audio recordings from the PE sessions and complete in vivo exposures. During Session 1, an overview of treatment and the rationale for exposure-based treatment was provided. Relevant details of the firefighter’s trauma were reviewed, and a breathing exercise was introduced. During the second session, common reactions to trauma and the rationale for in vivo exposure were reviewed. An in vivo exposure hierarchy was developed, consisting of realistically safe situations and activities the firefighter had been avoiding. The firefighters were assigned daily in vivo exposures throughout the remainder of treatment. In the third session, imaginal exposure was introduced and continued through the remainder of treatment.
Firefighter 1
Mark (a pseudonym) was a White man in his thirties. He was married with two children. He began training as a firefighter as a teenager and gained additional expertise in firefighting during his 4 years in the U.S. Air Force. After his military service, Mark continued his career as a firefighter and, at the time of treatment, had been with his current station for nearly a decade. He presented with an extensive trauma history that included childhood sexual assault, combat, and exposure to accidental and violent deaths. He was most distressed by a building fire that occurred 2 years prior to treatment that was started by an arsonist. After battling the fire for some time in the building, he felt unable to safely continue inside, and instead was assigned to operate the fire hose. As a result of this fire, one crewmember died and two were severely injured. He described feeling a deep sense of guilt for the death of the crewmember and said, “I wish I would have focused more on saving him and less on surviving.”
Mark experienced an onset of his PTSD symptoms and a notable increase in alcohol consumption following this building fire. In particular, he reported intrusive memories, psychological distress, avoidance of both internal and external reminders of the event, significant cognition and mood symptoms, and sleep disturbance. When his symptoms were at their most severe, he reported drinking approximately 5 days a week, with heavy alcohol use (5+ drinks on each occasion) approximately 4 days a week. He described taking increased risks by driving under the influence. In addition to his PTSD symptoms, he also acknowledged his depression was severe and was negatively impacting many areas of his life, particularly his relationship with his wife and family. Mark was motivated to decrease his drinking and treat his trauma-related symptoms in order to be a better father, husband, and firefighter. He was referred for treatment by a psychologist within his fire department.
Baseline Assessment
A baseline assessment was administered to determine Mark’s suitability for PTSD treatment. Mark met full criteria for a PTSD diagnosis on a clinician-administered measure (CAPS-5 = 47), consistent with his responses on a self-report measure of PTSD symptoms (PCL-5 = 62; see Table 1). His self-reported depressive symptoms were in the severe range (PHQ-9 = 22). He also reported occasional, passive suicidal thoughts (DSI-SS = 2). Mark reported feeling capable of managing his passive suicidal ideation by thinking about his family and leaning into his faith beliefs. Given these findings, Mark was considered a good candidate for daily PTSD treatment using the Massed-PE protocol.
Summary of Firefighter Assessment Measures.
Note. CAPS-5 = Clinician Administered PTSD Scale for DSM-V; PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire-9; DSI-SS = Depressive Symptom Inventory-Suicidality Subscale.
Course of Treatment
From the beginning of treatment, Mark quickly grasped the rationale for PE and drew a connection between exposure-based therapy and training to become a firefighter. He developed his own treatment metaphors, which both the clinician and Mark referenced throughout treatment. Although Mark understood the benefits of approaching realistically safe trauma reminders, he expressed some reluctance to share his feelings and to permit himself to feel vulnerable. Mark and the clinician discussed vulnerability throughout treatment, and he was able to more confidently share his emotions by the end of treatment. Mark also noted concern about his desire to use alcohol to cope throughout treatment. He described a strong desire to reduce his alcohol consumption but felt uncertain in his ability to do so. The clinician and Mark discussed alternative coping strategies, and the clinician used motivational interviewing to assist Mark in feeling capable in using other coping methods. Throughout treatment, Mark consistently reported a decrease in his alcohol use, particularly in using alcohol as a coping mechanism.
