Helping Mentally Distressed Firefighters Help Themselves

By CONNIE PIGNATARO

“The average person experiences these scenes in fiction movies from the comfort of his living room sofa or theater seat. But you, as a firefighter, know all too well that the mangled body in front of you is not “movie magic”; it is very real.”

The tradition of family and the strong bonds we develop in the fire service create a work environment different from any other. We count on one another for our safety and survival. Whether you are at a heavy extrication, a structure fire, or a medical scene that suddenly turns violent, you know that your fellow members have your back. This bond reaches into your personal life as well. Whether you need a ride to work because your car broke down or you need help repairing a roof after a storm, your fire department family will come through for you.

Firefighters also share a bond unlike any other because of the horrific scenes they experience together. We all retain haunting images from particularly gruesome calls: children lifeless because of abuse or trauma; human bodies that have been so mangled in a car accident that they are unrecognizable; charred victims that we could not save; or, sometimes, it’s one of our own who has been severely injured or killed. The average person experiences these scenes in fiction movies from the comfort of his living room sofa or theater seat. But you, as a firefighter, know all too well that the mangled body in front of you is not “movie magic”; it is very real. Although these experiences can bring us closer together, they can also tear us up inside and lead to depression, addictions, other behavioral health problems, and suicide.

The American fire service has recently suffered some devastating losses. The cities of Chicago, Phoenix, Philadelphia, and other agencies have experienced multiple high-profile suicides in close proximity.1 Chicago suffered six firefighter suicides in 2009. Phoenix had four firefighter suicides in a seven-month period in 2010, and Philadelphia lost eight firefighters to suicide in the past decade.2 Why is this happening, and what is the fire service doing about it?

Suicide is a serious public health issue; it is the 10th leading mode of death in the United States. According to the 2012 National Strategy for Suicide Prevention, suicide claims more than twice as many lives as homicide. Between 2001 and 2009, an average of 33,000 Americans died annually from suicide (or one person every 15 minutes).3 The report also states that for every completed suicide, 30 others make a suicide attempt.

Although there is growing concern regarding suicide in the fire service, very little is actually known about suicide rates among fire service personnel. (1) Currently, no national agencies track firefighter suicides.

“Suicide is one of those subjects that is taboo in our culture,” says Jeff Dill, founder of Counseling Services for Fire Fighters (CSFF) and assistant chief for the Palatine Rural Fire Protection District in Inverness, Illinois. “In the fire service, it’s a double taboo.”

Dill founded CSFF in 2009 to educate not only firefighters on the topics of behavioral health, depression, post-traumatic stress disorder (PTSD), and suicide but also those in the mental health field who work with firefighters about the unique needs and culture of the fire service. As he traveled across the country to different fire departments, Dill collected cases about firefighters who had committed suicide. Realizing the great importance of this issue, he began collecting confidential data through Internet research and contacting fire departments nationwide on firefighter suicides, eventually founding the Firefighter Behavioral Health Alliance in 2010. To date, Dill has validated that 261 firefighters, both active and retired, have suffered death by suicide.4 This includes 34 firefighter suicides in 2011 and 41 in 2012.

As a firefighter, you would risk your life on the fireground to save a fellow member. The opposite seems to be true when behavioral health is involved. According to Dill, we are either not noticing the behavioral signs and symptoms that one of our own needs help, or we are simply ignoring the situation.

“I’ve spoken to firefighters after they’ve attended the funerals of their brothers or sisters, and it’s sad,” says Dill. “You just don’t think that one day you could be having dinner with your brother or sister and a week later be attending the funeral. You didn’t even realize the person was suffering or maybe you did and just thought ‘I’ll let him try to handle it on his own.’ We can’t do that anymore.”

Although the majority of departments in the country have programs that provide behavioral health support to their firefighters, the fire service has a long way to go. In fact, very little significant data exist prior to the 1980s regarding the psychological aspects of firefighting, and current information is surprisingly weak.5

The need for quality behavioral health services in the fire service is being recognized on a national level. In 2004, the National Fallen Firefighters Foundation (NFFF), chartered by Congress, created the Everyone Goes Home® program to develop a strategic plan to substantially reduce firefighter line-of-duty injuries and deaths. At the NFFF’s first Life Safety Summit, 16 Life Safety Initiatives were created. Initiative 13 addresses the need for behavioral health assistance for firefighters and their families. Another summit was held in 2007 to review progress, incorporate new findings, and refine the focus of the Initiatives. In 2011, the NFFF convened an industry summit on the topic of firefighter suicide and depression to further address the focus of Initiative 13. Several of the nation’s leading behavioral health researchers and practitioners and fire service representatives met to discuss and better understand current information on suicidal behavior, prevention, and intervention in the fire service. The summit resulted in recommended starting points and a suggestion that the fire service develop a strategic plan for these issues.6

“It’s time for us to rethink how firefighters and their families are treated in terms of behavioral health,” says JoEllen Kelly, PhD, Initiative 13 project manager for Everyone Goes Home®. “The number-one focus of the NFFF is to take care of the families and coworkers who are survivors. But really, what we’d like to do is not have any survivors; to do that, we have to work on the prevention side. That’s the Everyone Goes Home Program®.”

