By Dena Ali
In recent years, suicide has been recognized as a problem that’s not well-addressed in the fire service. It’s also a difficult subject to study because there are no formal tracking mechanisms. The Firefighter Behavioral and Health Alliance (FFBHA), founded by Jeff Dill, conducts voluntary tracking. Because reporting is not mandatory, he suspects that only about 40 percent of fire service suicides are being reported. In 2015, the FFBHA validated 117 suicides. That number is even more alarming when you consider that the National Fire Protection Association (NFPA) reported only 68 line-of-duty deaths for that year. These findings are not new, unfortunately, and do not depict a change in fire service mental health.
In her 15-year study of firefighter deaths in North Carolina, Dr. Janet Savia found that a fire department is three times more likely to experience a suicide instead of a line-of-duty death in a given year. Although the causes of fire service suicide are not well understood, it’s clear that the culture of behavioral health in the fire service needs to change.
Culture Needs to Be Changed
The current culture inhibits help-seeking behavior. Suppressing emotion and using coping mechanisms, such as alcohol, increase the likelihood of suicide. A key finding of Chief Dan Degryse with the Chicago Fire Department is, “Suicide is one outcome of serious, internal struggles for an individual that may manifest for some time before he or she reaches the decision to die by suicide.”
Identifying internal struggles and intervening to offer help can prevent firefighters from completing suicide. Not all suicides can or will be prevented, but these techniques can change an individual’s life trajectory. Key objectives that firefighters need to understand regarding suicide prevention are the following: suicide is a dark secret in the fire service, the risk factors for suicide, the protective factors associated with prevention, and the company officer’s responsibilities.
Suicide as a Dark Secret
Historically, behavioral health has been largely ignored in the fire service. With increased awareness of the incidence of suicide, National Fire Protection Association 1500, Standard on Fire Department Occupational Safety and Health Program, now includes chapters “Behavioral Health and Wellness Programs” and “Occupational Exposure to Atypical Events.” The standard recommends annual training that covers suicide and depression and that members share personal success stories.
One reason suicide is a dark secret in the fire service is that members feel a responsibility to their community. They fear that expressing hardship—such as suffering from depression--may deem them unfit for duty. As a result, firefighters suffer in silence. Education and awareness on this subject can expose this dark secret and help to change the culture. By learning of the struggles of others, firefighters come to understand that any fellow firefighter may face depression at any time and shouldn’t be expected to manage it on their own.
To increase help-seeking behavior, the stigma associated with a firefighter who has attempted suicide must be eliminated. A suicide attempt should not lead to a diagnosis of mental illness. After evaluation and treatment, a firefighter who attempted suicide can become fit for duty. A powerful example is Gilles Moreau, the assistant commissioner of the Ottawa Police Department in Canada. Twenty years ago, he reached a point where he contemplated taking his life. A fellow officer learned of his problem and reported him to a supervisor. Officer Moreau was escorted to a Royal Canadian Mounted Police psychologist’s office, where he received the care that he needed. Once his underlying issues were addressed, he was able to return to work and rise in the ranks.
Although there are numerous causes of suicide, a few common risk factors can be identified early to help with intervention. One of the greatest risk factors is social isolation and withdrawing from others. Dr. Thomas Joiner developed a model for explaining suicidal behavior. He demonstrates that suicide occurs when three factors intersect: a thwarted sense of belonging, a perception that he/she is a burden, and a capacity to engage in lethal action. Remove one of these factors, and the risk for suicide is reduced.
The causes that lead to suicide are varied. For fire service members, they can be work-related, personal, or a combination. Post-traumatic stress disorder (PTSD) is one risk factor commonly associated with the fire service. Other warning signs include anger, aggressiveness, sleep deprivation, impulsive behavior, isolation, lacking a feeling of purpose, alcohol abuse, divorce, and the presence of a firearm in the home.
These factors are often additive, and they can interact in a synergistic fashion. For example, alcohol is the most common coping mechanism for depression, and it masks the signs of stress. Depression and alcoholism are also comorbid. Constant use of alcohol to self-medicate can lead to loss of health, loss of supportive relationships, and diminished thinking skills.
The effects of alcohol became evident in a fellow firefighter and one of our most highly regarded members. He unexpectedly suffered the loss of a child and turned to alcohol to help cope. This led to an incident of driving while impaired. He faced punitive actions at work and a conviction in court while still grieving for the loss of his child. This firefighter received help for his loss and moved forward. He has since been promoted and continues to excel as a role model for others. He is a reminder that anybody can need help and that even after hitting rock bottom, can move forward. He is now a volunteer on the peer support team development committee and is using his experience to help others.
