At the 2019 Fire Department Instructors Conference International classroom session “Lead from the Front: Fireground Tactics and Leadership,” Deputy District Chief (Ret.) Steve Chikerotis from the Chicago (IL) Fire Department (CFD) displayed the slide, “Don’t move next to an airport and complain about the airplane noise: Why PTSD?” This slide piqued my interest because PTSD (post-traumatic stress disorder) is a complex condition that develops in response to one’s coping skills, early life experiences, mental health, and social support before and after the event. Thus, two people can experience the same trauma and have drastically different outcomes. Neuroscience demonstrates that just as flexibility and fitness mitigate fireground injuries, so, too, do mindfulness and social support mitigate the effects of trauma and stress. Why is there so much focus on renaming PTSD to PTSI (post-traumatic stress injury) and providing benefits to “victims” rather than addressing prevention?
Post-traumatic stress symptoms are normal responses to trauma that will resolve and even lead to post-traumatic growth for most people. Lack of support after the event is more predictive of PTSD than the trauma itself; and when recovery is inhibited, post-traumatic stress can lead to PTSD.
In his book, Tribe, Sebastian Junger refers to PTSD as a “disorder of recovery.” Our responses to trauma are normal and protective, he explains, but, if we don’t process trauma and don’t feel safe or supported, the symptoms become destructive.1 For firefighters, lack of support, specifically organizational, is the greatest predictor of PTSD.2 Dr. Van der Kolk took this one step further by explaining that safety and trauma are incompatible and the greatest form of safety comes from the support of others.3
A 2015 review found a dearth of population-specific intervention studies into the cause, prevention, and treatment of PTSD among first responders.4 This has led to the difficulty in understanding and addressing population-specific protective factors. Fortunately, information has emerged in the past several years that has the potential to guide firefighters and other emergency responders in moving successfully through trauma and grief.
For example, simply stating the trauma out loud is necessary for processing and leads to positive outcomes. Conversely, failing to resolve trauma and using maladaptive coping, such as avoidance, alcohol, or both, lead to negative patterns and outcomes. Thoughtfully emphasizing positive coping skills not only protects individuals from PTSD but also reduces symptomology and alters the path from addiction, depression, and suicide. These skills include but are not limited to positive social support, mindfulness, and restorative sleep. As a whole, the fire service has not placed enough emphasis on teaching members the critical importance of not only learning coping skills but also continuously practicing these skills. Fortunately, these skills are easy to implement and understand.
This article combines evidence-based research and life lessons from those who have grown from trauma to demonstrate that we have the power to manage our responses to trauma and adversity. The greatest lesson is that firefighters equipped with coping skills who practice these skills are much more likely to experience growth from adversity and trauma instead of suffering from PTSD.
Don’t Like Noise? Don’t Move Next to an Airport
Chikerotis retired from the CFD in 2014 with 36 years of experience. He left an unforgettable mark on the city after working with the busiest companies, teaching at the fire academy, and rising to the rank of deputy district chief. Today, he continues to serve the fire service through teaching his class “Lead from the Front,” a motivational class designed to develop fire service leaders and enhance mentorship. In the sidebar “All We Can Do Is Our Best,” he shares how he learned to thrive in the face of adversity.
PTSD
New branches of neuroscience have led to an explosion of knowledge surrounding the effects of trauma, and they provide an understanding of how the brain supports mental processes, the dangerous effects of adverse early life experiences, and how our emotions influence our behavior. Surprisingly, the negative long-term effects of trauma are all positive short-term responses to stress. When not processed, these adaptations can become destructive. As explained by Van der Kolk,3 “[M]ost human suffering is related to love and loss, and the greatest sources of our suffering are the lies we tell ourselves.”
The truth is often subconsciously avoided when it coexists with shame, powerlessness, betrayal, or guilt. When stressful memories are ignored or avoided, automatic shortcuts develop that become seemingly uncontrollable negative thoughts. These shortcuts include symptoms of trauma such as hypervigilance, numbing, and confusion.