Kelly says that firefighters must understand their role in support and identification of a fellow firefighter who may need behavioral health services. To educate those in the fire service, Everyone Goes Home® will be disseminating information about depression, stress, suicide, and other behavioral health issues and how to go about getting help.

“A firefighter can be hurt just as much by a stress injury as a physical injury,” says Kelly. “What we want to do is give people the tools so that they understand they (may) have a stress injury and seek the help that they need.”

The National Fire Protection Association (NFPA) also recognized the need for behavioral health support for firefighters with NFPA 1500, Standard on Fire Department Occupational Safety and Health Program. It proposes that fire agencies must make psychological services available to its employees. The International Association of Fire Fighters and the International Association of Fire Chiefs held a Joint Labor Management Wellness-Fitness Initiative to recognize and discuss the importance of fire service-specific behavioral health programs.

Although there is a more prominent focus and concern regarding behavioral health for firefighters, there is not, as of yet, a system in place to evaluate behavioral health programs and to ensure that firefighters are receiving the most updated services based on the latest information. (5)

However, throughout the country, quality behavioral health services are available. The key is breaking the stigma that seeking help for behavioral health issues carries in the fire service so that firefighters feel comfortable and safe using these services.

“It’s a constant battle for me,” says Francine Roberts, a clinical psychologist in Marlton, New Jersey. “I specialize in people who don’t want therapy. I fight the battle of ‘I don’t want to ask for help’ on almost a daily basis.”

Roberts, a registered nurse who has worked in the emergency room, has specialized in treating first responders for the past six years. She says that firefighters are accustomed to being the helpers and solving other’s problems, and that they usually do not like being on the receiving end of the equation. “People in both fire and police service are concerned that (reaching out for help) will be deemed by their peers as a weakness,” Roberts says.

Roberts also says that, with the fire service being a male-dominated field, firefighters are less likely to process their feelings through talking and are more likely to cope with them by exercising or hanging out with each other. She also says that using humor following a bad call may provide a release of tension. Being able to laugh at some of these experiences is a way of letting them go.

“I think there comes a time, though, when a call will land in a place where the humor isn’t enough and you have to do some sort of processing on a different level; that’s where it becomes a critical incident as opposed to a regular call,” explains Roberts. “Those calls that don’t get intervention stick with you, and they can ruin careers. They can ruin lives.”

To provide this intervention, fire departments have commonly used critical incident stress debriefing (CISD) for many years to help emergency personnel deal with intensely stressful situations they may encounter while at work. However, recent studies have found that CISD is not as effective as initially claimed and it could possibly cause more harm than good.7 CISD’s main objectives are to mitigate the impact of traumatic events, facilitate the process of normal recovery and restore adaptive functions, and screen for those who might benefit from additional care. Sessions are conducted by a team of two to four specially trained lay people and mental health professionals.8 The hypothesis behind CISD is that the emotional release provided by the program will reduce distress and the incidences of PTSD, but study after study, including a three-year study commissioned by the Federal Emergency Management Agency, found that CISD was ineffective in preventing PTSD. The World Health Organization agrees, stating, “Because of the possible negative effects, it is not advised to organize forms of single-session psychological debriefing that push persons to share their personal experiences beyond what they would normally share.” (7)

Mitigating the impact of the traumatic event, however, is critical to the well-being of firefighters. Organizations and researchers are recommending a “psychological first aid,” which differs from CISD and is considered a more effective response to the acute needs that may arise. Although this is not treatment, it is provided by competent mental health professionals and includes comfort, immediate support, and information on where to get psychological help. In addition, researchers recommend that mental health professionals be available to screen personnel for stress-related symptoms and/or PTSD within two months of the critical event. (7)

Whether it is through “psychological first aid,” an employee assistance program (EAP), or other behavioral health specialists, it is crucial to keep firefighters healthy mentally and physically. Not all traumatic events will lead to a need to seek behavioral health support, but when they do and the individual does not seek help, it may lead to critical behavioral health issues such as PTSD.

