When the City of San Diego’s workers’ compensation program manager Joseph Sousa analyzed departmental data, the statistics were alarming.  

First responders were more likely to die from suicide than in the line of duty, and the combined losses from police and fire-rescue departments accounted for nearly 70% of the city’s total workers’ compensation losses. Post-traumatic stress disorder (PTSD) claims were becoming increasingly common, especially after California passed legislation in 2020 making PTSD a presumptive injury for peace officers and firefighters.

The city faced formidable obstacles in addressing these claims effectively.  

Many medical providers were retiring or choosing not to accept workers’ compensation cases, and of those who did, few had experience diagnosing or treating PTSD. Most psychiatrists and psychologists treated these cases using the same framework for general stress claims without recognizing PTSD as a presumption injury, introducing unnecessary delays to an already complex process.

From a financial perspective, PTSD claims were characterized by high medical bills, lengthy absences, and added costs for overtime pay and new hires. Many individuals showed little to no improvement following traditional treatment approaches, with some remaining out of work for one to two years or experiencing relapses upon return. 

The stigma surrounding mental health assistance among first responders created additional barriers. Often, the police officers and firefighters in the city’s care would suppress their feelings, fearing that showing emotional distress would be viewed as weakness, potentially damaging their professional reputation or advancement opportunities. 

Some even worried about losing their jobs: “The stigma was much more difficult to combat in police than in fire,” said Sousa. “If a police officer loses their ability to have a gun, they’ve lost their job.” 

Tackling the Problem 

The City of San Diego recognized that a comprehensive strategy was needed to address PTSD among its first responders. Rather than attempting to eliminate trauma exposure, which was impossible given the nature of first responders’ work, the city focused on finding effective treatment for those impacted by PTSD to help them regain their footing and return to the job they loved.

The foundation of the city’s approach was building strong partnerships with key leaders within the police and fire-rescue departments. Sousa explained the critical importance of these relationships: “I think what makes our program stand out and what’s made our program so successful really starts with our partnership with our police and fire departments. Through the wellness groups that we partnered with, we’ve developed a really good relationship with them, because they’re the boots on the ground.” 
 
The city developed a program that addressed several key principles.  

First, each PTSD case required individualized care, as no two cases were the same. Second, health needed to be viewed holistically, treating both physical and mental injuries. Third, the stigma around seeking mental health assistance had to be dispelled. Providers had to understand the cultural framework of each department and earn the trust of first responders, as well. And finally, treatment needed to be available as early as possible to prevent conditions from worsening.

To eliminate delays that could exacerbate PTSD symptoms, the city implemented a fast-track process that worked backwards from traditional claim procedures.  

“We don’t wait for a claim to get filed, and then 24-hours for the claim to enter our system, then the adjuster gets to review the claim, and then the entire claim process starts days later,” Sousa said. “It’s really critical that we address these issues up front, and that we don’t have any processes delay our program.”

The city partnered with the Institutes of Health to create what became known as the Gold Standard for first responder treatment.  

Joseph Sousa, workers’ compensation program manager, City of San Diego

The program utilized a transdisciplinary biopsychosocial therapeutic community approach, where care was delivered in a therapeutic community setting among peers. First responders worked alongside each other on their journey toward healing and recovery, with access to a range of clinical specialists under one roof, who worked together in a coordinated fashion.

A crucial element was having the right medical partners who were culturally competent and understood the unique needs of first responders.  

The city’s vetting process involved bringing police and fire department leaders, along with wellness leaders, to meet potential providers.  

“I brought in police and fire. I brought in their wellness leaders, and I brought all the people to the table, and said, ‘Let’s go meet this provider, and you guys come with your questions from a health and safety standpoint, and I will come from a work comp perspective, and let’s address whether this is a good fit for the program,’ ” Sousa explained.

The program addressed the critical issue of stigma through messaging driven by health and safety departments. The message was clear: Employees would not lose their jobs for seeking PTSD treatment, and earlier intervention led to better outcomes.  

Word spread organically as members saw their colleagues returning to work healthy and successful.

To ensure appropriate care levels, the city implemented both inpatient and outpatient components with seamless continuity of care. The program also utilized a fast-track approach for utilization review, pre-approving treatments known to be necessary for effective PTSD care rather than creating additional delays.

Success to Build On

The City of San Diego’s innovative approach to PTSD treatment has yielded exceptional results.  

Among first responders who participated in the intensive outpatient program, 94% returned to full duty upon completion of treatment, and 94% no longer met diagnostic criteria for PTSD.  

Organization: City of San Diego * Location: San Diego* Number of Employees: 12,000 * Category: Government & Public Sector

The average time to return to work in full duty capacity was 5.5 months, compared to the previous standard of one to two years. Remarkably, 100% of first responders who attended the programs reached maximum medical improvement upon completion.

The program’s success extended beyond individual outcomes to broader organizational benefits as well.  

 The city experienced lower litigation rates, reduced turnover among highly skilled positions, and improved response times that directly impacted public safety. Claims that previously might have resulted in permanent work restrictions or employee departure were now resolving with full return to duty.

The transdisciplinary approach proved particularly effective, with all treatment modalities coordinated together.

 “When you have this type of program in place, it is so critical that it’s all under one roof,” Sousa said. “When you have different physicians who have no relationship with each other, who are treating the same patient, the treatment gets lost.”

The program’s reputation spread beyond San Diego, with other cities and municipalities seeking to replicate the model. However, the city emphasized that successful implementation required understanding local program structures, stakeholders, and desired outcomes, as there was no one-size-fits-all solution.

Further, the impact on families and the broader community has been profound. First responders who had lost hope in traditional treatment approaches discovered that PTSD could not only be treated but reversed, allowing them to reclaim their personal lives and continue their calling to serve others.

The City of San Diego’s success demonstrates that with proper partnerships, early intervention, and evidence-based treatment, even the most challenging workplace mental health issues can be addressed effectively.  

“We want to take care of our members, and we want to take care of them early on with the best medical care that we can provide under workers’ compensation,” said Sousa. “That is our ultimate goal.” & 

The Theo Award celebrates its sophomore year, honoring 32 workers’ compensation programs for their excellence and service to workers across the nation. To learn more about the award and amazing qualities each winner possesses, visit here.