One of the most surprising findings was that the left frontal lobe in the speech center of the brain went offline whenever a flashback was triggered, demonstrating that the effects of trauma can overlap physical ailments such as stroke.3 Brain scans also discovered that traumatic responses activate the right side of the brain while deactivating the left side. The right side of the brain controls emotion, sight, and intuition; the left side controls speech, sequence, and analysis. Because both sides of the brain must work together, when one side deactivates, its consequences are debilitating.3
The brain consists of three levels that are built from the base up: the reptilian brain, the emotional limbic brain, and the rational neocortex. The limbic system is where fight-or-flight exists and, through life experiences, creates maps that can be recognized as preprogrammed escape plans. Without any sort of thought or planning, it is able to respond instinctually to protect the body from threat. In fact, the amygdala (unconscious brain) receives information several milliseconds before the rational brain (conscious awareness) and can signal fight-or-flight without the rational brain’s knowledge. The amygdala’s job is to keep us alive. Because of this, it is also known as the fear receptor, whereas the neocortex helps us to think beyond our emotions to make rational decisions. It is the birthplace of empathy and is usually responsible for protecting us from things that will cause embarrassment. Unfortunately, the neocortex goes offline during traumatic experiences, so humans must rely on instinct and conditioning during times of stress.
Post-traumatic stress symptoms are common after a stressful situation and are normal protective responses. These reactions have evolved in mammals to keep them reactive to danger and out of harm’s way until the threat has passed.1 For example, the body can experience nightmares as a way of attempting to resolve the event, hyperarousal as a means of physical protection, and numbing and depression as ways to conserve energy. Typically, these symptoms resolve on their own when the individual recognizes that the threat is over, and they had no control over the outcome.
However, when the event is not processed, the symptoms can worsen. After stressful situations, as happens with PTSD, the balance between the amygdala and the rational brain shifts, and it becomes harder for individuals exposed to trauma to control emotions.3 The subcortical brain reduces activity in the frontal lobe, and this leads to highly emotional states that include intense fear, sadness, and anger. In PTSD, an event gets stuck in survival mode, and energies are focused on fighting unseen enemies.3 Sadly, when this happens, one’s ability to enjoy life by imagining, loving, playing, learning, and paying attention is subdued.
Fortunately, humans can train their brains to become less judgmental and reactive to the input received. Proactive practices such as mindfulness, cognitive behavioral therapy, and even gratitude can alter the brain’s pathways to stop these negative processes and protect individuals from the development of PTSD. Each of these skills is learned and requires practice to become effective. Additionally, the active use of social support and adequate sleep serve to release an event from the limbic system and allow that event to become sequenced and stored as a memory without reactivation of stress symptoms. Basically, positive coping skills impact the brain’s response to trauma so that post-traumatic stress symptoms resolve rather than develop into PTSD. All of these skills protect against many other mental health disorders including anxiety, depression, and suicide.
All We Can Do Is Our Best
By Steve Chikerotis
December 1979 was nearly 40 years ago, but to me, it seems like Tuesday. It was 5 a.m. as I drove to my first day on Engine 93. I barely slept the night before, but I was energized beyond belief as I looked forward to my first day at a firehouse. After several months in the fire academy, I couldn’t wait to finally crawl hallways with the best of the best.
I wouldn’t have to wait long. I spent a few hours making introductions, inventorying equipment, washing the fire engine, and scrubbing more toilets than a hotel maid. Finally, the bells rang! My heart raced with excitement as we pulled out of the house. An old-timer standing next to me on the back step pointed to black smoke billowing a few blocks away. Speaking as calmly as if ordering from a drive-up window, he said, “We got a hit.”
(1) Steve Chikerotis. (Photo courtesy of author.)
I expected firefighting to be exciting—it didn’t disappoint me. My first fire was a fully involved 2½-story frame. I was surrounded by some tough firefighters, and the fire attack went like clockwork until …. We were extinguishing the last of the fire in the basement when I crawled onto something. Leaning in through the thick smoke, I was face-to-face with the charred body of a small child, and he was clinging to a smaller child. This little five-year-old hero died trying to shield his baby sister with his body. They had been left home alone that morning.
After evidence photos were taken and arson investigators finished working the area, the battalion chief had me place the victims into body bags. Trying not to appear weak, I prayed silently as I zipped up the bag. I observed the others to see how they handled it. Although the mood seemed somber as we returned to quarters, most acted as if was just another day at the office. I found out it was.