In vivo Exposures
Mark readily identified situations and places that he had been avoiding and created an in vivo hierarchy to guide treatment (See Table 2). Mark’s in vivo hierarchy included trauma reminders (e.g., being near the location of the fire, hearing bagpipes similar to those played at the funeral), situations that felt dangerous (e.g., being in a crowded restaurant or mall), and enjoyable activities in which he had not been engaging (e.g., going to the movies with his children). Mark’s in vivo hierarchy included activities that had a wide range of low-, medium-, and high-distress activities.
Summary of In Vivo Exposure SUDS Ratings: Anticipated SUDS and Final Session SUDS.
Note. “Anticipated SUDS” were gathered during Session 2 while constructing the in vivo hierarchies; “Final Session SUDS” were gathered in Session 10 during a review of the in vivo hierarchies. SUDS = Subjective Units of Distress Scale (0–100).
Throughout treatment, Mark consistently approached activities and situations on his in vivo hierarchy. The intensity of the in vivo exposures gradually increased, beginning with walking in a park with his wife, increasing to driving near the location of the fire, and finally ending with watching old news coverage on the arsonist who had started the fire. Each day he reported success with both habituating to the assigned in vivo exposures, as well as feeling a sense of mastery of his emotions in the situations. Mark also began engaging in activities that were enjoyable to him, particularly spending time with his children. Occasionally, time spent with his family, particularly when his children were being “rowdy,” caused his SUDS to increase due to his desire to “control” the situation. Throughout the course of treatment, in vivo exposures that involved not “jumping in” to control the situation were added as homework. Cognitive restructuring was used to help him manage his urge to control various situations that were realistically safe without his intervention.
Several in vivo exposures were particularly important for Mark, including going to the site of the fire and seeing reports on the arsonist who caused the fire. In Session 9, Mark was assigned the homework of conducting computer searches of reports on the arsonist as his final in vivo exposure. When his original in vivo hierarchy was constructed, he expected his SUDS to be 90 when reading or watching video-recorded reports about the arsonist and the fire. Mark came into Session 10 smiling. He reported that, whereas he had before felt “rage” at the arsonist and the fire, he now “didn’t like seeing [the arsonist],” but it did not cause the same level of anger he used to feel. His SUDS remained at 20 or lower when viewing reports about the arsonist. One notable characteristic of Mark was his willingness to engage in the in vivo exposures even when they felt difficult. When a particularly challenging in vivo exposure was assigned, he would often remark that, although he expected it to be difficult, he was determined to approach the situation.
One difficulty for Mark was not using safety behaviors when he engaged in in vivo exposures. For example, during his first in vivo exposure, which involved going to a park with his wife, he reported having difficulty paying attention to the activity, and he spent time scanning the area and being “hyper-alert” to noises around him. By revisiting the rationale for treatment and with encouragement, Mark was successful in limiting, and eventually eliminating, his use of safety behaviors during in vivo exposures.
Imaginal Exposure
The imaginal exposure proved to be one of the most impactful parts of treatment for Mark. From the very first imaginal exposure, Mark recounted the traumatic memory of the fire in vivid detail with little prompting, and he did not limit the graphic details in the description of the event. The theory and research behind PE suggest that the more vivid and strong the memory, the more emotional processing and habituation occurs (Foa et al., 2006). Mark’s vivid recollection of the event resulted in a peak SUDS rating of 100 during the first imaginal exposure in Session 3. However, his subsequent SUDS ratings decreased quickly and his peak rating was 10 out of 100 in Session 8. His pre- and post-SUDs levels decreased even more rapidly, ending at 25 in Session 5 (third imaginal exposure), and 5 in the final session.
Mark tolerated the imaginal exposure well, and although he became emotional during the first few exposures and cried, he was able to fully recount the memory and successfully habituated to the memory each day. In addition to successfully habituating to the imaginal exposure throughout treatment, Mark also actively engaged in processing his emotional experience around the memory. Although he voiced a fear of becoming emotional and feeling vulnerable, he was willing to discuss his feelings with the clinician. Toward the beginning of treatment, he reported feeling “weak” when he recounted the memory, and time was spent processing this feeling and redefining strength to include emotional vulnerability. Tying emotional vulnerability to his success in his marriage and with his family proved to be a useful intervention.
