By Dena M. Ali
In recent years, suicide has come to be recognized as a growing problem in the fire service. In July 2011, the National Fallen Firefighters Foundation (NFFF) held the first fire service suicide and depression summit. Most people at the conference recognized suicide as a problem in the fire service and even knew members who had taken their lives, but there were no statistics on how many firefighters die by suicide each year or data that could help the fire service to assess the suicide situation or to prevent suicide among its members.
Several fire departments have been affected by suicide and, consequently, have started researching prevention programs. The Chicago (IL) Fire Department (CFD), for example, suffered seven firefighter suicides in an 18-month period and is ahead of the curve with suicide prevention research and strategies. One of its key findings is that “suicide is one outcome of serious, internal struggles for an individual that may manifest for some time before he or she reaches the decision to die by suicide.”1 Identifying these internal struggles and intervening may prevent firefighters from completing suicide.
The focus of this article is on identifying common causes of firefighter internal struggles and encouraging the fire departments to develop a program for employee suicide recognition and prevention. It is hypothesized that a program aimed at identification and prevention will likely lead to increased firefighter help-seeking behavior and a reduction of depression and completed suicide.
Literature Review
Suicide is now the 10th leading cause of death in the United States.2-3 It is a complicated topic to study because it remains a mystery to clinicians, researchers, and those who have been left behind. The person with the answers is gone, and all that are left are the loss, grief, and pain.4 The greatest obstacle in prevention is there is no completed definitive epidemiologic study of emergency responder suicide.5-7 (4) Although there is no formal tracking mechanism of firefighter suicides, one study that examined North Carolina firefighter line-of-duty deaths (LODDs) discovered that suicides occurred three times as often as LODDs. (7, 50) This statistic is alarming because death by suicide is not tracked by profession, so these numbers could be much higher.
The NFFF has expanded its mission to research the causes of firefighter suicide and develop a plan for prevention. It has teamed with several leading organizations in the fire service to find answers and develop a procedure that can lead to prevention.
As reported by Hirschfeld, research has confirmed that “an individual who is determined to commit suicide will most likely prevail despite the best efforts of health care professionals.”8 Hope lies in the fact that most people who desire to kill themselves at one time will feel different after receiving help with their underlying problems. (8, 679)
Dr. Thomas Joiner developed a model for explaining suicidal behavior. It demonstrates that suicide occurs when three factors intersect: a thwarted sense of belonging, a perception that the person is a burden, and the capacity to engage in lethal action. With the removal or alteration of one of these factors, the likelihood of suicide is reduced. Efforts to reduce suicide should be directed at changing the individual’s life trajectories before he becomes acutely or severely distressed and suicidal. (2, 5) Simply said, with appropriate identification and intervention, suicide can be prevented.
Military and Fire Service Similarity
The fire service has recognized that there are several similarities between members of the emergency services and members of the military. Unfortunately, suicide is the second most common cause of death in the United States military.9 As a result, there has been extensive research into causes and prevention of suicide in the military. One critical finding is that prevention needs to reduce the stigma associated with help-seeking behavior. Military personnel are reluctant to seek help because of fear of an administrative discharge. (9) This mirrors a key finding in fire service research conducted by Willing: “Feeling that they cannot reveal vulnerability to their peers can lead to a sense of isolation. A sense of alienation or isolation is often a factor that contributes to suicidal intention.” (4)
Canadian authorities have also recognized that one problem for first responders is that they see themselves as pillars in society, and this can cause them to suppress emotions that can build into a major crisis.10 Identifying members who have begun to isolate themselves and have withdrawn from others is critically important in suicide prevention. In addition to the fear of vulnerability, work-related stress has also been associated with mental health problems and a much higher incidence of post-traumatic stress disorder (PTSD) among first responders than for the general population.11 (3)
PTSD is a mental disorder that potentially follows one or more traumatic events where an individual experiences a potential or actual loss of life or experiences a sense of helplessness or horror. The regularity of these events, as evidenced by emergency medical services (EMS) personnel, police, and firefighters, may be cumulative and add to the risk of PTSD. (11)
Firefighters are vulnerable to PTSD because of the nature of their work and the types of calls they answer. They are responsible for stressful situations such as extricating mangled bodies from vehicles, locating overcome victims in fires, and acting as first responders on any high-acuity medical responses such as heart attacks and strokes.