Later that night, I put a third victim in a body bag. This was a teenage gangbanger who took second place in a gunfight. This one hurt a lot less, but he was still just a kid. After a sleepless 24-hour shift full of action, I drove home the next morning excited about my new career and wondering, Would I ever be the same? The answer to this was no. When you take on this career, you will never be the same—mostly in good ways. Firefighters experience a sense of fulfillment and purpose that few others do. They also learn to truly appreciate life, family, teamwork, and the ability to accomplish tasks that few others can do. However, because we meet our customers on the worst day of their lives, and sometimes the last day of their lives, we sometimes end up carrying some of that pain in our hearts and minds.
The fire service will certainly make us stronger physically and mentally, but sometimes it can tear us apart. Every incident affects us differently; sometimes it can hit you hard, but we can’t blame the fire service. You can’t move next to an airport and complain about airplane noise. But we must be aware of it, watch out for each other, and be open to seeking help when needed. Over a 36-year career on the Chicago (IL) Fire Department (CFD), there were a few times that I was hit hard.
One such hit came while I was a lieutenant on Rescue Squad 2. It was a summer night, and we were working our third fire of the day, which was about average for us at that time. At two in the morning, we pulled up on a fire in a three-flat apartment building. Flames pushed out of several windows of the first floor. The first engine was attacking the fire from the front, protecting the stairway leading to the upper floors. The battalion chief assigned us primary search on the second and third floors. I split our guys into two groups, and we were off to the races.
Having a crew of tough firefighters on Squad 2 made my job easy. After sending three firefighters up to the third floor to search, my partner Billy Duffy and I headed up to search the floor above the fire. After forcing the door to the second-floor apartment, we crawled through zero-visibility smoke and high-heat conditions as we started our search.
After quickly searching the living and dining rooms, we reached the first bedroom. I located a queen-sized bed and swept the top of the mattress with my arm and under the bed with my leg while Billy was sweeping the rest of the room and closet. Finding nothing, Billy yelled out, “Clear!” I responded, “Next room!” We worked our way down the hall and repeated these actions in two more bedrooms and the kitchen. By the time we reached the back door, my team above reported nobody found on the third floor either. I got on the radio, “Squad 2 to Battalion 7: Primary search on second and third floors are negative.” The chief ordered us to complete a secondary search on the same floors.
As we started our secondary search, I noticed that the conditions were much better. Although still close to zero visibility, the smoke was a little lighter and there was much less heat—the engine was making good progress on the fire below us. Billy and I repeated our search, this time back to front. After a short while, we were back in that first bedroom. Billy once again was searching the closet and I was checking on and under the bed. One side of the bed was flush against the wall, so I grabbed the frame and pulled it off the wall. As I did, I heard a thump. My heart started racing. I dove onto the bed and reached down to find a child, about five years old, who had squeezed between the mattress and the wall.
I grabbed him and raced outside—he wasn’t breathing. I gave him mouth to mouth as I raced down the street to the ambulance. I jumped in the back of the ambulance, and a medic and I did CPR all the way to the hospital. He didn’t make it. It still hurts me now even though many years have passed—but back then, I can’t even describe the pain I felt. I blamed myself. Would he have survived if I would have found him on the primary search? Several minutes had elapsed before I found him in the secondary search. I felt guilt and pain.
I remember sleepless nights as I thought of that little guy, yet I never talked to anybody about it. I had four sons at home—two who were about his age. Over the next few months, I still did my job, raised my family, and tried to act like nothing was wrong—firefighters are not supposed to show weakness, I thought. Post-traumatic stress was not discussed during this era—at least not in the CFD—and stress counseling was unheard of. Over those months, I was riding an
Meaningful Social Connection
A good support network is the most powerful protection against PTSD, stress, and suicide.3,5 Meaningful social connection occurs when one is able to share thoughts and feelings without fear of judgment and is a two-way street that requires trust, empathy, and vulnerability. Healthy support systems are not just sources of strength and protection; they also provide us with purpose and the ability to support others.5 Without the relationship and trust he had in Burns, his former captain, Chikerotis may not have discovered the power of sharing his thoughts as a means of understanding and resolving them.
Advances in science explain how talking works to reverse the damage done by trauma. Using the brain’s natural neuroplasticity by simply talking to others allows us to “know and understand what is going on with us while also processing the memories of the trauma.”3 Silence about trauma reinforces the isolation of the trauma, but speaking aloud to another human being becomes the first step to healing.
