By Dena Ali
Four years ago, the thought of suicide as a way out for me was persistent and powerful. I could not shake it. I vividly remember staring into the mirror one day, trying to understand my thoughts, and suicide was the loudest and most shameful of them. I desperately wanted to talk to someone, to reach out, but I knew how stigmatized suicide was, and I couldn’t think of anybody who would understand. As a firefighter and a former police officer, I knew how people with suicidal thoughts were treated. Those with suicidal thoughts, addictions, or other mental health disorders were rarely treated with sympathy or compassion. I had no desire to be judged or labeled; life was hard enough. I remember justifying suicide to myself. I rationalized that it was my decision and my decision alone; nobody had the right to stop me; and, if nobody could understand me, why open up to anybody? I also recognized how dangerous this conclusion was.
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Fortunately, though, a school assignment helped me to understand my situation better. The assignment involved action research. While trying to brainstorm for a fire service topic, I reached out to one of our progressive officers. I asked him to recommend a subject that I could research and for which I could develop departmental better practices. He suggested “suicide in the fire service.” This surprised me. This topic had never been discussed among first responders in my community. As I worked through the assignment, I recognized that the root causes for my thoughts of suicide were common, and I was finally able to address them. I no longer felt alienated. Through my research, I learned that many myths surrounded suicide in general and suicide in the fire service.
I discovered that suicidal ideation (having thoughts about suicide) and mental health disorders are much more common than thought. In fact, research has shown that one-third of the population was found to have suicidal ideations at one point in their lives.1 For many, opening up and talking about these thoughts help them to understand the thoughts and negate their power. Many first responders, however, believe that they must keep silent to remain considered fit for duty. Silence causes negative thoughts to multiply and magnify and become a pathway to alienation. This alienation leads to isolation, which perpetuates the negativity and increases the thoughts of suicide. Isolation has been identified as a well-known predictor of suicide.
This article discusses some common myths surrounding suicide and mental health disorders as they relate to first responders. The goal is to displace these myths with facts established through research so that we can chip away at the stigma that prevents first responders from seeking help that can prevent suicide. This stigma is a main contributor to suicide in the fire service. Replacing these myths with truths can create meaningful conversations that will prevail over lonely thoughts of suicide. A final thought that goes through the mind of those who complete suicide is that nobody would care or that if they did care, they would be better off if the person committed suicide and would no longer be a burden to them. These are thoughts that a mind experiencing a suicidal crisis is unable to understand or recognize as being false.
MYTH: THE ASSOCIATION BETWEEN FIREFIGHTING AND SUICIDE IS CAUSAL AND, AS SUCH, FIREFIGHTERS ARE AT AN INCREASED RISK FOR SUICIDE.
In recent years, suicide has been recognized as a significant issue for first responders—more specifically, firefighters. In her 2007 retrospective study that examined the death certificates of career firefighters who died in North Carolina between 1984 and 1999, Dr. Janet Savia concluded that a firefighter was three times more likely to die by suicide than in the line of duty.2 Disappointingly, not all published information on this subject is accurate. I recently read a well-intentioned article claiming that firefighters are five times more likely than the general population to die by suicide.3 Although it is possible that our suicide rates are higher than those of the general population, there are no data to endorse this claim. Correlation does not prove causality. For example, would we claim that nurses are at an increased risk for breast cancer? No, because nurses represent a population in which women are overrepresented. Women are more likely to have breast cancer; thus, nurses will likely present with more cases of breast cancer compared to other groups, but not because they are nurses.
What does this mean for firefighters? Demographics are a piece of the puzzle. A sample in which white men are overrepresented will have more deaths by suicide simply because white men are more likely to die by suicide.4 According to the American Foundation for Suicide Prevention (AFSP), white men account for seven out of 10 suicides. The fire service is still overrepresented by white men. According to National Fire Protection Association (NFPA) data, between 2012 and 2016, women represented 4.5 percent of firefighters, and blacks represented 9.2 percent of firefighters.5 According to FirefighterNation Editor Bill Carey, it is estimated that white males account for 81 percent of firefighters.
