Mental health treatment settings: Firehouse or neutral style?

Dr Kristen Wheldon, President and Founder of the Fire Service Psychology Association, discusses how firehouse-like settings impact PTSD recovery for firefighters and the importance of neutral therapeutic environments

While each person needs to find what treatment settings best suit their individual needs, there are some basic concepts we should consider when finding the ideal resource. Mental health care includes the dynamics of provider-patient fit, treatment modality, and treatment setting.

Over the last few years, I have been approached by many members of the fire service inquiring as to whether a “firehouse” style or neutral setting for “in-patient” mental health services is the best option for a firefighter seeking treatment for Post Traumatic Stress Disorder (PTSD).

To best answer the question, I believe it is important to understand the underlying mechanisms for the onset, maintenance, and resolution of PTSD. PTSD symptoms occur in response to a traumatic event. Beyond the inception, classical conditioning processes activate symptoms and leave the potential for deterioration.

Research suggests PTSD occurs within the context of a classical conditioning model. For example, if you are at a carnival and there is an earthquake, your brain might associate the sounds and visuals of a carnival with danger. The brain starts associating neutral information with the emotional and physical responses of fear, anxiety, or danger.

For someone with PTSD, the brain continues to react as though the danger is still present, even in the absence of the original trauma. The previously neutral stimuli (such as a sound, smell, or sight present during the traumatic event) become “conditioned stimuli.” When these stimuli are encountered later, they can trigger a “conditioned response”—such as anxiety or a panic attack—because they are now associated with the traumatic event.

Thus, PTSD involves the brain’s learned association between certain stimuli (previously neutral) and the intense fear or stress experienced during the trauma, leading to heightened emotional responses when those stimuli are encountered in the future. This is why people with PTSD often have flashbacks, nightmares, or other symptoms triggered by reminders of the trauma.

For a firefighter with PTSD, a treatment facility that resembles a firehouse could be problematic because it may trigger distressing memories or flashbacks associated with their traumatic experiences on the job. Firehouses often evoke strong associations with the workplace environment, the dangers of firefighting, and potentially traumatic events such as life-threatening situations, accidents, or the loss of colleagues.

• Triggering of traumatic memories: A firehouse-like environment may unintentionally serve as a conditioned stimulus, evoking distressing memories or flashbacks related to traumatic events experienced on the job. This can interfere with the individual’s ability to feel safe and focus on healing.
• Increased emotional reactivity: The familiar sights, sounds, or smells associated with the firehouse could heighten emotional responses such as anxiety, fear, or hypervigilance. This may exacerbate PTSD symptoms rather than help the individual regulate and process their emotions.
• Difficulty establishing a neutral therapeutic space: Effective treatment often requires a sense of separation from the environment linked to the trauma. A firehouse-like setting may prevent the individual from achieving the emotional distance necessary to fully engage in treatment and recovery.

This can interfere with the healing process, as the person may struggle to feel safe or be able to relax in a setting that closely mirrors the environment that caused their trauma.

The goal of treatment is to provide a sense of safety and a supportive environment, which may be difficult to achieve if the surroundings are too closely linked to the traumatic memories that the person is trying to process and overcome. In such cases, a neutral or calming environment would be more beneficial for facilitating recovery and emotional regulation.

In some cases, a treatment facility that resembles a firehouse could potentially be helpful for a firefighter with PTSD, but this would depend on the individual’s specific needs, experiences, and stage of recovery.

• Gradual exposure: For some individuals, incorporating familiar elements from their work environment (like the firehouse) in a controlled, therapeutic setting could be a form of “gradual exposure therapy”. In this approach, the patient might slowly confront their traumatic memories in a safe environment, allowing them to process emotions and reduce their fear or anxiety associated with firehouse-related triggers. Over time, this exposure might help them gain a sense of control and resilience in the face of their trauma.
• Reframing positive associations: A familiar setting could evoke these more positive feelings if the firefighter has positive memories tied to the firehouse (such as camaraderie with colleagues or a sense of purpose and pride). The goal would be to help the individual reconnect with the supportive aspects of their job and environment, which might help them regain a sense of normalcy or meaning.
• Building trust: A treatment facility resembling a firehouse could also be comforting for someone deeply connected to their professional identity as a firefighter. If the person feels that the treatment facility acknowledges their unique experiences, it could create a sense of trust and understanding with the staff, leading to better therapeutic engagement.

However, these potential benefits must be carefully managed; not all individuals would find this approach helpful. The setting could easily trigger distressing memories or reinforce the trauma for others, making it necessary to personalize treatment and consider the specific needs of the individual. The key would be to balance the environment’s familiarity with the need for safety, emotional support, and space to process traumatic experiences.

The specific needs of the firefighter need to be considered when making a referral for in-patient treatment. This decision may include the individual and referring party (if not self-referred), but it should involve a clinical psychologist capable of identifying these specific variables to make a referral to the appropriate treatment setting.

Ultimately, there is no one-size-fits-all approach to mental health care. As the fire service continues to evolve to meet the mental health needs of its people, it must consider these important nuances and involve the clinical expertise of those who serve in these capacities.