By: Dr. Tomer Anbar, CEO, Institutes of Health

June 5, 2025

The transdisciplinary, biopsychosocial, therapeutic community (TBTC) model of care requires the first responder to become an active participant in treatment and healing

More firefighters die by suicide than in the line of duty – an alarming reality that’s still not fully acknowledged in the firefighting culture. Post-traumatic stress disorder (PTSD) is a very real and often devastating consequence of repeated and long-term exposure to traumatic events on the job. While healing physically and mentally from that kind of psychological wear and tear has often felt elusive – or even impossible – new treatment alternatives are showing consistent outcomes. As research conducted by the City of San Diego and Institutes of Health demonstrate, the mental and physical damage caused by PTSD are being systematically reversed. But here’s the problem: the firehouse wasn’t built for healing.

Firefighting for many individuals is a calling. It is what the person was meant to do and becomes a life-defining identity. In some cases, the call to serve is passed down through the generations from parent to child. While individuals are unique and each firehouse culture is different, there are some common themes among both that can impact response to PTSD and seeking treatment.

Culture of Strength, Stigma of Vulnerability

First, firefighters view themselves as helpers and not the ones to be helped. Physically demanding conditions and shrewdness to address present dangers and risks in real-time are part of the job. While they don’t view themselves as heroes, most possess a mental tenacity that few people will ever understand.

Similarly, firehouse cultures vary from station to station; but again, there are commonalities. Most will describe the firehouse culture as a fraternity of strong peers who share common values and life experiences. Many put on a façade of being unshakable and ready to respond at a moment’s notice. While some of the newer leaders are more progressive in thinking and establishing a culture more open to an individual’s needs, many still hold to the long-established stigma that asking for help is a sign of weakness, particularly where mental health is concerned.

But a singular event or repeated exposure to intense trauma can take a toll. Responding to devastating home blazes, fiery interstate crashes, or grief-stricken water emergencies leaves an indelible mark on even the toughest human beings. Even the seemingly more routine, never-ending calls can become taxing. Cracks begin to show as the once jovial personalities seek solitude at the firehouse, shun storytelling and activities, and even flare at the most innocuous incident during downtime. 

When Peer Support Isn’t Enough

The peer support within a firehouse can be a first line of defense against everyday stressors. Further, team defusings and debriefings can be helpful following a traumatic incident. However, there comes a point when post-traumatic stress (PTS) erupts into full-blown post-traumatic stress disorder (PTSD) requiring professional clinical attention.

PTSD in firefighters is more than a temporary feeling of sadness. With PTSD, it is difficult to control emotions. Interactions with other people become troublesome, even with fellow firefighters and family members. Angry outbursts, aggressive confrontations, increased social isolation, and excessive self-medicating alcohol use are common. Firefighters may experience nightmares, flashbacks or uncontrollable thoughts related to a particular incident or series of events. In other instances, PTSD may be less obvious, resulting in difficulty concentrating or completing tasks.

The longer PTSD goes untreated, the more unnecessary suffering occurs leading to generational impact. This can ultimately lead to severe anxiety, depression, cognitive decline, chronic pain, substance abuse, changes in gene expression or suicide. The good news is that with proper treatment, the effects of PTSD can be reversed, and firefighters can return to the job for which they were called and resume the family activities they enjoy.

Not All Injuries Heal the Same Way

All job-related injuries are not the same. Some are treated and respond well to X-rays, surgery, or medication. But PTSD is different. It is important to be aware of effective clinical solutions and facilities where firefighters can heal from the effects of PTSD versus the firehouse, which was not built for this purpose.

The key is proper vetting of facilities to administer treatment to ensure use of evidence-based medicine that is backed by science. Holistic care rooted in biopsychosocial principles is also necessary. Further, care should be delivered by a well-coordinated team of specialists who work together to develop and execute a seamless treatment plan. Additionally, care should be administered in a trusted peer-supported therapeutic community setting. Taken together, this multi-component approach has been deemed the transdisciplinary, biopsychosocial, therapeutic community (TBTC) model of care.

Fractured and fragmented treatment plans have proven unsuccessful. By way of contrast, the traditional, biomedical tools need to be intrinsically integrated to treat the overall and sometimes hard-to-see conditions associated with PTSD. While the concept of treating the whole person is not new, the delivery of care in a highly coordinated, tightly integrated plan that considers all symptoms and addresses cultural needs to remove barriers to recovery is differentiating and new.  

Community, Rhythm, and Reintegration

Further, the therapeutic community component provides individuals with an opportunity to participate in structured, supportive outpatient, and residential environments. These provide a daily rhythm that mirrors work, life structure, and responsibilities. The therapeutic community environment helps restore trust, self-regulation, and readiness for reintegration into family, work, and society. It provides an opportunity for an emotionally corrective experience that allows individuals to invest in the behavioral changes necessary for improved self-efficacy leading to sustainable outcomes and improved resilience to stress.

The effectiveness of the TBTC approach depends on the trust and confidence a firefighter places in the process and their comfort with the treatment environment. Trust is only earned when medical providers and clinicians exhibit cultural competency and establish a connection. Mutual understanding and trust must develop for effective two-way communication and treatment to begin. Unlike many traditional treatments, the TBTC approach requires the first responder to become an active participant in treatment and healing. 

Healing is Possible, and Necessary

The bottom line is that when specialty clinicians are brought together to treat in an integrated transdisciplinary fashion and view the needs of the whole person through a biopsychosocial lens within a therapeutic community setting alongside other firefighters, targeted outcomes can be achieved, and the effects of PTSD have been shown to be reversible.  

Frequent and repeated exposure to trauma and devastation wreak havoc on mental health and wellness. The pathway to recovery is intense and challenging. And yet, the rewards are unspeakable. Firefighters have answered the call to serve others. Now they need to be ready and fully equipped to seek and secure help for their own survival and well-being when needed. Knowledge is power. With proper treatment using the TBTC model of care, the effects of PTSD can be reversed.

Dr. Tomer Anbar is CEO of the Institutes of Health (IOH), specializing in the research and advanced treatment of such epidemics as chronic pain, complex post-traumatic stress disorder, brain injuries and related conditions.  IOH is made up of specialty clinics and institutes with specific focus and mission. The IOH First Responder Institute is a component of the Institutes of Health engineered to recognize and respond to the unique challenges these professionals face. For more information, visit www.institutesofhealth.org or contact Duane Johnson to request a copy the Institutes of Health’s Expert Commentary titled “Taking Aim at Complex Post-Traumatic Stress Disorder: Introducing Life-Changing Care for First Responders,” at djohnson@institutesofhealth.org