PTSD Is Common Among Firefighters — but Workers’ Comp for Treatment Is Hard to Get

Todd Nelson could feel it coming on. And he began to run. He was going dark again, retreating to a place where he would curl into a fetal position with his thumb in his mouth, watching from behind closed eyes as his personal reel of horror unspooled. Sights and sounds from three decades of firefighting cued up — shrieks from behind an impenetrable wall of flame, limbs severed in car accidents and the eyes of the terrified and the dead he was meant to save.

Nelson was running on the Foresthill Bridge, the highest in California, fleeing cops and firefighters after his wife reported that he was suicidal. He hurdled a concrete barrier and straddled the railing of the bridge in the Sierra Nevada foothills, staring down at a large rock 730 feet below. As the rescuers closed in, Nelson leaned precariously over the chasm. His strategy — making the fatal plunge appear accidental, allowing his family to collect his life insurance.

It was not Nelson’s first suicide attempt — the former Cal Fire captain had tried to take his life many times before. But after that 2021 ordeal, which led to an involuntary 72-hour psychiatric hold, something in him shifted. He was ready to admit that he had a problem and seek medical help.

The incident began the firefighter’s arduous, years-long journey toward wellness, threaded through a bureaucratic labyrinth strewn with more obstacles than he’d ever encountered on a California wildfire: finding qualified medical help, battling an insurance company to pay for it and navigating the tangled morass of California’s workers’ comp. All without going broke or returning to his dark place.

No one tracks how many of Cal Fire’s 12,000 firefighters and other employees suffer from mental health problems, but department leaders say post-traumatic stress disorder and suicidal thoughts have become a silent epidemic at the agency responsible for fighting California’s increasingly erratic and destructive wildfires. In an online survey of wildland firefighters nationwide, about a third reported considering suicide and nearly 40% said they had colleagues who had committed suicide; many also reported depression and anxiety.

California’s workers’ comp — which is supposed to help people get medical treatment for workplace illnesses and injuries — can be a nightmare for firefighters and other first responders with PTSD.

Claims filed by firefighters and law enforcement officers are more likely to involve PTSD than claims by the average worker in California — and they have been denied more often than claims for other medical conditions (PDF), according to the research institute RAND.

From 2008 to 2019 in California, workers’ comp officials denied PTSD claims filed by firefighters and other first responders at more than twice the rate of their other work-related conditions, such as back injuries and pneumonia, RAND reported. About a quarter of firefighters’ 1,000 PTSD claims were denied, a higher rate than for PTSD claims from other California workers.

“It’s a fail-first system. You have to get a broken leg to show you are in need of support. With mental illness, we are constantly having to prove to everybody why we were ill. You have to get to the point of suicide,” said Jessica Cruz, the California chief executive officer of the National Alliance on Mental Illness.

Jennifer Alexander, Nelson’s therapist, said patients in acute crisis simply don’t have the mental capacity to ride herd on stubborn workers’ comp claims. Alexander said she was once on hold for more than six hours with Cal Fire’s mental health provider attempting to get one of her bills paid, and she has waited years to get paid for treating firefighters.

“People give up. It’s a battle … They are not fully functional,” said Alexander, who for 21 years has specialized in treating first responders with trauma and PTSD and has spent an estimated 25,000 hours treating them. “You are not talking about healthy individuals who can sit on the phone for hours.”

Cal Fire firefighters and other workers also have trouble finding qualified therapists, especially outside major cities in rural areas, where many are based. In 2021, less than half of people with a mental illness in the U.S. were able to access timely care. Therapists are reluctant to take workers’ comp, or sometimes any type of insurance, because they often have to wait months or years to be reimbursed.

Michael Dworsky, a senior economist at the research institute RAND and one of the study’s project leaders, called workers’ comp “challenging and bureaucratic.”

“Even if the claim is accepted, there can be disputes about the medical necessity of individual bills. Just because your claim is accepted, doesn’t mean you are done fighting with the insurance company,” he said.

A presumption of pain but still a tangled web

Employers in California must provide workers’ comp insurance that will pay for medical costs when a worker is injured on the job. However, in reality, workers’ comp, which serves 16 million Californians, can be ungainly, confusing and, sometimes, no help at all. The system, administered by the state Department of Industrial Relations, is massive: In 2022, almost 750,000 workers’ comp claims (PDF) were filed statewide.