PTSD is just one factor that has been identified as a risk that may lead to responder suicide. Other risk factors and warning signs include anger, aggressiveness, sleep deprivation, impulsive behavior, isolation, lacking a feeling of purpose, alcohol abuse, divorce, and the presence of a firearm in the home. (1, 11, 8) Sher reports in her research that while the risk factors are typically addictive, they may also interact in a synergistic fashion. (8) In their work to develop a suicide prevention program, the Royal Canadian Mounted Police (RCMP) found that a cumulation of events, sometimes both work related and personal, can trigger a need for intervention. (10) Another risk factor is the unique schedules that firefighters work. Research has found that shift work negatively impacts length of sleep, quality of sleep, and mood. This is a concern because sleep difficulty and insomnia have been confirmed to be risk factors for depression and suicide. (7)
Alcohol
A coping mechanism that has been identified in a significant number of studies is alcohol. It is the most common coping mechanism used to deal with depression and mask the signs of stress. (7, 46) Additionally, firefighters unfamiliar with how to address their problems may self-medicate with alcohol or drugs.12 Although alcohol is commonly approached as a temporary fix or method of stress relief, its use often becomes constant, which leads to several negative outcomes including increased mood disorders, loss of health, loss of supportive relationships, and diminished thinking skills. (7) All of these effects have been found to contribute to the risk factors associated with suicide. Furthermore, Savia reported that depression and alcoholism are often found to be comorbid and that the combination leads to an increase of suicidality. (7)
When the CFD began addressing its concerns about suicide, it educated its entire staff, including line personnel and chief officers, through the city’s Employee Assistance Program (EAP). The department learned from the EAP that 90 percent of suicidal patients have a diagnosable mental-health or substance-abuse disorder. This helped them realize that suicide should be addressed during alcohol and drug assessments. (1, 8) They also learned that employees facing substance abuse problems should receive adequate support.
Support
Strategies aimed at prevention have been identified in studies that have targeted the risk factors for suicide. One risk factor is the removal of support, whether resulting from a divorce, the loss of a loved one, or being ostracized at work. (7) Whereas loss of support has been associated with increased chance for attempted suicide, positive support has been identified as having protective effects on individuals. One of the most important findings is that an adequate support system can be a protective factor. (2, 11, 7) Additionally, increasing the number of protective factors has been shown to combat risk factors and thereby reduce suicidal behaviors. (5) Examples of protective factors include establishing a sense of purpose, occupational post-trauma support, positive coping skills, self-esteem, social support, and destigmatizing help-seeking behavior. (5, 3) The greatest protective factor is positive social support. (7)
Stigma
Decreasing the stigma associated with a firefighter who has attempted suicide can help to prevent suicide and increase help-seeking behavior. A suicide attempt should not lead to a diagnosis of a mental illness. It is important to educate all members in the fire service that after professional mental health care, a firefighter who once attempted suicide can become fit for duty. (5, 3) Terminating a firefighter who has attempted suicide will only compound the firefighter’s physiological issues. (5, 3) Additionally, having people come forward and share their stories about depression and suicide will help others realize that they can seek care and do not have to hide their illness. One example is the assistant commissioner of the Ottawa Police Department, who is now a mental health strategy champion. He contemplated taking his life 20 years ago. After uttering vague suicide threats to another coworker, his supervisor took him to a RCMP psychologist’s office, where he was able to receive the care he needed; he later returned to duty. (10)
Proposed Solutions
Currently, most fire departments do not have a program, a policy, or established efforts in place to identify and help prevent a completed suicide. It is hypothesized that a program aimed at identification and prevention will lead to increased firefighter help-seeking behavior and a reduction of depression and completed suicide.
