By Dena Ali
In recent years, suicide has emerged as a national public health crisis.1 According to the Centers for Disease Control and Prevention (CDC), more than 40,000 people in the United States die by suicide annually, and these high rates of suicide have led the U.S. Department of Health and Human Services to advocate for the examination of at-risk subgroups and high-risk occupational groups.2 Firefighting was identified as having an elevated risk for workplace suicides.3 A 15-year retrospective study of firefighter deaths in North Carolina revealed that a firefighter was three times more likely to die by suicide than in the line of duty.4
Because of the stigma surrounding mental health disorders and suicide, these topics have historically not been discussed in the fire service; yet, firefighters suffer from many mental health problems. Past research has revealed elevated rates of depression, substance abuse, alcohol abuse, sleep disturbances, post-traumatic stress symptoms (PTSS), and post-traumatic stress disorder (PTSD).
RELATED
The Power of Peer Support in the Fire Service
Strategies for Preventing Suicides in the Fire Service
Addressing Internal Conflict to Understand Suicide
A combination of high-profile suicides5 and emerging research has led to a call for action. The National Fallen Firefighters Foundation Firefighter Life Safety Initiative #13, for example, is finally getting more attention. It recommends firefighters and their family members have access to counseling and psychological support. However, better research is needed. Studying peer-reviewed literature has revealed a scarcity of research examining factors associated with firefighter suicidality.6 Clinicians, researchers, and society are still studying and learning about PTSD and suicide.
In 2016, the CDC called for the empirical investigation of potential interventions that may prevent suicide among high-risk occupational groups. In response to this call for action, the Laboratory for the Study and Prevention of Suicide-Related Conditions and Behaviors at Florida State University has started producing empirical evidence surrounding suicidality among firefighters. However, there remains a gap between its findings, awareness of its research within the fire service, and distribution of its findings and best practices to firefighters.
PTSD is just one psychiatric disorder strongly linked to suicide. It is tied to suicidal ideation (SI), a past suicide attempt, and can be predictive of a future suicide attempt. (3) This article was written to address suicide in the fire service while also providing recommendations for mediation and prevention based on the recent research.
Some authors have speculated that the cumulative nature of stressors for firefighters may result in a unique symptom profile for PTSD.7 Emerging research has found that the exposures to traumatic events do not always lead to negative outcomes for firefighters; they can also lead to positive outcomes such as post-traumatic growth (PTG). Additionally, practices such as Mindfulness-Based Resilience Training (MBRT) and social support are becoming recognized as protective factors against PTSD and burnout among first responders.
Post-Traumatic Stress
The severity of PTSS is related to SI and falls into several symptom clusters. Post-traumatic stress is common after a scary, traumatic, or dangerous event. Dr. Jeffrey Mitchell, clinical professor at the University of Maryland, views stress as a “normal response, by normal people, to abnormal events.”8 People experience a range of symptoms after a traumatizing event; most recover naturally, but some develop PTSD. According to the National Institute of Mental Health, PTSD symptoms typically emerge within three months of a traumatic event, but they can take years to manifest in some people. A diagnosis of PTSD in an adult is based on the presence of the following symptoms for at least one month: at least one episode each of re-experiencing and avoidance and at least two episodes each of arousal and reactivity and cognition and mood symptoms.
Symptom Clusters
• Re-experiencing includes flashbacks, nightmares, and frightening thoughts.
• Avoidance includes actively pushing away images and memories, avoiding locations, and the inability to recall certain aspects of the trauma.
• Negative alterations in cognition and mood (numbing) include negative thoughts about oneself and the world, distorted thoughts including guilt and blame, and loss of interest in enjoyable activities.
• Alterations in arousal and reactivity (hyperarousal) include problems with sleep and concentration, exaggerated startle response, hypervigilance, and angry outbursts.