In addition to emotional vulnerability, a theme in Mark’s imaginal exposure and processing was related to the feeling of guilt. In the middle of treatment, he began to process feelings of guilt and question whether he “did enough” during the fire. Part of his trauma memory involved him being exhausted after two trips into the fire and feeling unable to safely continue. Processing his guilt, having compassion for himself with his exhaustion, and looking for evidence to support his actions were discussed.
Another important change that Mark noted occurred in Session 6, when he reported a change in how “personal” the fire felt. In earlier sessions, he described the fire as a “living thing,” and that the damage and death caused by the fire was personal to him. He shared in Session 6 that the fire felt less personal and had “less of a hold” on him.
Toward the end of treatment, Mark’s SUDS continued to drop consistently as he revisited the memory. In addition, he identified that he noticed a difference in how he felt and was proud that his crew noticed the difference. He noted he was smiling more and felt a “pressure off” of him. Mark noted the stark contrast and decline in his SUDS and reported feeling “settled” with the memory. He voiced understanding of the need to “go through it” in order to “get over it.”
Mark voiced concern about how to maintain his progress out of treatment, and concern for his ability to continue to practice the strategies he learned in treatment. The clinician and Mark discussed ways to help maintain progress such as continual exposure, challenging unrealistic beliefs and thoughts, and continuing general mental health treatment if he noticed an increase in anxiety or depression. Mark’s values were revisited to help encourage his continued work and maintenance outside of session.
Outcome Assessment
Mark completed posttreatment assessments during Session 10 (see Table 1). He reported minimal PTSD (PCL-5 = 9) and depression symptoms (PHQ-9 = 2). He also reported no recent suicidal ideation (DSI-SS = 0). These treatment gains were maintained at a 1-month follow-up. Mark no longer met criteria for a PTSD diagnosis on clinician administered (CAPS-5 = 1) or self-report measures (PCL-5 = 2). He also continued to endorse minimal depressive symptoms (PHQ-9 = 2) and no suicidal ideation (DSI-SS = 0).
Firefighter 2
Shane (a pseudonym) was a married Hispanic man in his fifties with two children. Shane served in the U.S. Army for 17 years where he worked as military police and field artillery. After leaving the Army, he became a firefighter and had remained at the department for over 20 years. His trauma history included combat, exposure to human remains, witnessing bodily harm to others, nearly drowning during a training incident, and learning about the attempted suicide of his son 1 year prior to treatment.
Shane identified a nerve gas attack that occurred during his deployment to Saudi Arabia as his most distressing trauma memory (i.e., the index event). During this attack, his friend panicked and attempted to pull off his mask. Shane had to forcibly hold him down to prevent him from removing the mask. He described feeling “terrified” and thinking “we’re going to die.” In addition to his index trauma, Shane reported a second trauma that he believed was strongly related to his current PTSD symptoms. During the same deployment, Shane was asleep, tightly bound in his sleeping bag, when a nerve gas attack alarm went off. Shane attempted to jump into action, but the zipper on his sleeping bag got stuck, and he was unable to quickly get out and put his protective gear on. Shane believed this trauma was related to his current difficulty with being in cramped, crowded spaces and general sense of “claustrophobia.” Although Massed-PE treatment usually focuses on one memory, Shane was able to sufficiently process his index trauma with enough time to focus on this second trauma for several sessions.
Shane was referred to treatment by a psychologist within his fire department. Shane’s motivation for treatment was his family and his career. His difficulty with tight spaces, feeling constricted, and not having visibility proved difficult for him in his job as a firefighter. Wearing his mask for his job was particularly difficult for him. The main symptoms of PTSD he reported were intrusive memories, psychological distress, avoidance of both internal and external reminders, significant cognition and mood symptoms, and sleep disturbance including nightmares.
Shane presented as friendly and highly motivated for treatment. He reported his sleep disturbances and avoidance as his most distressing symptoms. He reported concern about the impact of his avoidance on his career, especially his difficulty with wearing his mask. In addition to his PTSD symptoms, he acknowledged that his depressive symptoms made it difficult to engage in his life in meaningful ways. He reported wanting to “enjoy my life again.” He reported having strong faith beliefs that had been a continuous source of comfort and strength for him, and he continued to lean on his faith throughout treatment. Shane’s spouse, son, faith community, and boss proved to be great sources of support for Shane throughout treatment.