When a firefighter requests coverage for medical treatment, insurance adjusters review the case to determine if it’s medically necessary. If the claim is denied, delayed or modified, a patient may request an independent medical review by so-called “ghost doctors” who review the case.

Systemwide in California, patients who appeal their denied workers’ comp claims, don’t fare well: Last year 3,238 appeals for mental health claims were filed, but workers’ comp officials rejected three-quarters of them, about the same as the 10-year average, according to data from the Department of Industrial Relations requested by CalMatters. (Agency officials said they could not provide data on claims from first responders.)

For decades, the California Legislature has wrestled with how to fix workers’ comp — in one year alone, lawmakers proposed nearly two dozen bills.

In 2020 lawmakers took a major step, adding a legal shortcut or “presumption” to the state labor code, stipulating that firefighters and other first responders are considered at high risk for PTSD in the course of doing their job.

That means first responders no longer carry the burden of proving their illness is work-related. However, a claims adjuster can still question the diagnosis or assert that the trauma was caused by other factors, such as military service or family events. A law enacted last year extended the presumption to 2029.

In practice, experts say that, despite the law, proving a mental health claim is still almost as difficult to overcome as the psychological injury itself. Break an arm while fighting a wildfire, and, backed up by x-rays, claims are approved. But break your mind after decades of exposure to on-the-job trauma? Prepare for battle.

Before enacting the law, state officials asked RAND researchers to report on the scope of the problem. They analyzed nearly 6 million claims filed between 2008 through 2019 and interviewed dozens of experts, including a representative sample of 13 first responders.

The researchers found a consistent and troubling trend among the 13: “Nearly all workers said that they had filed a workers’ compensation claim for their mental health conditions — yet almost none received PTSD care paid for by workers’ compensation.”

Paying out of pocket “caused severe financial strain in some cases. Some were eventually reimbursed by workers’ compensation, but only after litigation and substantial delay. Some who pursued care through workers’ compensation also noted that claim denials led to delays in the start of mental health treatment,” the RAND researchers wrote.

The 13 first responders they surveyed stressed “over and over again about self-pay and barriers,” said Denise D. Quigley, a RAND senior policy researcher who was a project leader on the study. “It’s not like we heard it once or twice, we heard it over and over again. It’s highly unlikely that we talked to the (only) people in California that had this happen.”

Firefighters told of borrowing money from family members and taking out home equity loans to pay for care, Quigley said. The litany of their struggle weighed on her team. “It’s difficult to hear people break down crying while talking to us because of all the things they’ve seen.”

According to the RAND research, for the 12-year period from 2008 through 2019, before the new law took effect:

• Firefighters and other first responders were about twice as likely to file PTSD claims as the general workforce — but the numbers are small, under 1% of all workers’ comp claims.

• Firefighters’ PTSD claims were denied more often than claims of other workers: About 24% were denied, compared to about 19% of PTSD claims for all workers, including those in high-stress occupations. About a quarter of firefighter claims for all mental health conditions were denied.

• Their PTSD claims were denied at more than twice the rate of their other presumptive medical conditions related to their jobs, such as hernias and back injuries. Even their cancer and heart disease claims were accepted at a higher rate than PTSD.

• These denial rates were calculated using a sample of only 258 PTSD claims filed by firefighters. But researcher Dworsky said the total number of claims is far higher, about 1,000, with about 230 claims denied, during those 12 years. And countless other firefighters who suffer from PTSD didn’t seek care through workers’ comp.

The RAND report was the most detailed look at the inequities between how physical and mental health are treated among firefighters and how first responders’ claims were handled compared to other workers. However, the researchers struggled with incomplete data and difficulty identifying which claims were from firefighters.

Quigley said she is frustrated that no one since has tracked whether the 4-year-old presumption law — known as the Trauma Treatment Act — has helped patients and improved the system.

Many therapists say they haven’t seen much, if any, improvement. Nelson’s therapist, Alexander, called workers’ comp a “total system breakdown.”

A spokesman for the Department of Industrial Relations refused to grant interview requests from CalMatters or answer questions or provide data about firefighters’ mental health claims.

Navigating the system

During his 28 years with Cal Fire fighting wildfires in combustible regions, such as the Napa Valley and the Sierra Nevada foothills, and responding to other emergencies, Nelson never reported any mental health issues to anyone. Not once. Even as he would regularly pull his truck off the side of the road during wildfires and weep. Even after responding to the scene of traffic accidents, extricating children from crushed cars as their parents fought to get to them. Even after answering a call to a suicide to find a man hanging from the rafters in his barn. Even after the unbidden images began to intrude with greater frequency.