In general population studies, re-experiencing PTSS has been associated with SI, and numbing PTSS is the only symptom to be consistently linked with SI. This is attributed to a lack of empirical research on the other individual symptom clusters. Future empirical studies of PTSD and firefighters using the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) screening criteria are expected to reveal elevated rates of PTSD among the firefighters. Regardless, the clinical implications of PTSD and its relationship to suicidal behavior among firefighters and the general population are well-supported. (3)
To date, only one peer-reviewed study has explored the relationship between PTSS and suicide risk in the firefighter population—the Department of Psychology at Florida State University study mentioned above, which examined 893 firefighters and found PTSS was significantly associated with SI and suicide attempts during their firefighting careers. The study controlled for other known risk variables, such as depression. (3) Results suggested that re-experiencing and numbing symptoms are uniquely related to SI in firefighters and that only re-experiencing symptoms are significantly related to prior suicide attempts. (3)
Interpersonal Psychological Theory of Suicide
The Interpersonal Psychological Theory of Suicide (IPTS) provides a theoretical model of suicidal behavior that consolidates a broad range of suicide risk factors and provides testable predictions of who will wish to commit suicide and who will be capable of suicide.9 According to the IPTS, suicidal desire is caused by a simultaneous presence of two proximal risk factors: thwarted belongingness (loneliness) and perceived burdensomeness (self-hate/liability). The presence of these two factors for a long enough time is sufficient to produce the desire to die. Fortunately, this desire is not sufficient to translate into enacting lethal self-injury.10
Suicidal desire alone is an insufficient predictor of suicidal behavior. A third element, acquired capability, is necessary to move from suicidal desire to attempted or completed suicide. In fact, the capability for suicide is typically a limiting factor in enacting suicide. The capability is acquired after the individual overcomes the inherent drive for self-preservation and loses the will to live. Repeated exposure to physically painful or fearful experiences or an elevated tolerance of physical pain lowers the fear of death. (9)
Based on the various traumas that firefighters are exposed to and the fearlessness of death they can develop, it is reasonable that they are able to acquire an elevated capability for suicide.11 In a study of 863 firefighters, fearlessness about death scores were comparable to levels of fearlessness in a study of military personnel. (11) This suggests that the experience of being a firefighter may contribute to the acquired ability to complete suicide.
Perceived burdensomeness, the second construct of the IPTS, often translates into self-sacrificial thoughts in which the individual believes that others would be better off without him or that his life is worth less than another person’s life. (10) By the nature of their work, firefighters place themselves in harm’s way to save others. Although this is an essential job trait, it may develop into a belief that one’s death is worth more than one’s life. (11) Also, shift work has been associated with significant strains in relationships; the difficulties in maintaining work-life balance can contribute to a thwarted belongingness.
As mentioned earlier, the symptom of numbing (loss of interest) is related to SI. Numbing PTSS reflects the inability to experience pleasure in normally pleasurable acts, which is related to the IPTS components of perceived burdensomeness and thwarted belongingness. In fact, the detachment/estrangement symptoms of numbing PTSS are related to SI beyond depressive symptoms and other known risk factors. (3)
Depression and PTSD symptomology frequently co-occur with one another and with alcohol use disorders. Furthermore, depression and post-traumatic stress are significantly common in firefighters who engage in drinking to cope with occupational stress, and they are also significantly associated with SI. Data analysis from 2,883 male firefighters found that alcohol dependence was significantly associated with suicide risk and that depression and post-traumatic stress accounted for an additional 14 percent of variance in suicide risk.12
Prevalence of PTSD Among Firefighters
As mentioned, there is significantly less research pertaining to PTSD and firefighters than to the general population, police officers, or the military. Prevalence rates of PTSD for firefighters are estimated to be anywhere between 6.5 percent and 37 percent. (3) These estimates at times appear to be three times as high as those for the general population, which range from 1 percent to 8 percent.13 However, this phenomenon is likely attributed to the method of analysis and use of the obsolete DSM-4. The studies examined were all based on self-report rather than structured clinician interviews, suggesting inaccuracy. One exception to the self-reporting is a study that employed a structured interview involving 132 Canadian police officers, which found that 7.6 percent of responders developed full PTSD and 6.8 percent developed partial PTSD following a work-related exposure to a traumatic event. (7) There is no known nationally representative large-scale study of firefighters, but a meta-analysis of the prevalence of PTSD among rescue workers worldwide based on 28 studies noted approximately a 10 percent rate of full PTSD and no incidences of partial PTSD.14
Development of PTSD
Response to a traumatic event can vary significantly from person to person.15 One risk factor for the development of PTSD symptoms is maladaptive mental assessment in response to a traumatic event. (13) A 2007 study of rescue and recovery workers involved in the World Trade Center disaster found that sustaining an injury was the strongest risk factor for developing PTSD.16 Other risk factors for PTSD in firefighters were prior psychiatric impairment, depression, psychosomatic complaints, substance abuse, and social dysfunction. (16) The National Health Institute lists the following as additional risk factors for PTSD: injury; feelings of horror, helplessness, or extreme fear; having little or no social support after the event; dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home; having a history of mental illness or substance abuse.