Baseline Assessment
A baseline assessment was administered to determine Shane’s suitability for PTSD treatment (see Table 1). Shane met full criteria for a PTSD diagnosis on a clinician administered measure (CAPS-5 = 33), consistent with his responses on a self-report measure of PTSD symptoms (PCL-5 = 50). He reported that his symptoms of PTSD did not become concerning until approximately 5 years prior, after watching a war-related movie. His responses on a self-report measure of depression indicated severe depressive symptoms (PHQ-9 = 22). He also reported one occasion of “fleeting” suicidal thoughts (DSI-SS = 2). Shane reported having control over his suicidal thoughts and that he was able to think about his family in order to stop them. Given these findings, Shane was considered a good candidate for PTSD treatment.
Course of Treatment
Shane reported understanding the rationale for exposure-based treatment. Although he had some concern over what it would be like to engage in exposures, he was “fully committed” to pushing through treatment in order to get better. He reported having a high level of hope to improve his symptoms of PTSD and demonstrated immense effort throughout treatment.
During treatment, Shane struggled with perfectionism when completing his exposure exercises. For example, when he was unable to approach a particularly difficult in vivo exposure for the prescribed length of time, he viewed the experience as a total failure rather than a step toward healing. Similarly, when an exposure felt uncomfortable and his SUDS remained high, he initially believed that he failed at the task. Part of the processing and homework review was spent using cognitive restructuring and reviewing the rationale to help encourage Shane’s continued effort in exposures. At the end of treatment, he was successful in conceptualizing his efforts and his plans for continued exposures after treatment as a “journey of healing” rather than a single end goal of “being better.”
In line with the sense of perfectionism, Shane expressed feeling weak for having his symptoms. At the time, this prevented him from seeking disability and other services through the VA, and invalidation of his emotions related to his traumas. He also had a rigid definition of emotional control and vulnerability, and he avoided negative emotions (e.g., crying) for fear it made him seem “out of control.” These concerns were treated as opportunities for exploration in treatment, and time was spent reframing and exploring vulnerability and Shane’s definition of strength. At the end of treatment, Shane reported feeling more ready to approach several situations that he previously avoided due to feeling “weak.”
In Vivo Exposures
In creating his in vivo exposure hierarchy, Shane and the clinician developed a comprehensive list of activities to approach (See Table 2). The list included trauma reminders he avoided (e.g., wearing his mask, being in cramped spaces like a sleeping bag or an audio booth), realistically safe activities that felt dangerous or threatening (e.g., being in crowds, being on or in water), and enjoyable activities in which he had not been engaging (e.g., hiking, playing/writing music, walking with his wife). His in vivo exposure hierarchy list included activities that ranged in SUDS levels between 5 and 100. His anchor point for 100 on his SUDS scale was being surrounded by chaos with no visibility.
Overall, Shane tolerated the in vivo exposure exercises well and reported successful habituation to many of the exposure activities. Shane was quick to experience habituation with many activities early on, such as his first in vivo exposure of wearing his mask with no visibility. Shane leaned into his support systems during some of the in vivo exposures that involved being in public. He recruited his family and boss to help him with his in vivo exposures by helping him stay accountable for not using safety behaviors and sitting in a non-preferred seat. Both the use of his social supports to encourage him and the provision of psychoeducation about accommodation of PTSD were useful to Shane in successfully habituating to many of his exposure activities.
There were some in vivo exposures that proved very difficult for Shane and helped inform treatment. Shane was assigned to listen to the sound of the nerve gas attack alarm, and his SUDS peaked at a 90. He was also assigned to lie in a tight sleeping bag. He reported having a panic attack after 20 seconds of being in the sleeping bag and having to get out. This reaction was informative for treatment progress and was a strong indication that processing his secondary nerve attack trauma was important. After both the nerve attack alarm and sleeping bag exposures, Shane returned to treatment feeling disappointed in his efforts, and time was spent reframing his experiences as small successes and a step toward his goals.