The Firefighter Behavioral Health Alliance (FBHA) (www.ffbha.org) developed an online tracking mechanism and began collecting data on firefighter suicide in January 2013. This confidential system is voluntary, so compliance is minimal. However, the organization hopes to encourage greater compliance. With a greater understanding of the circumstances that surround firefighter suicides, it will become easier to develop programs aimed at prevention and identify trends that lead to completed suicide.13
Two successful prevention methods are developing adequate support and removing the stigma associated with help-seeking behavior. Fire departments should become compliant with the 2013 edition of National Fire Protection Association 1500, Behavioral Health and Wellness Programs, which includes the chapter “Occupational Exposure to Atypically Stressful Events.” These efforts will continue to focus on critical incident stress debriefing (CISD). Additionally, using outside behavioral health professionals has been shown to be more effective with first responders who have been exposed to atypical incidents. (12) With increased awareness and understanding, firefighters will be willing to seek help when faced with a crisis.
The military has devoted significant efforts to developing programs to help prevent suicide. Because of the similarities between military personnel and fire service personnel, the fire service is working to adopt programs that have proved successful for the military. The NFFF is working on an outreach campaign based on the U.S. Army’s “Ask, Care, Escort” (ACE) program, which the NFFF will entitle “Ask, Care, Take” (ACT).14 ACT would emphasize training on awareness, reducing the stigma associated with seeking care, and encouraging peer support. Using ACT will emphasize the need for all members to take action to assist a coworker in need.
Additionally, the NFFF has adapted the U.S. Navy/Marine Corps Combat Operational Stress First Aid (SFA) program for the fire service. The SFA model consists of basic elements that can be taught to all firefighters at three levels: an awareness level for all firefighters, an operations level geared toward company officers, and a technician level for those who will provide organizational support within the agency. (14)
Training
Fire departments should combine these two behavioral health programs and train all employees on them annually. This training would help coworkers identify the warning signs and understand the appropriate steps to care. The training should emphasize that all members may need help in the course of their careers and that it is perfectly acceptable to admit that they need help. It is also recommended that fire departments follow the RCMP program, which helps all members to recognize early warning signs of dangerous behaviors and teaches them how to take care of themselves. Care can be as simple as going to the gym or taking time off from work or as serious as getting medical attention. Annual training would be interactive and include success stories that illustrate that most people need help at times and can be helped.
Training company officers will be especially important in these initiatives. They will be in the best position to recognize changes in the employees and to develop open relationships so that the employees will know they can go to them. Company officers should notice when an employee is acting in an unusual manner and foster an environment that is supportive and inclusive. The officer must be vigilant of situations in which an individual is being isolated, taunted, or ignored by other crew members. These officers are responsible for ensuring that their employees know that the officers will be available to talk with them whenever the need arises. With proper training, company officers will be available to assist members, and members will not fear outside referral or being removed from duty.
The best-case scenario would be to ensure that the company officer has the training, knowledge, and willingness to be the first line of defense for an employee who needs help. The company officer may not be the best option in every situation; that’s the reason the training should be given to all employees. All personnel should be taught the warning signs and the best approaches for dealing with a coworker in need of assistance. Coworkers can be valuable in providing positive social support or reporting dangerous behavior. One mechanism for developing peer support would be to establish a peer support team. Wake County (NC) Emergency Medical Services (WCEMS), for example, recently developed a Peer Team Support Division whose mission is to provide support to any employee in need. All WCEMS employees attended a session where they were taught about the program and then received an e-mail with a contact number they could access any time of the day. One of the best known national peer support teams is the Illinois Firefighter Peer Support team (www.ilffps.org), which was developed in 2013.
Evaluation of Program’s Effectiveness
Establish a focus group (FG) composed of members and leaders of the fire department, the EAP, psychologists, and experts from other EMS and fire departments that have already initiated a suicide prevention program. Have the FG help to develop a multifaceted educational and awareness program that will be distributed to all members. FG members will also be tasked with developing a survey for members that can be used to determine the program’s effectiveness and how to administer the survey.