According to Dr. Van der Kolk,
As long as you keep secrets and suppress information, you are fundamentally at war with yourself. Hiding your core feelings takes an enormous amount of energy; it saps your motivation to pursue worthwhile goals, and it leaves you feeling bored and shut down. Meanwhile, stress hormones keep flooding your body, leading to headaches, muscle aches, and irrational behaviors that may embarrass you and hurt the people around you.3
Moving through trauma requires understanding the experience; often, this must be done through communication. The quintessential dimensions of humanity state that “(1) our capacity to destroy one another is matched by our capacity to heal one another; (2) language gives us the power to change ourselves and others through communicating experiences, helping to define what we know, and finding a common sense of meaning.”3 When we abandon these dimensions, we inhibit healing from trauma through inhibiting the restoration of autonomy. A key to understanding healing from trauma is recognizing the importance of being a participant in one’s healing rather than a victim of the trauma.
Recovery from trauma is heavily influenced by the society to which one belongs.1 According to Sebastian Junger, “In humans, lack of social support has been found to be twice as reliable at predicting PTSD as the severity of the trauma itself.” He says that a mild trauma can become long-term PTSD if there is a lack of social support. On the other hand, a person who experiences severe trauma but has a strong support system both personally and professionally can experience significant growth after the trauma. Junger views PTSD as a disorder of recovery. Generally, those who develop PTSD do so because they were unable to process and recover from their trauma.
Humans are hardwired for connection.5 The innate need to belong, when not met, can lead to a range of negative health outcomes.4 Social support is not just being in the presence of others; it requires meaningful connection and a visceral feeling of safety. You have to feel safe to share your thoughts and know that you are understood. Because of this, perceived belongingness is one of the most important variables to consider in the context of PTSD symptoms.
That is why maladaptive coping mechanisms such as alcoholism, substance abuse, isolation, and risk taking can be so destructive. Through avoidance and isolation, we fail to address, understand, and resolve the trauma. Often, these maladaptive coping skills become hard-to-break cyclical habits that can increase susceptibility not just for PTSD but also for depression, anxiety, and suicide.
When discussing trauma, PTSD, and suicide among firefighters, there is a tendency to shy away from protective factors inherent in the profession. These in-built protectors include camaraderie, familial social support, organizational support, and a sense of purpose.2 Although these are powerful protectors, their absence can be crippling. The absence of connection is the most robust predictor of adverse response to trauma. Members who are not supported and who don’t feel they can rely on anybody to listen to their personal problems become at greater risk for the development of PTSD.4 This finding helps to explain why members who find themselves in the minority can find themselves at greater risk.
To prevent PTSD, firefighters must be able to open up and talk about their potentially traumatic experiences.
445 Biltmore: The Story of Jay Bettencourt and Captain Jeff Bowen
On July 28, 2011, Firefighter Jay Bettencourt survived the most traumatic experience of his life. Both he and his captain ran out of air while fighting an arson fire. At that fire, Captain Jeff Bowen died. Today, Bettencourt still rides Rescue 3 and is one of the most positive and passionate individuals alive. He says he owes his recovery to practiced coping skills and social support. (See the sidebar “As a Tribe, We Can Carry Each Other.”)
Mindfulness-Based Resilience Training
The human brain is magnificent in its capacity for continuous alteration of the neural pathways and synapses. For example, just eight weeks of practicing mindfulness can bring positive changes to the gray matter of the brain by providing long-term psychological benefits.5 Mindfulness is the super power that allows humans the opportunity to own the space between a stimulus and the response. Through the practice of mindfulness, humans have the ability to preprogram their automatic escape routes well before a traumatic incident. This is because mindfulness increases activation of the neocortex while decreasing activation of the limbic system and amygdala.3 Mindfulness increases control over the emotional brain.
Mindfulness grants the practitioner ownership of the present moment without interruption from thoughts of the future or the past. Because of this, mindfulness is a cornerstone to recovering from PTSD. In addition, a large body of evidence has found that mindfulness can also help improve sleep, decrease depressive episodes, and limit anxiety. It works in a manner similar to the way stretching and exercise improve flexibility. Through a practice of mindfulness, the brain is better able to respond to stress and anxiety. As Bettencourt explained, the moment between stimulus and response is the moment that is ours to savor and control.
Just a few minutes a day practicing mindfulness can yield dramatic improvements in health. Although mindfulness has been used in the non-Western world for thousands of years with positive results, the Western world has been slower to pick it up and still considers it an “alternative” practice. Often, people are afraid they may not do it well, so they don’t even try. However, one does not have to be a monk to enjoy the benefits of the practice, just like one does not need to be Stephen Curry to enjoy playing basketball.