One challenge of the in vivo exposures was that Shane’s motivation was high to push himself to engage in the most difficult in vivo exposures early on. At various times the clinician and Shane discussed the benefit of gradual exposure and the potential drawbacks of jumping in too quickly with more intense exposures. For example, at one point he wanted to complete two of his highest-rated exposure activities in one evening. The clinician was careful to communicate it was not that he could not handle even the most difficult exposure activities; instead, the risk lay in not being ready for a more difficult exposure and it not going as well as he hoped, which could play into his perfectionism and feeling “weak.” Shane understood the rationale for gradual introduction of in vivo exposures and was open to conversations and negotiating his in vivo exposure activities.
At the end of treatment, most of Shane’s in vivo exposure activities were rated significantly lower than at the beginning of treatment. Each attempted situation was reduced by at least 10 SUDS points; with the majority dropping by at least 20. Shane reported a sense of calmness about many of the situations he had previously avoided and had even reframed wearing a mask as a source of safety rather than distress. In line with other conversations throughout treatment, Shane acknowledged there were still activities he planned to continue to expose himself to after treatment. For example, being in the tight sleeping bag occurred after Session 8, so the repeated exposures that were necessary for habituation did not occur during treatment. Shane reported high motivation for continuing to push himself outside of treatment and identified a plan for continued in vivo exposures moving forward.
Imaginal Exposure
Imaginal exposure with Shane began with his index trauma. During the first imaginal exposure in Session 3, Shane’s SUDS peaked at 100. With a laugh, he reported the first imaginal exposure felt “terrible.” He continued to engage in imaginal exposure each day. He recounted the memory with a rich amount of detail and required little questioning and probing to elicit important sensory details. During the first few imaginal exposures Shane cried, and time was spent processing his reaction to the memory.
As imaginal exposure continued with his index trauma, Shane’s SUDS decreased each session. In fact, after the second imaginal exposure he found that his anticipatory anxiety about the imaginal exposure was worse than recounting the memory. Time was spent processing his thoughts about each exposure and discussing alternative thoughts to help reduce his anticipatory anxiety. After his third imaginal exposure, Shane’s SUDS peaked at 40, and he reported it was “mind blowing” how different the memory felt to him. Shane and the clinician collaboratively decided to switch to his second trauma memory in Session 7, after Shane had a strong distress response to listening to the nerve attack alarm that sounded in his second trauma memory. The second trauma memory proved to be difficult, and his SUDS peaked at 90 during the first imaginal exposure. Shane reported this memory felt “surprisingly worse” than the first. At the end of treatment, his peak SUDS for the second trauma memory had decreased to 40.
Shane continued to push himself throughout all imaginal exposures and allowed himself to be vulnerable. Processing after the imaginal exposures involved some psychoeducation about the connection between his thoughts, emotions, and behaviors, as well as his sense of “needing to save the world.” His fears of weakness and vulnerability were often discussed, and cognitive restructuring was used to help Shane reframe his definition of strength and weakness. At the end of treatment, Shane reportedly felt “ready” to continue engaging in exposures and not avoid distressing situations. Although his SUDS remained higher than he wanted, he acknowledged the success he had gained from his efforts in therapy and a strong motivation to continue efforts after treatment.
Outcome Assessment
Shane completed posttreatment assessments during Session 10 (see Table 1). He reported below-threshold PTSD (PCL-5 = 21) and mild depression symptoms (PHQ-9 = 6) at the end of treatment. He also reported no recent suicidal ideation (DSI-SS = 0). At a 1-month follow-up, Shane’s scores were still well below his baseline scores for both PTSD on a clinician-administered interview (CAPS-5 = 16) and self-report measures (PCL-5 = 34). He also endorsed moderate depressive symptoms (PHQ-9 = 14) and no suicidal ideation (DSI-SS = 0). Shane attributed his increase in symptoms from end of treatment as being related to an increase in workload and associated stress due to the COVID-19 pandemic.