Instead, his mantra became “I’m good.”

That stoicism, common among first responders, short circuits the insurance system designed to help them — a system that works best with prompt reporting and meticulous documentation.

Claims adjusters usually handle clear-cut cases where the date of injury can be pinpointed. More common among PTSD claims, though, is Nelson’s experience with cumulative trauma, with no paper trail of injuries or complaints. He can’t offer a single event as the origin of his trauma and no coherent chronology. Cal Fire folks tend to wait until their dam bursts before asking for the water to be turned off.

One Southern California mental health provider told the RAND researchers that firefighters and police officers typically have severe cases of trauma.

“On the clinical side, as a mental health provider, it is not realistic to expect a firefighter or a police officer to come in and have had a little trauma or some minor stress condition … Most departments have people with a lot of stress and trauma,” the therapist said. “Just because you had something happen recently, the straw that broke the camel’s back, it is really the cumulative stress that is the issue.”

Now retired, Nelson, 54, has been fighting for workers’ compensation for almost three years, since his suicide attempt on the Placer County bridge. He and his wife already have spent more than $10,000 out of pocket for medical care and could face thousands more in legal bills.

Nelson’s case is unusually severe and complex, requiring two extended stays in a facility that specifically treats firefighters to diagnose his conditions and finally set him on a treatment path of therapy and multiple medications.

Cal Fire Battalion Chief Brad Niven said he has more than a dozen firefighter friends who have had similar experiences.

“Talk to anybody that tries to do anything through workers’ comp — it is an absolute nightmare,” he said. “Everybody knows you file your first workers’ comp claim and they will deny it. One guy I worked with went through the works with them. He had to prove beyond a shadow of a doubt that you have problems. You have to relive everything you’ve gone through. It does not make for a friendly system.”

Niven considered suicide before Cal Fire’s employee support personnel helped him find a therapist, streamlining what had been a hit-and-miss process.

“They blasted away the stumbling blocks,” he said. But the fire agency does not make the decision to approve or deny a claim or handle the bureaucratic thicket that is workers’ comp.

Scott O’Mara, a San Diego-based lawyer whose firm represents first responders, said adjusters’ training is to look for what they can develop to deny the case. “Their goal is to contain and control cost,” he said. “We do a lot of cases where the compensation is nickels.”

Although California law now considers PTSD for first responders a presumption, it is a “disputable presumption.” That means claims administrators can consider other traumatic events in a firefighter’s life that may play a role in a PTSD case.

“With cumulative trauma, or stress over the course of their entire employment, we need to request more information from the doctor so that we can see it isn’t because they were in the military or they are going through a divorce, etc.,” one claims adjuster told RAND researchers.

The complexity of the system wears down the resistance of injured workers, who need a jungle guide to find their way at a time of profound pain and disorientation.

“They can’t navigate this on their own, they really can’t. They’ve got professional litigators opposing them,” said Richard Elder, a workers’ comp lawyer in Concord who regularly represents state firefighters. “The average claims adjuster on the job for more than a month knows more about the system than the average firefighter. They’ve got lawyers on speed dial. The injured worker is adrift. It’s like a do-it-yourself heart transplant.”

Elder, who has been in practice for 54 years, used to work as an insurance company claims adjuster. The system, he said, has always been adversarial.

“It’s against the law for employers to discriminate against a worker who files a psyche claim. But they do discriminate,” said Elder, who said in the past five decades he has pursued about 500 psychiatric claims.

“I just filed a psychiatric claim and the response was ‘give us a list of every medical facility that treated the claimant in the last 10 years,’” he said. “The workers’ comp medical treatments system is a stain upon the soul of the politicians and officials of California.”

Diagnosing PTSD is ‘a complicated process’

One day in March, Nelson sat next to his wife, Leticia, in a quiet room in a Nevada City library near their rental home. He was in the grips of a seizure, brought on by retelling his firefighting nightmares to a CalMatters reporter. His hands were clenched and his torso taut. He stuttered, his eyelids fluttering. The episode lasted a few minutes.

During the interview, Nelson was fidgety, his thick fingers constantly worrying about the items he had put on the table in front of him. One was a tiny aluminum cylinder containing medication for his seizures, another was a brass medallion, the iconic firefighter symbols of an ax and firehose nozzle stamped on one side and the serenity prayer on the other.