The Centers for Disease Control and Prevention (CDC) reported the following 2016 data: The suicide rate for the total U.S. population was 13.5 per 100,000. Broken down by demographics, the suicide rate for white men was 24.8 per 100,000, 10.2 per 100,000 for black males, 7.2 per 100,000 for white females, and 2.4 per 100,000 for black females. Based on these statistics, recent findings reported in the Ruderman White Paper6 indicating that the rate of suicide for firefighters as 18 per 100,000 may show data that have not been controlled for demographics. Does that mean that firefighters have a higher suicide rate than the general population?
We need to control for gender and race. To do that, we must find data that have 100-percent compliance with reporting; these data are not yet available. Jeff Dill, through his organization the Firefighter Behavioral Health Alliance, has been collecting these data, but the stigma of the subject matter has interfered with members’ reporting the data. Battalion Chief Daniel DeGryse attempted to compile these data while reviewing the death certificates of more than 2,000 Chicago firefighters. He discovered some death certificates were listed as confidential and some suicides were improperly classified. Despite reviewing every death certificate, he was still unable to determine the exact number of suicides. It is suspected that the improper classifications were a result of the stigma, shame, or dishonor associated with suicide.
The relationship between being a firefighter and suicide is not causal. A host of other individual and linked factors may be involved; these factors include sleep disorders, anxiety, post-traumatic stress (PTS), substance abuse, and depression. Each of these factors can be targeted and mitigated through deliberate actions at the individual, company, and agency levels. I challenge members of emergency services to look beyond the job to identify the individual actions we can take to better protect our members. Eliminating the stigma behind mental health disorders is a start. It is estimated that the lifetime rate of mental health disorders for the U.S. population above the age of 17 is 45 percent. (4) Educating members of the fire service about the commonality of mental health disorders can help break barriers that inhibit seeking proper treatment.
MYTH: PTSD IS THE PRIMARY CONTRIBUTOR TO FIREFIGHTER SUICIDE.
It is no secret that firefighters are exposed to trauma at higher rates than the general population. During their careers, they witness death, loss, and pain more often than most other populations. However, to attribute most firefighter suicides to trauma ignores a host of other causes. Also, by addressing only one cause of firefighter suicide, we ignore the debilitating effects associated with other causes, such as the shame firefighters feel when suffering from factors not associated with trauma or post-traumatic stress disorder (PTSD) and who feel their stress is not as “worthy” as job-related trauma, which further amplifies their feelings of alienation.
Additionally, PTS does not always lead to damage or disorder; it can provide an opportunity for growth. Lt. Col. Dave Grossman explains that when treated appropriately, trauma more often leads to growth.7 Post-traumatic growth (PTG), identified in the mid-1990s by psychologists Richard Tedeschi, PhD, and Lawrence Calhoun, PhD, is defined as the final positive outgrowth of a person’s enduring and working through adversity. PTG is not the same as resilience. It is not bouncing back after trauma. It is growing from adversity. It is the outcome of an event that hits individuals so hard that their core beliefs are challenged; through pain, struggle, time, and energy, they find a new normal.8 Grossman has observed that veterans who have experienced trauma and addressed their PTS are more often better at coping than members who have never experienced such trauma. (7)
Other military findings estimate that more than 75 percent of service members exposed to combat do not develop PTSD or other significant psychiatric problems.9 Trauma has the potential to contribute to emotional distress, but it is a mistake to assume that it is always detrimental to service members. (9) Teaching members how to evaluate their experiences as a source of growth is more beneficial than focusing on the negative effects of trauma. This can be done by teaching members the basic principles of psychology (e.g., better cognitive processing or finding meaning in life) prior to exposure to trauma. Knowing that you can grow from both positive and negative experiences has been shown to buffer the effects of extreme stress by using active forms of coping and social support. (9) Providing members with the skills to enhance hardiness and coping can help them to mitigate the emotional distress and vulnerabilities that contribute to suicide risk. A successful Air Force program reduced suicide rates by decreasing daily stress and enhancing quality of life by teaching its members to recognize that good mental health, physical health, and social health go hand in hand. (9)
The trauma of the job did not cause my thoughts of suicide. They came from a combination of organizational, personal, and relationship issues that seemed to intersect all at once. Compounding my stress was company-level conflict. For the first time in my professional life, I was enduring daily disrespect and rudeness from a member of my crew. My company officer recognized the disrespectful behavior and told me that I did not deserve it, but he also said there was nothing he could do. Enduring this daily treatment, pretending it didn’t affect me, was painful and demoralizing. It made me feel as though I wasn’t worthy to be treated with respect or to be defended, and this took a terrible toll. I now recognize how crucial it is for company officers to have the courage to advocate for their members.