Discussion
These two clinical case reports provide a description of the successful use of a 2-week, Massed-PE treatment with two firefighters. This is the first study of its kind to specifically assess the clinical utility of using a Massed-PE approach to treat PTSD in firefighters. The symptom reductions seen in both firefighters indicate promising results for the use of this treatment approach for firefighters and similar populations. Each case highlighted similarities in treatment challenges, successes, and future considerations for the use of Massed-PE with firefighters. The use of Massed-PE may be specifically suitable for firefighters, considering their unique work schedules. The condensed format for Massed-PE, occurring over 2 to 3 weeks rather than 2 to 3 months, may have been a contributor to the success seen in these two cases. Foa et al. (2018) found that dropout rates in PE treatment were almost twice as high when using the standard weekly treatment format as compared to the 2-week, Massed-PE format. Evidence has also shown that adherence to homework, particularly listening to the session recording, predicts the perception of helpfulness of PE and reduced PTSD symptoms and end-state functioning (Cooper et al., 2017). The timing of the Massed-PE sessions, with homework assignments completed within the same or the next day rather than over a week, helped to increase homework adherence and improve outcomes for Mark and Shane. Both firefighters were adherent to homework on all days and engaged in active problem solving when obstacles to completing homework arose.
Another factor that likely contributed to the firefighters’ successes was the support from their respective supervisors at their fire stations. With his chief’s support, Mark was able to take time during duty days to attend the 90-minute sessions and to take the necessary time to engage in his in vivo exposures. Shane was on leave during treatment; however, he remained in close contact with his chief throughout treatment and noted the support he received from his chief about getting treatment and the importance of seeking help. Shane met with his chief at least once during treatment to discuss his experience, and he described it as a positive and helpful meeting. In military and first responder careers, the level of preparedness needed for mission readiness and focus on the team rather than the self are promoted and consistently reinforced. The importance of fire station leadership support for both Mark and Shane highlight the importance of broader organizational help for mental health treatment. As Mark shared near the end of treatment, “[We have] evaluations for physical health and [we need] to have them for mental health.” The massed format that was used in their treatment, with expectations of symptom improvement over a couple of weeks rather than over several months, may help increase the willingness of supervisors to allow firefighters to take 90 minutes a day for treatment.
Mark and Shane both identified that it was in the best interest of maintaining their careers that they seek treatment, and they had full supervisory support for doing so. Without fear of negative career consequences for entering treatment or receiving a diagnosis of PTSD, both firefighters also described a strong desire to maintain their careers. Mark and Shane both reported high satisfaction and fulfillment from their careers, as well as a strong desire to continue as firefighters after treatment. In addition to their concern about the effect PTSD had on their families, they were both adamant that they did not want PTSD to negatively impact their careers. This strong desire to stay in their respective positions may have helped motivate them to engage in treatment.
A commonality between the two firefighters was a strong grasp of the rationale from the beginning of treatment. PE treatment has a strong focus on psychoeducation to help patients understand the rationale for treatment and assigned activities; some time is spent in each of the first three sessions reviewing the rationale and providing psychoeducation. Both Mark and Shane demonstrated a quick understanding of the reason for various activities in treatment. Firefighters are frequently tasked with difficult training activities and situations in their day-to-day careers, some of which involve “pushing through” when things get tough in order to be successful. Mark described his experience of having a gradual exposure to a challenging firefighter-training task and ultimately successfully completing the task, not unlike what patients are asked to do during PE treatment through in vivo and imaginal exposure activities. Mark described a sense of becoming “desensitized” to his difficult training task, which he quickly connected to the concept of habituation in PE. Similarly, Shane was quick to grasp the treatment rationale. Although he did not have a specific training exercise to pull from, he strongly identified with the metaphors used to describe habituation and exposure, and he frequently stated that although it felt difficult to approach the exposure activities, he understood the importance of approach versus avoidance. It is possible that through training—both as military personnel and firefighters—individuals learn to push through challenging or uncomfortable situations in order to be successful in their assigned mission or task. This ability to lean into discomfort in order to reach a successful end may have contributed to the treatment successes seen with Mark and Shane.