The coin was a kind of talisman given to him after graduating from a specialized rehab clinic for firefighters, where he was given his daunting medical diagnosis: He suffers from complex PTSD, psychogenic non-epileptic seizures and dissociative identity disorder.

Such anxiety-induced seizures are unusual but not rare, his therapist said, and the totality of Nelson’s mental health issues makes his case unusually severe. Weekly therapy sessions and multiple medications have tempered, but not extinguished, his struggle with crippling anxiety.

Nelson wears a medical alert wrist bracelet intended to give first responders a bare-bones outline of his conditions and which medications to avoid when he is experiencing an anxiety-induced seizure. In his back pocket, he carries, always, a medical card with his list of red flags, so extensive that it unspools like an accordion.

His seizures may occur several times a day. Some last for hours. Nelson’s usually benign aspect changes: His eyes cross, his hands clench into what he calls “spidey fingers.” He stumbles and stutters through sentences and repeats words, often losing his ability to speak at all. At times he drags his head and face along walls. Leticia Nelson describes the seizures as his body undergoing earthquakes.

Nelson’s unusual body movements during a seizure, his inability to respond to questions and his propensity to run away when confronted puts Nelson in a precarious place in airport lines or with law enforcement, where his non-response has been misconstrued as defiance.

Even doctors can misunderstand. Diagnosing and treating PTSD and acute trauma like Nelson’s is notoriously difficult.

“Diagnosing PTSD is a complicated process. Diagnostic criteria are complicated,” said Sidra Goldman-Mellor, a UC Merced psychiatric epidemiologist who studies depression and suicidal behavior. “Your average primary care clinician is probably not willing to go down that road.”

For patients like Nelson, any number of stress-related disorders present themselves and muddy a specific diagnosis that would satisfy a claims adjuster or a workers’ comp review.

“That’s the thing with psychiatric disorders, we don’t have a lot of objective measures for a mental health diagnosis. We don’t have blood tests and we don’t have MRIs,” Goldman-Mellor said. “They (mental health issues) are harder to recognize, harder to test for and easier to ignore.”

However, firefighters cannot move easily through the workers’ comp or medical insurance system if they don’t have a diagnosis. Constantly proving your pain becomes its own trauma.

“He has to prove his world is falling apart,” Leticia Nelson said. “It’s hard to explain to someone that you are broken. They look at you, they think that you look fine. They can’t see in your brain. They can’t see in your mind.”

It took four years for Nelson to find the right medical care. One physician’s therapeutic approach was to ask the former firefighter to pray with him.

The problem was much more fundamental than finding a compatible therapist: He could not find one to take his case. Many Cal Fire employees are stationed in rural or remote areas of the state, in communities underserved by health care specialists.

Living in rural Nevada County, Nelson faces a barren mental health desert where it’s difficult to find a competent therapist who might have worked with other first responders and understands the specific challenges of the high-stress job.

“It’s an absolute specialization. There’s not near enough of us,” said Alexander, Nelson’s therapist. (Nelson granted her permission to speak about his case.) “In the larger Sacramento area, there are less than a dozen competent providers.”

Cal Fire is self-insured and offers medical coverage through private companies. The agency does not manage medical claims or workers’ comp but does have programs to assist employees in finding care.

Rob Wheatley, staff chief of Cal Fire’s Behavioral Health and Wellness Program, told CalMatters in an email that the agency has expanded support for employees who seek help for mental health issues with peer counseling or referrals for treatment. The agency has a staff of 28 assisting about 12,000 employees.

But Wheatley and other Cal Fire officials refused to grant an interview and did not answer CalMatters’ questions about the problems that their employees face with workers’ comp and mental health issues.

“Any denial of a mental health claim is concerning,” Wheatley said in the email.

 Can the system be repaired?

The Nelsons have seen the insurance and workers’ comp system from the inside, been batted around by it and, they would say, abandoned by it. Still, they have few suggestions for fixing it.

They are not alone. Lawyers say that the system is based on how to save money, is too often adversarial and deeply entrenched.

Even the employers who participate in the workers’ comp system say it’s not working well. In a recent survey, more than half of the respondents said the system performs poorly, while 42% described the system as challenged but adequate.