Not all individuals exposed to the same trauma develop PTSD, suggesting that individuals who have developed resilience are better able to manage and cope with adversity. Resilience is the ability to adapt and successfully cope with acute or chronic adversity. Resilience has been found to reduce the susceptibility to depression and suicide in individuals with childhood trauma and in veterans. (13) The National Health Institute lists the following resilience factors that can reduce the risk of PTSD: seeking out support from other people, such as friends and family; finding a support group after a traumatic event; learning to feel good about one’s own actions in the face of danger; and having a positive coping strategy or a way of getting through the bad event and learning from it and being able to act and respond effectively despite feeling fear.
Dr. Edna Foa, a leading expert on PTSD, recommends that firefighters understand the facts and the preparedness; be tolerant of themselves if they have symptoms, especially immediately after; don’t isolate themselves but stay connected; and talk to the one person they really trust. She points out that these things are normal because the mind “is processing a terrible event.” (8) She also recommends physical fitness and proper nutrition as forms of prevention.
In a 2014 study of Korean firefighters, researchers found that although PTSD symptoms were significantly correlated with perceived stress, they were inversely correlated with individual resilience. (13) The study also showed that the greater the number of traumatic events experienced by firefighters, the greater the level of their perceived stress and that high levels of perceived stress are highly predictive of depression. This suggests that exposure to traumatic events directly and indirectly amplifies perceived stress and influences the development of PTSD symptoms. (13)
Despite the increased exposure to traumatic and stressful events, recent research has found that firefighters are also uncommonly resilient because of the growth they experience following critical incident exposures. Firefighters generally have greater support structures within their stations and crews. However, they can become vulnerable when they suffer from poor sleep, work-family conflict, transfer, ostracism, or a significant loss.17 A meta-analysis conducted in 2000 found that reduced social support is strongly related to PTSD across general population and military samples. A lower perception of support is related to an increased risk of PTSD among firefighters.18
One study showed that experiencing multiple sources of trauma and greater operational and organizational stress predicted an increase in PTSD and that self-care coping was a mitigating factor. (18) Another suggested that organizational characteristics that increased work-related stress were linked to the development of PTSD. (16) Research has also shown that social support from superiors and organizational buffers could reduce this stress.
Post-Traumatic Growth
The concept of PTG is still being defined and investigated, but it is becoming established as a flagship topic.19 PTG was first articulated by Tedeschi and Calhoun in 1995 and asserts that some individuals are able to experience positive changes following a traumatic event. Paradoxically, life-altering negative effects of trauma can often be catalysts for positive changes as trauma survivors rebuild their world views after the event. (15) PTG is suggested as being an outcome of effortful and deliberate rumination following PTSS.
Although traumatic experiences can result in severe psychological distress, they can also produce positive psychological changes such as the development of new perspectives and personal growth. Studies have shown that 30 percent to 90 percent of people report some positive change after a trauma. (15) Some researchers have theorized that PTG is a coping style; others believe it is an outcome of coping with traumatic stress. A number of personality factors have been associated with PTG; they include hope, extraversion, openness to experience, and agreeableness to higher levels of PTG. (15) In addition, social support, positive reframing, turning to religion, and problem solving have also been linked to PTG.