Our unique work schedule is another risk factor. Shift work has a negative impact on sleep (length and quality), and mood. Sleep difficulty and insomnia are risk factors for depression and suicide. As noted earlier, these factors can be additive, and shift work can compound the risk of suicide.
Whereas isolation is the most significant risk factor for fire service suicide, positive social support is the greatest protective factor. We’re fortunate that the fire service has positive social support built into its work environment and work groups. Increasing the number of protective factors can combat the risk factors and, thereby, help to prevent suicide. Examples include establishing a sense of purpose, occupational post-trauma support, positive coping skills, self-esteem, social support, and destigmatizing help-seeking behavior.
Because the fire service hasn’t always been historically conducive to help-seeking behavior, reducing the stigma associated with reaching out is critical. One way to do this is to conduct annual refresher training on behavioral health and remind members that anyone, at any time, may need help, and that asking for help is okay.
The National Fallen Firefighters Foundation’s “Ask, Care, and Take” (ACT) suicide-prevention campaign is based on the Army’s ACE program that encourages members to ask if suicide is a concern. When a person has reached the point of considering suicide, simply someone’s asking about it and intervening can make a difference, as was demonstrated by Ottawa Police Department.
Developing a peer support team is another strongly recommended method of prevention. This team should consist of a group of members with diverse backgrounds. Additionally, the team should include Employee Assistance Program (EAP) members and outside mental health consultants. The Illinois Firefighter Peer Support Team and the Phoenix (AZ) Fire Department Peer Support Team are two of the nation’s premier peer support teams that can be used as models. The Phoenix Fire Department Web site firestrong.org lists resources for members.
Company Officer Responsibility
Company officers must be trained to recognize behavioral changes in their employees. They must also develop open relationships with their crews so each member knows they can go to their company officer for help. Firefighters should not fear being removed from duty for seeking help from their company officer. Company officers must foster an environment that is supportive and inclusive to all members of their crew. Officers must also be vigilant to the company’s dynamics and watch for individuals who are isolated, taunted, or ignored by the rest of the crew.
The ideal scenario ensures that company officers have the training, knowledge, and willingness to be the first line of defense for an employee in need of help. However, company officers are not always the best option in every situation; and, thus, it’s important to extend training to all line members. All personnel should be taught the warning signs and best approaches for dealing with a team member who may need assistance.
Raleigh Fire Department Training Course
The Raleigh Fire Department designates each July as a “safety stand down month” for the operations personnel. Line personnel dedicate their training to learning more about safety and safe practices on and off the fireground. During July, we taught a three-hour course on suicide prevention, developed by Battalion Chief and Safety Officer Frankie Hobson and me, in a series of fire station classroom meetings. The idea for the course began as a conversation between Chief Hobson and me in October 2015. I am a second-year graduate student at UNC Pembroke; during my fall semester, my assignment was action research. My research subject was suicide prevention.
In April 2016, Chief Hobson suggested that we develop my research material into a course for the department. We contacted several experts and developed the material at a basic awareness level. The first class was delivered on July 1.
We taught the course to all line personnel. Our presentation covered awareness, risk factors, and prevention. We also included the personal testimony of a battalion chief, who shared his personal experience, including negative feelings of suffering in silence and how much better he felt after receiving help.
We were assisted by Dr. Mark Holland, a local behavioral health counselor who works with first responders. He assisted with course preparation and answering questions during class. We also stayed in contact with Dill, a leading advocate for firefighter behavioral health and suicide prevention. He helped answer any questions that arose during course delivery.
The feedback from the members of the department was astounding. They were grateful for the information, and we immediately recognized a change in their culture. Line personnel are now willing to discuss things they had once suppressed and to admit needing help. Some firefighters also offered to participate in future programs.
This class is just the beginning of our efforts at firefighter behavioral health. The next step is to organize a peer support team like those in other cities, and even locally with our partner agency, Wake County EMS.
Our plans include creating a poster for fire stations with a list of warning signs, available resources, and faces of our members. The goal is annual training that includes success stories and resources to help remind members of the importance of behavioral health.
Dena Ali is a captain in the Raleigh (NC) Fire Department, where she has been a member for nine years. She is a graduate student at the University of North Carolina-Pembroke.