While collecting data as the director of the Local 2 EAP Gatekeeper peer support team, DeGryse analyzed data from 2,803 contacts over 15 years and reported that PTSD was not the most common complaint. The most common complaints, in order, were relationship/marriage issues; work-related; alcohol; legal/financial; drugs; and, finally, PTSD. This mirrors data collected from the Fire Department of New York counseling center between 2005-2016, which found that the complaints, in order, were marital/family relationship issues, anxiety, depression, substance abuse, and mental/physical health caused by exposures at the World Trade Center terrorist attacks. These data are consistent with findings in the general population, which found that divorced men are almost three times more likely to end their lives by suicide.10
MYTH: SUICIDE IS IMPULSIVE.
The idea that suicide is impulsive cannot be further from the truth. Suicidal behavior is part of a process that can be understood and tracked; therefore, there is hope for intervening. (4) The process that leads to suicide can take years; to view it as impulsive is to neglect everything but the final act. Completed suicide requires previous experiences that include habituation toward painful and fearsome experiences. The psychological process that leads to suicide can take months or years to manifest. (4)
Suicide is a progressive illness just like heart disease. Heart disease is often preceded by poor diet, lack of exercise, and smoking. For many, the trajectory leading to a heart attack can be mitigated through actions such as improved diet, increased exercise, and smoke cessation. Suicide, too, travels along a trajectory consisting of habituation to pain and repeated depressing experiences that lead to a point where one feels death will be worth more than life. People who are suicidal can be brought back; but for this to happen, they must be identified and understood. (4) Suicide can be mitigated through actions such as improved social support and addressing the underlying causes.
There is a misunderstood relationship between impulsivity and suicide. Some people are prone to impulsivity. This does not translate into suicide, but impulsive people seem to develop more habituations toward painful and fearsome experiences that make them more capable of suicide. However, it is well known that suicide is tractable, and we owe it to those at risk to make it more understood. (4)
MYTH: YOU MUST BE OUT OF YOUR MIND TO DIE BY SUICIDE.
One reason suicide is so difficult to understand is that most people cannot wrap their minds around the concept. However, this doesn’t mean that people who complete suicide were impaired, delusional, or psychotic. “That most of us have trouble wrapping our minds around this concept shows the distance necessary to travel both behaviorally and physiologically before one has developed the capacity for serious suicidal behavior,” explains Dr. Joiner. In his research, he found that fewer than one-third of the people who died by suicide had alcohol in their system. (4) He discovered that even daily drinkers had no alcohol in their system at the time of their deaths. He attributes this to the daunting and difficult nature of suicide. To ensure success, he says, one recognizes that they cannot be impaired when enacting suicide.
Though they may be suffering and in a great deal of emotional pain, most people who die by suicide are relatively sane at the time of their deaths. However, autopsy reports have regularly returned rates of mental disorders in more than 95 percent of people who completed suicide. These mental disorders are surprisingly common. At any given time, around 25 percent of the population is suffering from some sort of mental disorder. Major Depressive Disorder (MDD) presents the greatest risk for suicide. A person suffering from MDD is 20 times more likely to die by suicide. (1) Lifetime rates for U.S. adults (above the age of 17) with MDD are 17 percent. (1) Substance abuse has been associated with a risk of suicide approximately 5.7 times greater than that of the general population. (1)
Nearly 100 percent of people who died by suicide had a diagnosable mental health disorder, such as anxiety, depression, PTSD, or substance abuse, at the time of their death. These disorders are common, tractable, and treatable, and those suffering from them should not be ashamed. We must work to remove the stigmas and avoid accusations so those silently suffering will seek help and be able to heal.
MYTH: PEOPLE WHO DIE BY SUICIDE DON’T MAKE PLANS FOR THE FUTURE.