“Nobody believes it’s ideal,” said Jerry Azevedo, a spokesman for the Workers’ Compensation Action Network, a coalition of California insurers, employers and agents advocating to improve the system. “Every constituency has complaints.”

Azevedo said California’s workers’ comp system, which has been in place since 1913, is plagued by persistent problems: high costs to operate, huge claim volume, frequent litigation, slow claim resolution and fraud and abusive practices.

“The fundamental challenge we all contend with is complexity. California’s system is arguably the most complex in the nation,” Azevedo said. The good news, he said, is that 86% of workers’ comp claims overall are accepted, according to the California Workers’ Compensation Institute.

It’s easy to get the sense of a general throwing up of hands. The state Commission on Health & Safety & Workers’ Comp dedicates a webpage to tracking workers’ comp reforms, but the last entry was in 2012.

Sean Cooper, executive vice president and chief actuary of the Workers’ Compensation Insurance Rating Bureau of California, said the system is groaning under its own weight — there are a lot of people filing claims and a lot of lawyers on all sides.

Administrative costs are high in California: The cost to deliver $1 of medical benefit from California’s workers’ comp system is 46 cents, compared to two cents for Medicare, 19 cents for private group health insurance and 25 cents for the national state median for workers’ comp according to the group’s 2023 report.

One way to fix the inequity is to turn the system on its head, said Cruz of the National Alliance on Mental Illness.

“There is a disparity about how we treat, respond and react to behavioral health versus physical health,” she said. “Maybe we need to start talking about that disparity in workers’ comp. When you have (a claims) approval rating that is flipped on its backside, that’s an obvious parity issue.”

Legislators, when they turn their gaze to the massive program, chip away at the edges. The law extending the PTSD presumption will be revisited when the state Commission on Health and Safety and Workers’ Compensation presents its report on claims and denials to the Senate Committee on Labor, Public Employment and Retirement and the Assembly Committee on Insurance, by the end of this year.

Cruz said there is more legislative focus on behavioral health than ever, but there are limits, beginning with which groups carry the most influence. Managed health care companies are powerful advocates of the status quo, she said. “We are David and Goliath when we come up against these folks.”

“So many great people want to do wonderful things and they have big ideas, but it gets chopped down to a Band-Aid once everyone gets what they want,” she said.

‘A slap in the face to all of us’

Leticia Nelson refers to herself, with only slight exaggeration, as her husband’s “service dog.”

She’s the keeper of the couple’s appointment schedule; she’s the chauffeur; and the manager of the financial spreadsheet. And it falls to Leticia to devote untold hours on the phone with insurers and medical providers, bird-dogging bills, late payments and coverage lapses.

She has watched her husband humiliated, scared and angry. Their two adult daughters, also have been treated for PTSD, after witnessing their father’s anxiety and mania, and knowing about his suicide attempts.

At times, Leticia Nelson said, “I’m mad at God.”

The Nelsons, lifelong Californians, want to leave the state and its frightening tableau of wildfires. They sold their house, changed their mind about moving and now are financially shut out of the real estate market, especially because of the high cost of fire insurance in the foothills where they live. They are nomads, shuttling between Airbnbs with two large dogs and three cats in tow and their possessions in storage.

Money is tight. Leticia would like to go back to work, but she can’t leave Todd alone.

Nelson gave up fighting the state over a disability claim after his attorney told him that an appeal would cost $50,000 — and he would lose because he didn’t claim a disability when he retired.

“It’s a slap in the face to all of us because we sacrificed as a family,” Leticia Nelson said of Todd’s long career with Cal Fire. “We sacrificed our time with him so that he could help the whole state. And nothing has been there for the family since this happened. Nothing.

“I wish that there’s things in place that would guide us that wouldn’t be so hard. But it just seems like we hit every, every obstacle possible. We’re struggling. We need help. We need to be seen. We need to be treated like humans and not criminals.”

For his part, Nelson is coming to terms with the devastation his career wrought. Yet, years after retirement, he still listens to an emergency scanner and shows up at fires in his area, wearing his T-shirt, shorts and Birkenstocks. The pull to serve remains strong.

“The crazy thing is I miss my job. I miss it every day. I would do it all over again,” he said wistfully. “I loved the job but I didn’t realize the damage being done.”

If you are having suicidal thoughts, you can get help from the National Suicide Prevention Lifeline by calling 988 or visiting https://suicidepreventionlifeline.org

This story also was made possible in part by a grant from the A-Mark Foundation.