Several simple smartphone applications offer instruction in mindfulness. I have used resources of Headspace, a meditation Web site to learn the practice; I now use the Calm Web site to continue my practice. Another easy way to learn mindfulness is to practice the U.S. Navy SEALs breathing technique, also called “box breathing.” It works to bring one’s awareness to their breath as it also activates the parasympathetic nervous system by slowing the respiratory rate to about four times a minute. It’s incredibly simple; you can do it as follows:
- Find a comfortable chair or place to lie down.
- Inhale for four seconds by breathing through the nose.
- Hold air in your lungs for four seconds.
- Exhale for four seconds, emptying all of the air in your lungs through pursed lips.
- Hold your lungs empty for four seconds.
- Repeat for five minutes or as long as is necessary to feel refocused and relaxed.
Mindfulness improves psychological resilience, the ability to persist in the face of challenges and adversity, and has been shown to protect against the development of PTSD, depression, anxiety, suicidal ideation, and alcohol use disorder.6 A recent military study found that increased resilience through mindfulness across military services by just 20% was found to reduce the odds of developing PTSD, depression, and comorbid PTSD and depression by 73%, 54%, and 93%, respectively. 6 Today, the Asheville (NC) Fire Department runs all recruits through an eight-week Mindfulness-Based Resilience course. They are not only teaching their members the benefits of mindfulness, but they are also providing their members with the developed practice and skill.
Sleep
According to sleep scientist Dr. Matthew Walker, “Sleep loss and mental illness is best described as a two-way street of interaction.” He suggests that sleep disruption is a key contributor to many mental health disorders. Rapid eye movement (REM) sleep is necessary for healing from emotional wounds and has been found to be inbuilt overnight therapy. The sleeping brain works to reshape memory, address emotionally relevant information, and allow irrelevant information to fade away.3 REM-sleep dreaming works to store memories in a process that dissolves the emotional charge that may accompany a traumatic experience. Basically, REM sleep serves to process the trauma and convert it into a memory. Without REM sleep, painful memories can become stuck in the emotional fight-or-flight region of our brain.
To protect oneself from PTSD, sleep is necessary before and after the trauma. Sleep also serves to help control emotional responses for individuals. During analysis of brain scans, Dr. Walker found that the amygdala, the hot spot that triggers emotions such as anger and rage, experienced more than 60% amplification in emotional reactivity in participants who were sleep deprived.7 His research found that sleep deprivation was responsible for the brain’s reverting to a primitive pattern of uncontrolled reactivity.
Without appropriate sleep, we are less able to control our emotions and we experience more outbursts that can lead to greater adversity.8 Several studies have found that sleep deprivation leads to anger, impulsivity, aggression, and increased reaction to provocation.8 Without adequate sleep, the ability to make rational decisions and consider options becomes compromised. As you can see, adequate sleep is necessary both before and after a traumatic event to prevent the manifestation of PTSD.
As a Tribe, We Can Carry Each Other
By Jay Bettencourt
Walking into 445 Biltmore, I had more going for me than I realized. Before joining the fire service, I spent most of my time climbing mountains; and, in my travels, I discovered the practice of meditation. The clarity and focus that came with hanging off a cliff were something I wanted all the time, and I learned to capture that sensation by becoming acutely aware of my breath (mindfulness).
As I entered 445 Biltmore, all I knew was that I was on a jam-up crew that was hand-selected by my captain. Captain Jeff Bowen was the best of the best; he was dedicated; smart; fit; and, most of all, he loved being a firefighter. I truly believed he could lead us through anything. July 28, 2011, was my second anniversary as an Asheville (NC) firefighter, and going into a high-rise fire with my hero was a dream come true.
It was only 12 minutes or so after making entry that my dream turned upside down. Our crew had gone from five to just Captain Bowen and me. We were lost and out of air; I just knew we were going to die. My first time ever keying up the radio was to declare a desperate and pathetic sounding Mayday. The radio erupted into chaotic communications that only reaffirmed the idea that we had met our end. Things were not going well.
(1) The author Bettencourt (right) holds up Captain Bowen’s shirt during the Carolina Brotherhood’s inaugural ride. (Photo by Cal Barnard.)