A common mystery for those left behind is why people planning suicide make plans for the future. People in pain and contemplating suicide are dealing with the competing forces of life and death as a result of the survival instinct. These forces cause a deep ambivalence. Two mental processes are taking place simultaneously. The suicidal person wishes to die and also wishes to be rescued. The desire to be rescued allows the person to continue to make plans. This ambivalence can tip the balance of life and lead to a change of heart. (4)
Studies involving survivors who attempted suicide at the Golden Gate Bridge demonstrate how quickly a person can experience conflicting thoughts of life and death. Jumping from the Golden Gate Bridge is extremely lethal. The impact is the equivalent of running into a brick wall at 75 miles per hour. Less than 3 percent of people have survived the jump.11 (4) All survivors reported similar mental processes in their four-second drop. In the first second, they wanted to die; but, by the third second, they felt extreme regret and desired to live. (4, 10)
One survivor, Kevin Hines, now travels the country describing his ordeal. He says that when he hit the water, all he wanted to do was live. While fighting for his life in the water, his greatest concern was that nobody would know he no longer wanted to die. On the day of his suicide attempt, he experienced the competing thoughts described above. That morning, his father was concerned for him and tried to keep him home, but Kevin assured his father that everything was okay. Kevin had planned his suicide and attempted to conceal it from everybody around him. However, in the hour before his jump, while riding a bus to the Golden Gate Bridge, he had a change of heart. He desperately wanted to be rescued, and he hoped somebody would notice he was in crisis. Kevin stated, “Earlier I had feared that my father or someone at school would discover my plan. Now, I wanted nothing more than to be found out.” (10) He cried on the bus ride; though people noticed him, nobody said a word to him. Even as he exited the bus, the driver stated: “Come on, kid, get off the bus. I’ve got to go.” (10) Kevin’s final thought before jumping was, “Absolutely nobody cares.” However, immediately after jumping, Kevin’s first thought was, “What have I done? I don’t want to die. God, please save me!” (10) While Kevin was free falling headfirst, he realized the only way he could survive was if he landed feet first. Somehow, he managed to throw his head back and hit the water feet first. He believes this is the only reason he survived the 220-foot free fall.
This ever-present ambivalence can lead to a change of heart for those struggling with suicidal thoughts. People can be brought back from a suicidal crisis through understanding and compassion. Perhaps if one person on the bus or bridge had asked Kevin if he was okay, he would have accepted help.
MYTH: SUICIDE IS SELFISH.
Losing a loved one to suicide produces a wide range of emotions. As time passes, reports from the bereaved can paint an inaccurate portrait of the decedent. One example is the inaccurate perception that their loved one was acting selfishly. The idea that suicide is selfish is commonly created in the wake of pain. But there is little evidence demonstrating that those who die by suicide are more selfish than others. To the contrary, there is abundant evidence demonstrating that suicide decedents incorrectly believe their deaths will be a blessing to others. (4).
These deaths are a result of desperation induced by pain that incorrectly leads to the conclusion that their death is worth more than their life. Often, suicide decedents take steps to reduce the impact of their death on loved ones. For example, they often notify 911 or complete the act in an area away from family. Chief David Dangerfield, Indian County (FL) Fire Rescue, did just this. He drove to a remote area, contacted 911, and told them where to find his body. He then posted a message on Facebook stating: “PTSD for firefighters is real. If your loved one is experiencing signs, get them help quickly. 27 years of deaths and babies dying in your hands is a memory that you will never get rid of. It haunted me daily until now. My love to my crews. Be safe, take care. I love you all.”
Sheriff deputies later found him dead from a self-inflicted gunshot wound. Although his message mentioned PTSD, Dangerfield was also dealing with a divorce.12
To further prove that suicide is not a selfish act, Dr. Joiner and his colleagues studied a group of prison inmates and found that “Cleckley psychopath” features were negatively associated with suicidal behavior. Cleckley psychopaths are characterized as being utterly unfeeling, except when it comes to themselves. They are described as selfish to the core. Dr. Joiner’s research found them to be relatively immune from suicidal behavior. (4) In contrast, the less selfish group of antisocial personality disorder was found to be more vulnerable to suicide. (4)
MYTH: SUICIDE IS THE EASY WAY OUT.
The pain created in the wake of a suicide often leads to a loved one’s thinking, “It was the easy way out.” Suicide requires staring the product of millions of years of evolution in the face and not wavering. (4) The instinct to survive, supported by the amygdala, makes death by suicide incredibly difficult. The amygdala is a small nucleus in the brain that functions as the fear receptor and autonomically like the heart and lungs. We don’t control our fear; rather, fear controls us. However, as noted earlier, we can chip away at this fear through habituation to painful and fearsome experiences.