Although Mark and Shane both saw success in their treatment with clinically significant drops in PTSD and depressive symptoms, there were some challenges that arose that may be unique to firefighters and first responders. One major theme that was present in both firefighters was that of control—particularly of letting go of control in situations that were realistically safe and did not require complete control. For example, both Mark and Shane described sitting with their backs to the wall when they went to a restaurant as one way in which they attempted to control their surroundings. This behavior, like other safety behaviors that are common in individuals with PTSD, serve to temporarily decrease anxiety in these situations, but they do not result in habituation or the reduction of PTSD symptoms over time. Some time was spent with both Mark and Shane on processing their sense of control, when it may be more or less helpful, and how to determine when control of a situation may be unnecessary or even unhelpful. By the end of treatment, both firefighters were able to identify and approach situations in which control was not necessary.
Mark and Shane also reported a fear of vulnerability, specifically, that vulnerability left them open to experiencing pain, rejection, or other negative feelings. PE targets PTSD through exposure to the trauma memory and associated avoided activities, which naturally bring up feelings of distress, painful memories, and general avoidance that are central to PTSD. Both firefighters reported hesitancy to feel vulnerable in session and during homework activities. Approaching difficult situations, discussing the positive and human aspects of vulnerability, and relating the purpose back to the rationale of mastery and competency over their reactions to the trauma memory seemed to help both firefighters face the discomfort of vulnerability and experiencing unpleasant feelings throughout treatment.
Military and firefighter cultures both serve to enhance these themes within their ranks; vulnerability is a weakness and a threat to the mission, and control is necessary in order to be successful in duties and responsibilities (Center for Deployment Psychology, 2021; Crosby, 2007; Johnson et al., 2020; Phillips & Kane, 2021). These virtues are beneficial in the combat theater and while on duty as a firefighter, but they can be less functional and helpful once back home or off duty. Given that Mark and Shane received these messages throughout both their military and first responder training and service, it was not surprising that control and vulnerability were challenging themes in treatment. As such, treating PTSD with military veterans who are firefighters may involve more exploration of these themes and how they relate to their current symptoms and prior service.
Finally, both Mark and Shane expressed guilt for taking the time to focus on themselves rather than others. They described their strong desire to serve and help their communities, families, and friends. This focus on others began during or well before their time in the military and was a consistent theme throughout their lives. Shane described himself as needing to be “superman” and fulfilling that role throughout his life. An important component of treatment was working toward giving themselves permission to focus on their own healing. An approach that proved useful was addressing their ability to help others when they themselves were suffering. The reframe of taking time for themselves and seeking treatment as a strength and a way to move forward to help others more effectively, rather than a sign of weakness, seemed beneficial in processing their feelings of guilt about needing treatment.
These two cases highlighted the successful treatment of military veterans who were firefighters with clinically significant PTSD and depression using a 2-week, 10-session, Massed-PE protocol. Both firefighters saw clinically significant improvement that remained at a 1-month follow-up. The significant reduction in symptoms of PTSD, depression, and suicidality, as well as subjective improvement in functioning for both firefighters, indicate that the use of a Massed-PE protocol may be particularly effective for this unique population. As the first study of its kind to assess the clinical utility of using a Massed-PE approach to treat PTSD in firefighters, this study sets the stage for future controlled studies utilizing the Massed-PE approach with firefighters and first responders. In addition, the case illustrations give rise to the unique challenges and strengths of firefighters and their implications with using Massed-PE. These illustrations provide a rich view into the processes that helped these firefighters see symptom improvement, as well as the obstacles to consider for future use of this approach with similar populations. Clinicians and researchers alike may use these considerations in future use of Massed-PE with firefighters. The unique factors that likely contributed to the success of these firefighters included their histories of engaging in exposure-based activities during their careers as firefighters, having strong supervisory and personal support, and a strong motivation to remain in their careers. More research on the use of Massed-PE with firefighters and first responders is necessary. These case reports only highlighted two firefighters and are limited in generalizability; however, the results are promising for the use of Massed-PE as a treatment for PTSD in firefighters. Additional controlled research is needed to better understand and evaluate the effectiveness of Massed-PE for firefighters and its potential benefit for increasing adherence to treatment, reducing dropout, and decreasing symptoms of PTSD and depression.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