Someone once said, “In the end, our lives will be made of what we had paid attention to.”
That day, my meditation practice was at a lifetime high because I dedicated the time to be consistent at sitting and watching my breath, savoring the space between the past and the future. More importantly, I focused on the moment between stimulus and response. What I learned was in that razor-thin space lies our power; and paying attention on purpose in the present moment gives us the clarity to make decisions. We have the power to choose how we respond to stimulus, but it takes practice to get there.
As the walls closed in around us, it seemed impossible to make a “right” decision, but I chose to trust my officer. Even though it seemed impossible, I was determined to make it back to our families together. Though the space between the past and the future became the tiniest sliver, I knew it was all I had. Right then, in that moment, I could take another breath and another step.
Fourteen minutes and 13 seconds after running out of air and declaring a Mayday, Captain Bowen and I were found in the South stairwell unresponsive and barely alive. For some reason, I lived and he died.
The following year was very hard for me, and my recovery was slow. The anger and shame threatened to take me, and I was lost in grief and guilt. Even though the fire service was there for me every step of the way, I had to talk myself through each day. I survived, but I wasn’t living. I felt empty, isolated, and alone. I missed my friend and mentor, and I couldn’t make sense or meaning of anything around me.
What saved me was the social support I experienced after the event. At Captain Bowen’s wake, an audacious fellow from a nearby department asked if I would come to a firefighter survival school to share my experience. While it sounded like an honor, it also felt a bit like a chore. There, I shared Captain Bowen’s story with the group, and that was when my recovery truly began. With this community, I found purpose and belonging. Working with other people who had been in similar situations made me feel like I wasn’t alone. They became a tribe that helped me heal and grow. Sharing the story of 445 Biltmore was a chance to make something positive out of such an immense loss.
As my home and work life started to come back into focus, my tribe expanded. In 2012, the Carolina Brotherhood’s inaugural ride was dedicated to Captain Bowen and his family (photo 1). This organization is dedicated to honoring the fallen and their families through an annual 700-mile cycling fundraiser. Each day, we shared stories about Captain Bowen and other fallen brothers. It was so cathartic to discover that our pain was not unique. This grief was shared by all, and it lightened the load for each individual. I did not need to suffer alone because my brothers and sisters were willing to share the burdens we all faced.
As I finally started to heal, I realized that merely surviving the way I had long after the fire was no way to live. Living in a state of hypervigilance limited my ability to savor the good things in life. Cherishing life and connecting with those around us make life worth living. Otherwise, what’s the point?
There is a space between the past and the future; there’s strength between stimulus and response. As individuals, we make choices from moment to moment that help us to survive and grow. As a tribe, we can carry each other and create the conditions where we can thrive.
Risk Factors
Protection from PTSD requires a holistic approach that encompasses social support, learned coping skills, adequate sleep, and organizational support. PTSD does not occur in a vacuum, and it is not simply a result of a trauma or an event but rather an inability to process and recover from that event. When any of the above protective factors are missing, the ability to process trauma becomes inhibited.
Alcohol is the most common coping mechanism used to deal with depression and mask the signs of stress. Often, it is used as a means to self-medicate or for a temporary fix, but it often becomes constant and destructive. When used as a sleep aid, alcohol has a sedative effect that prevents both REM and restorative sleep. If used consistently to aid sleep, alcohol can increase the risk of not only PTSD but also suicide. Several studies have found that symptoms of “depression and post-traumatic stress are increasingly common in firefighters and police officers who engage in drinking to cope with organizational stress.”9 Although individuals with depression or PTSD drink to cope with stress, paradoxically, this numbing increases negative mood and exacerbates symptoms of depression and PTSD.” Brene Brown says it best when she says, “We cannot selectively numb emotions; when we numb the painful emotions, we also numb the positive emotions.”10 Shame and fear of showing weakness to our peers are among the greatest contributors to negative coping.
A critical piece of the puzzle that is often neglected when discussing PTSD is early life adversity. Because the ability to cope is often developed early in life, early life adversity has been found to be a key predictor of PTSD for all populations, including firefighters. Early life adversity consists not only of trauma but also of the support experienced as a child. Those who did not feel safe, wanted, or loved often struggle with social support later in life. Adverse childhood experiences are common among all populations and, as reported by Dr. Van der Kolk, one of our nation’s largest public health problems.3 This conclusion is based on findings that adverse childhood experiences are predictive of chronic depression, addiction, suicide, and PTSD in adulthood.3 Just as talking about acute trauma is an antidote, so, too, is resolving early life adversity through addressing the experiences.