Suicide is tragic, fearsome, agonizing, and awful. It is not easy. Populations that had the highest rates of suicide in history were those in concentration camps during the Holocaust. Prior to their deaths, these people endured unimaginable pain and starvation, demonstrating the habituation necessary to become capable of suicide. As another example, the suicide rate for winners of the Tour De France is 5,000 per 100,000, and the rate for a group of anorexic women was found to be 3,765 per 100,000. (4) These people have endured physical pain and pushed their bodies beyond their natural boundaries.
MYTH: SUICIDE IS AN ACT OF ANGER.
Anger is cited as a risk factor or warning sign for suicide in several suicide-prevention campaigns, including the American Association of Suicidology’s “IS PATH WARM” suicide prevention acronym. The second “A” in the acronym stands for anger. However, anger is a complicated risk factor: There are many angry people, and few die by suicide; most people who die by suicide do not display anger. (4)
Those who died by suicide generally experienced thoughts of burdensomeness and alienation. They turned their anger or hate inward and became sad, which led them to believe that their death would be of service to others. The thing to be mindful of here is that we should be careful when identifying warning signs and risk factors. Although they can guide us, they can also lead to “false positives.” We can make a greater impact by working to remove the stigma surrounding mental health disorders and suicide so that firefighters will be more likely to reach out for help instead of suffering in silence.
These are just a few of the myths surrounding suicide in the fire service. A truth that adds some perspective to the suicide dilemma of today is a fact that is rarely discussed: The suicide rate for most U.S. populations has drastically increased during the past few decades. According to the CDC, from 1999 through 2014, the age-adjusted suicide rate (adjusted to accurately represent the population) in the United States increased by 24 percent. Although suicide is a leading cause of death, its research has been underfunded. One reason for this, I believe, is the stigma surrounding suicide and mental health disorders. To make strides in prevention, we must work to remove this stigma. During his keynote address at the 2018 Fire Department Instructors Conference (FDIC), DeGryse explained how we can do this: “We need to modify the thoughts and perceptions of being the tough, rugged, strong, and resolute individuals and what that means.” To do this, he says, we should lead by example and model the behavior we want to see in our coworkers. We must demonstrate vulnerability and encourage others to do the same. Through having this courage, we can start to break down the stigmas that inhibit help-seeking behavior. I highly recommend watching his keynote address “Straight Talk.”
REFERENCES
Joiner, T.E., & Staff, A.P. (2009) Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients. Washington: American Psychological Association.
Savia, J. (2007). Suicide among North Carolina professional firefighters. Virginia: ProQuest, 1-106.
Dimond, D. (2018, April 21). OPINION | Provide first responders the help they need. Retrieved from https://www.abqjournal.com/1161855/provide-first-responders-the-help-they-need.html.
Joiner, T.E (2011) Myths about suicide. Cambridge, MA: Harvard University Press.
Firefighting occupations by women and race. (n.d.). Retrieved from https://www.nfpa.org/News-and-Research/Fire-statistics-and-reports/Fire-statistics/The-fire-service/Administration/Firefighting-occupations-by-women-and-race.
Heyman, Miriam, et al. “The Rudeman White Paper on Suicide and Mental Health Of First Responders.” Ruderman Family Foundation, Apr. 2018, pp. 1–41.
Grossman, D. (2017, May 15). “Behind the Shield,” Episode 27 [Interview by J. Geering]. In Behind the Shield. Ocala, FL.
Collier, L. (2016, November). Growth after Trauma. Retrieved from http://www.apa.org/monitor/2016/11/growth-trauma.aspx.
Bryan, C.J., Jennings, K.W., Jobes, D.A., & Bradley, J.C. (2012) Understanding and Preventing Military Suicide. Archives of Suicide Research, 16(2) 95-110.
Suicide Statistics. (2018). Retrieved from https://afsp.org/about-suicide/suicide-statistics/.
Hines, K. (2013) Cracked, not broken: surviving and thriving after a suicide attempt. Lanham: Rowman & Littlefield.
Hawkins, D. (2017, August 6). “Behind the Shield,” Episode 39 [Interview by J. Geering]. In Behind the Shield. Ocala, FL.