One suggestion is that it be distributed by e-mail to a random sample of approximately 100 members. As an incentive, participating members could be given a gift card. A year after the initiatives and educational programs are put in place, distribute a second random sample survey to 100 members. Use the results to evaluate the program’s effectiveness. Survey questions should cover areas such as whether members feel comfortable going to their supervisors for help, if they fear repercussions for making it known that they were considering suicide, and if help was available when they needed it.
Because the fire service culture values tradition and takes pride in its history, attempting to change the perception of help-seeking behavior may take time; therefore, it is recommended that this training be repeated annually. A suicide awareness program will lead to increased firefighter help-seeking behavior and a reduction in depression and suicide.
References
1. DeGryse, D. (2012, Aug. 14). “Chicago Union EAP Embarks on Firefighter Suicide Study.” Retrieved October 11, 2015, from http://firechief.com/suicide/chicago-union-eap-embarks-firefighter-suicide-study.
2. Caine, E. (2012). “Suicide Prevention Is a Winnable Battle,” Am J Public Health 102(S1), S4-S6.
3. Wilmont, J. (2013, Oct. 1). “Now is the time for open discussion on firefighter suicide,” Fire Chief.
4. Willing, L. (2011, July 18). Firefighter suicide prevention: The company officer’s role. Retrieved October 06, 2015, from http://www.firerescue1.com/cod-company-officer-development/articles/1080052-Firefighter-suicide-prevention-The-company-officers-role/.
5. Antonellis, P Jr & Thompson, D. (2012, Dec. 1). “A Firefighters silent killer: Suicide,” Fire Engineering; 165(12):1-10.
6. Rodgers, P; Sudak, H; Silverman, M; & Litts, D. (2007). “Evidence-Based Practices Project for Suicide Prevention,” Suicide and Life-Threatening Behavior; 37(2), 154-164.
7. Savia, J. (2007). Suicide among North Carolina professional firefighters. Virginia: ProQuest, 1-106.
8. Sher, L. (2004). “Preventing Suicide,” QJM Quarterly Journal of Medicine; 97(10), 677-680. doi:10.1093/qjmed/hch106.
9. Mahon, M; Tobin, J; Cusack, D; Kelleher, C; & Malone, K. (2005). “Suicide among Regular-Duty Military Personnel: A Retrospective Case-Control Study of Occupation-Specific Risk Factors for Workplace Suicide,” American Journal of Psychiatry AJP; 162(9), 1688-1696.
10. Zacharias, Y. (2015, Mar. 7). “First responders ramp up stress management after rash of suicides.” Retrieved Nov. 15, 2015, from http://www.vancouversun.com/health/First responders ramp stress management after rash suicides/10868487/story.html.
11. Gunderson, J; Grill, M; Callahan, P; Marks, M. (2014, March). “An Evidence-Based Program for Improving and Sustaining First Responder Behavioral Health,” JEMS, Responder Resilience,” JEMS, 57-61.
12. Wilmont, J. (2014, May 1). “Trouble in Mind,” NFPA Journal; 53-59.
13. Dill, J. (2013, May 15). “Top 5 Warning Signs of Firefighter Depression, Suicide,” Fire Chief.
14. National Fire Fighter Foundation, “Confronting Suicide in the Fire Service” (2013, Oct. 23). Lecture presented at Strategies for Intervention & Prevention in the National Fire Academy, Emmitsburg, Maryland; access at http://thefirsttwenty.org/downloads/Confronting_Suicide.pdf.
DENA M. ALI is a lieutenant with the Raleigh (NC) Fire Department and an EMT Intermediate with Wake County (NC) EMS. She has a bachelor’s degree and is a graduate student at the University of North Carolina, Pembroke, where she is pursuing a degree in public administration. She is a founding member of the Carolina Brotherhood and a fitness advocate with 555 Fitness.
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