A 2014 Australian study of 214 firefighters discovered that coping strategies including cognitive understanding of work events, seeking support, and self-care are strongly associated with the development of PTG. (18)
Another interesting characteristic of PTG is its relationship to post-traumatic stress. After the attacks of September 11, 2001, it was reported that empirical evidence discovered that greater post-traumatic stress was associated with greater PTG, up to a point. Based on this and several other studies, a curvilinear relationship between post-traumatic stress and PTG is implicated; the greater the post-traumatic stress, the greater the opportunity for growth. (19)
Clinical Implications
Treatments targeting cognitive distortions, such as cognitive behavioral therapy (CBT), continue to be the most effective at reducing negative post-traumatic thoughts and PTSD.20 Another treatment, Eye Movement Desensitization and Reprocessing (EMDR), has been extensively researched and has been proven effective for the treatment of trauma. Although no one form of treatment works for all people, EMDR has been found to have a direct effect on the way the brain processes information. If successful, it prevents a person from reliving the negative feelings associated with a past event. With EMDR, the negative event is not forgotten, but it is less upsetting. In addition to PTSD, EMDR has been found to be effective in the treatment of other conditions, including panic attacks, phobias, stress reduction, addictions, and complicated grief.
More treatment studies of PTSD and PTG among firefighters are needed before empirically informed approaches to treatment can be recommended. (3) Both military and law enforcement have been the focus of large-scale funded research studying suicide and its related conditions. Because of the population-specific considerations among firefighters, similarly funded research into the specific symptom clusters is paramount because of the individual and organizational factors that have led to barriers when attempting to conduct research on the firefighter population. (3) For instance, firefighters avoid treatment out of fear of being considered unfit for duty, their unusual hours limit time to access treatment, and the stigma behind treatment leads to a fear of treatment.
Based on the accruing evidence suggesting the validity of the IPTS and given that firefighters are routinely exposed to situations that contribute to elevated levels of acquired ability to complete suicide, it is recommended that they be regularly assessed for factors contributing to suicidal desire (contributing and connecting). Encouragement of social support as a protective factor against the development of SI cannot be overstated. Among firefighters, social support and meaningful social connection is a primary protector against suicide risk. Joiner (2007) states, “The need to belong is so powerful that, when satisfied, it can prevent suicide even when perceived burdensomeness and the acquired ability to enact lethal self-injury are in place.” (10)
Critical Incident Stress Debriefing
Critical Incident Stress Debriefing (CISD) is one of the most widely applied interventions for acute stress among firefighters, and it has been anecdotally associated with improvement in PTG.21 CISD involves sharing observations and facts about the event and discussing emotional reactions and thoughts about the incident with peers and facilitators immediately following the event. (17) However, several systematic reviews and meta-analyses have concluded that CISD is ineffective and may exacerbate PTSD by re-exposing patients to traumatic experiences. (17) According to Dr. Foa, “Critical incident debriefings do not seem to be helpful, as they can cause secondary victims. But the part of critical incident stress management that uses pre-training to focus on talking/seeking peer support, advocating the value of professional assistance, and wellness are quite helpful.” (8)
Current opinions regarding the efficacy of CISD are mixed although its components, such as peer involvement and social support, have been strongly linked to resilience and the development of PTG in response to PTSS. (17)
Mindfulness-Based Resilience Training
Research has found that firefighters with high levels of resilience were less susceptible to developing PTSD symptoms than those with lower levels of resilience. (13) These findings demonstrate the importance of individual resilience as a protective factor. Individual resilience was a key factor when evaluating fitness for duty in firefighters frequently exposed to traumatic events. It was found that clinical interventions that bolster individual resilience might be effective for firefighters with a low resilience who have experienced many traumatic events. (13)
Mindfulness training has not been well explored in the firefighter community, but several studies among military veterans have found that increased mindfulness can significantly reduce PTSD symptoms. There are various definitions of mindfulness, including the nonjudgmental awareness of richness, subtlety, and variety of the present moment.22 Another definition of mindfulness is the process of paying attention, on purpose, in the present moment, and nonjudgmentally.23 A more simple definition is, paying attention to the present moment without thoughts of the past or the future. Mindfulness is not the same as meditation; however, meditative exercises are a form of mindfulness.