Finally, easy-fix psychiatric medications have a serious downside, as they deflect attention from the underlying issue. Through use of these medications, insurance companies often control symptoms while failing to address the underlying issues causing these symptoms. In the past two decades, the number of people treated for depression has tripled. According to Van der Kolk, because drugs are so profitable, major medical journals rarely publish studies of nondrug treatments because they are rarely funded despite unanimous findings that nondrug treatments are more efficacious and lead to better long-term outcomes.
Nobody is immune from the effects of trauma. However, we all have the power to control how trauma shapes us. No two people will respond to trauma the same because it is not the trauma that predicts the outcome but rather one’s life experiences, coping skills, and mental health. A recent conversation with a friend helped me to understand how addressing trauma heals. She told me that after she lost her boyfriend to suicide, all of her coping skills failed, and she found herself in desperate need of help. When she finally had the courage to seek therapy, she learned that her boyfriend’s death was just one more microtrauma added to a growing list. What she learned, though, was the earlier unresolved traumas were the ones that shaped her response to the most recent loss. She explained that trauma is not just the bad calls we respond to as firefighters, but it can also be the grief and loss we experience in our personal lives. Processing each of these is necessary for creating the resilience to positively move through the next trauma. Each event is akin to another light added to a strand. Alone, a single light on the strand is not very bright, but together the lights can become overpowering and difficult to control. We are all human, and we must know that it’s okay to seek support from others when faced with life’s adversity. 
Endnotes
1. Junger, Sebastian (2016). Tribe: On Homecoming and Belonging. New York: Twelve.
2. Stanley, IH, Hom, MA, Spencer-Thomas, & Joiner, TE. (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 (A).
3. Van der Kolk, BA. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking.
4. Stanley, IH, Hom, MA, Joiner, TE. A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and paramedics. Clinical Psychology Review. 2016 Mar; 44:25-44. doi: 10.1016/j.cpr.2015.12.002. Epub 2015 Dec 12.
5. Marks, M, Callahan, P, Grill, M. (2019) A community of one: building social resilience. Tulsa, OK: Fire Engineering Books and Videos.
6. Vyas, KJ. (2016). Preventing PTSD and Depression and Reducing Health Care Costs in the Military: A Call for Building Resilience among Service Members. Military Medicine,(181) 1240-1247.
7. Walker, MP. (2018). Why we sleep: the new science of sleep and dream. Penguin Books.
8. Hoge, Charles (2010). Once a Warrior, Always a Warrior: Navigating the Transition from Combat to Home—Including Combat Stress, PTSD, and MTBI . Guilford, Connecticut: Lyons Press.
9. Martin, et al. (2017) Alcohol use and suicidality in firefighters: Associations with depressive symptoms and posttraumatic stress. Comprehensive Psychiatry. 2017 Apr;74:44-52. doi: 10.1016/j.comppsych.2017.01.002. Epub 2017 Jan 7.
10. Brown Brené. (2015). Daring greatly: how the courage to be vulnerable transforms the way we live, love, parent, and lead. London: Penguin Life.
DENA ALI is a captain with the Raleigh (NC) Fire Department. Previously, she was a police officer in North Carolina for five years. Ali is a founding member of the Carolina Brotherhood and founder and director of North Carolina Peer Support. She has a master’s degree in public administration from the University of North Carolina at Pembroke; her research focused on firefighter suicide. She has an undergraduate degree from North Carolina State University. She teaches a class on suicide prevention at FDIC International.
STEVE CHIKEROTIS is a 38-year veteran of the fire service and spent 36 years in the Chicago (IL) Fire Department, from which he retired as a deputy district chief. He was a chief officer for 18 years and held the positions of director of training, chief of fire academy operations, and battalion chief. He has been a fire service instructor for more than 25 years.
JAY BETTENCOURT is an engineer with the Asheville (NC) Fire Department with which he has served 10 years, assigned to Rescue Company 3. He’s a founding member of the Carolina Brotherhood and an instructor with the North Carolina Breathing Equipment School. Bettencourt is the co-creator and implementor of Asheville’s “Resilient Mind” program and serves on the board of directors for North Carolina Peer Support.