Just as PTSD is grouped into distinct symptom clusters, mindfulness contains a five-factor structure consisting of Non-Reactivity to inner experience, Observing, Describing, Acting with Awareness, and Non-Judging of inner experience.24 This suggests that some but not all aspects of mindfulness are helpful in alleviating PTSD symptoms and that only certain clusters of PTSD may be improved from increased mindfulness. (24) A recent mindfulness study of first responders found that increased mindfulness leads to enhanced resilience, which in turn leads to decreased burnout. (21)
In a four-year study of veterans in a large Veterans Administration hospital, participants who reported increased mindfulness over the course of treatment also reported reduced PTSD symptoms. The strongest predictors of symptom reduction for each symptom cluster of PTSD were changes in acting with awareness and non-reactivity. (24) A similar study of National Guard soldiers deployed to Afghanistan in 2011 found that higher levels of mindfulness significantly predicted lower levels of self-reported distress and anxiety. (23)
The most common method of teaching mindfulness for mental health disorders is the Mindfulness Based Stress Reduction (MBSR) course. The MBSR protocol includes 2½-hour weekly sessions over eight weeks, followed by a one-day retreat.25 The above findings suggest that increasing a nonreactive relationship with stressors inherent in the daily lives of firefighters may be a significant first step in reducing the effects of burnout and PTSD.
A growing body of evidence suggests that firefighters are at an increased risk for developing the capability for completed suicide. PTSD is just one risk factor associated with suicide among firefighters. PTSD and suicide are topics that are still being understood by clinicians, researchers, and educators. However, a growing body of evidence suggests PTSD, like the other risk factors associated with suicide, can be mitigated with positive social support. Understanding that stress is a normal reaction to abnormal situations and that conversation is a critical factor in addressing the problem, organizations should implement stress reduction and forms of social support including active listening as best practices.
Endnotes
1. Despite the surgeon general’s initiating a call to action in 1999.
2. Stanley, I.H., Hom, M.A., Spencer-Thomas, S., & al. (2017). “Suicidal thoughts and behaviors among women firefighters: An examination of associated features and comparison of pre-career and career prevalence rates.” Journal of Affective Disorders,221, 107-114. doi:10.1016/j.jad.2017.06.016.
3. Boffa, J.W., Stanley, I.H., Hom, M.A., & al. (2017). “PTSD symptoms and suicidal thoughts and behaviors among firefighters.” Journal of Psychiatric Research,84, 277-283. doi:10.1016/j.jpsychires.2016.10.014
4. Savia, J.S. (2007) Suicide among North Carolina professional firefighters: 1984-1999. Dissertation AbstractsInternational, 69, 1-59.
5. Nicole Middendorff, Fairfax County, Virginia, April 2016 and David Dangerfield, Indian River County, Florida, October 2016.
6. Stanley, I.H., Hom, M.A., Spencer-Thomas, S., & al. (2017). “Examining anxiety sensitivity as a mediator of the association between PTSD symptoms and suicide risk among women firefighters.” Journal of Anxiety Disorders,50, 94-102. doi:10.1016/j.janxdis.2017.06.003
7. Haugen, P.T., Evces, M., & Weiss, D.S. (2012). “Treating posttraumatic stress disorder in first responders: A systematic review.” Clinical Psychology Review,32(5), 370-380. doi:10.1016/j.cpr.2012.04.001.
8. Tustin, C. (2017, October 19). “You’ve Been Diagnosed with PTSD, Now What?” Retrieved November 08, 2017, from http://www.firerescuemagazine.com/articles/print/volume-12/issue-10/departments/toolsnewstechniques/you-ve-been-diagnosed-with-ptsd-now-what.html.
9. Ma, J., Batterham, P.J., Calear, A.L., & al. (2016). “A systematic review of the predictions of the Interpersonal–Psychological Theory of Suicidal Behavior.” Clinical Psychology Review,46, 34-45. doi:10.1016/j.cpr.2016.04.008.
10. Joiner, T. (2007). Why people die by suicide. Cambridge, MA: Harvard University Press.
11. Chu, C., Cuchman-Schmitt, J.M., Hom, M.A., Stanley, I.H., Joiner, T.E. (2016). “A test of the interpersonal theory of suicide in a large sample of current firefighters.” Journal of Psychiatry Research, 240, 26-33. Doi:10.1016/j.jpsychires.2016.03.041.
12. Martin, C.E., Vujanovic, A.A., Paulus, D.J., & al. (2017). “Alcohol use and suicidality in firefighters: Associations with depressive symptoms and posttraumatic stress.” Comprehensive Psychiatry, 74, 44-52. doi:10.1016/j.comppsych.2017.01.002.
13. Lee., J.S., Ahn, Y.S., Jeong, K.S., & al. (2014). “Resilience buffers the impact of traumatic events on the development of PTSD symptoms in firefighters.” Journal of Affective Disorders, 162, 128-133. Doi:10.1016/j.jad.2014.02.031.
14. Berger, W., Coutinho, E.S., Figueira, I., & al. (2011). “Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers.” Social Psychiatry and Psychiatric Epidemiology,47(6), 1001-1011. doi:10.1007/s00127-011-0408-2.
15. Slyke, J. V. (2013). “Post-Traumatic Growth.” Combat and Operational Stress Control, 1-5.
16. Kleim, B., & Westphal, M. (2011). “Mental health in first responders: A review and recommendation for prevention and intervention strategies.” Traumatology, 17(4), 17-24. doi:10.1177/1534765611429079
17. Sattler, D.N., Boyd, B., & Kirsch, J. (2014). “Trauma-exposed Firefighters: Relationships among Posttraumatic Growth, Posttraumatic Stress, Resource Availability, Coping and Critical Incident Stress Debriefing Experience.” Stress and Health, 30(5), 356-365. doi:10.1002/smi.2608.
18. Armstrong, D., Shakespeare-Finch, J., & Shochet, I. (2013). “Predicting post-traumatic growth and post-traumatic stress in firefighters.” Australian Journal of Psychology, 66(1), 38-46. doi:10.1111/ajpy.12032
19. Joseph, S., Murphy, D., & Regel, S. (2012). “An Affective-Cognitive Processing Model of Post-Traumatic Growth.” Clinical Psychology & Psychotherapy, 19(4), 316-325. doi:10.1002/cpp.1798.
20. Losavio, S.T., Dillon, K.H., & Resick, P.A. (2017). “Cognitive factors in the development, maintenance, and treatment of post-traumatic stress disorder.” Current Opinion in Psychology, 14, 18-22. doi:10.1016/j.copsyc.2016.09.006
21. Kaplan, J.B., Bergman, A.L., Christopher, M., & al. (2017). “Role of Resilience in Mindfulness Training for Fire Responders.” Journal of Mindfulness, 8, 1373-1380.
22. Joiner, T. (2017). Mindlessness: the corruption of mindfulness in a culture of narcissism. New York: Oxford University Press.
23. Call, D., Pitcock, J., & Pyne, J. (2015). “Longitudinal Evaluation of the Relationship Between Mindfulness, General Distress, Anxiety, and PTSD in a Recently Deployed National Guard Sample.” Mindfulness, 6(6), 1303-1312. doi:10.1007/s12671-015-0400-0.
24. Stephenson, K.R., Simpson, T.L., Martinez, M.E., & al. (2016). “Changes in Mindfulness and Posttraumatic Stress Disorder Symptoms Among Veterans Enrolled in Mindfulness-Based Stress Reduction.” Journal of Clinical Psychology, 73(3), 201-217. doi:10.1002/jclp.22323.
25. Lang, A.J. (2017) “Mindfulness in PTSD treatment.” Current Opinion in Psychology, (14), 40-43 https://doi.org/10.1016/j.copsyc.2016.10.005.
Dena Ali is a captain with the Raleigh (NC) Fire Department and an intermediate with Wake County EMS. Prior to becoming a firefighter, she served five years as a police officer in North Carolina. Ali has a degree from North Carolina State University. She is a graduate student at UNCP; her research focuses on firefighter suicide. Ali taught her class on suicide prevention at FDIC International 2017. She is an avid cyclist and founding member of the Carolina Brotherhood. Ali also serves as an advocate for 555 fitness.
Originally ran in Volume 171, Issue 3.