PTSD can be caused by an individual’s experiencing a traumatic or life-threatening event. Most people have some stress-related reactions following a traumatic event, but not everyone will get PTSD. When the effects of these experiences begin to disrupt a person’s life, that individual will need to seek help.9 With the high rates of exposure to traumatic events commonly found in the fire service, it is not surprising that studies have found that the rates of firefighters who meet the criteria of PTSD are between seven and 37 percent.10

Some studies have identified the factors that put firefighters at a greater risk for PTSD, which include joining the fire service at a young age, being unmarried, holding a supervisory rank, and feeling little control over one’s life. (7) Another important risk factor identified is experiencing a stressful event following a traumatic event.

“They’re human beings before firefighters, and they come (to me) with a range of complex issues,” says Roberts. “Family issues come up, too.”

Not only are firefighters dealing with the stressors of life such as relationship, family, financial issues, and their children’s health and education, they must also process the trauma and death they witness while performing their jobs. Brief feelings of depression or anxiety after experiencing a traumatic event are not uncommon. The problem arises when these feelings and other symptoms do not go away or when they appear to go away and resurface sometimes months or even years later. This is a sign of PTSD.11

Other signs of PTSD include excess emotions, recurrent intrusive recollections and/or nightmares of the stressful event, avoidance of any reminders of the event, decreased interest in formerly important activities, feeling detached from others, feelings of hopelessness about the future, difficulty sleeping, irritability or outbursts of anger, difficulty concentrating, jumpiness, or being easily startled. The symptoms usually last longer than a month, and people cannot function as well as they did prior to the traumatic event. Another key factor is the use of alcohol or drugs to self-medicate. These symptoms usually appear within three months of the traumatic event, but they can sometimes occur many months or years later. Keep in mind that people suffering with PTSD have an increased risk for suicide. (8)

In general, firefighters have some protective factors in place that can help decrease their risk for developing PTSD. According to Roberts, firefighters tend to have good core strength; they are people who generally function well but may end up getting overwhelmed by stressors. They also tend to have more effective coping skills. Their strong social support system at home and at work is also a protective factor. (7)

But, at some point in their careers, the support system at work that has always been in place may diminish or cease to exist because of retirement, or a permanent disability may keep them from working.

“I noticed in my suicide reports that we lose a lot of retired firefighters,” says Dill. “We need to prepare them for what they are retiring to and not what they are retiring from. We need to get involved with those who are about to retire instead of just giving them an ax or a party.”

Dill recommends that fire departments form a retirement community and suggests that firefighters and their families attend counseling to ease the transition into retirement for everyone involved.

The same holds true for those who have been injured. Not only are these individuals unable to return to the fire service and their support systems at work, but the medical treatment and physical therapy that the firefighters must endure can be excruciatingly painful, and the recovery from the injury may be long and arduous. A behavioral health support system already in place may make the firefighter’s transition a little easier.

So, where do we go from here? Awareness about the importance of providing quality behavioral health services in the fire service is growing, and it must continue to grow. It must be supported not only on the national level but also on the local level, especially by the chiefs and their command staff. Fire academies and schools must also include information on behavioral health awareness for new firefighters; this education must continue throughout a firefighter’s career, especially at the officer level. In the fire academy and throughout your career, you learn about the aspects of your job that can injure or kill you. You apply hundreds of hours to studying fire behavior, fire tactics, building construction, vehicle construction, apparatus placement on hazardous scenes, and how to deal with hazardous materials, just to name a few. But, how many hours do you spend learning how to recognize the signs and symptoms of depression, addiction, or PTSD and how to help one of your own who is exhibiting these behaviors?

If you or someone you know needs someone to talk to, there are a variety of confidential resources at your disposal. Many departments have an EAP or other behavioral health program. If that is unavailable or if you feel uncomfortable using a service, you may also get immediate assistance through Safe Call Now, a 100-percent confidential resource for public safety employees and their families, by calling (206) 459-2030. More information is available at its Web site at http://safecallnow.org. Another service is Firestrong; to get help 24/7 through its crisis line, call (602) 845-FIRE (3473). Firestrong also has general behavioral health information and confidential behavioral health assessments on its Web site at www.firestrong.org. There is also a National Suicide Prevention Lifeline that is staffed 24/7 at (800) 273-TALK (8255).

Whether you are a new firefighter or an officer with years of experience in the fire service, you can no longer ignore the need for firefighters to have access to confidential behavioral health services. If you or someone you know needs help or just needs someone to talk to, it’s only a phone call away.

ENDNOTES

1. Issues of Depression and Suicide in the Fire Service-Meeting Report. The National Fallen Firefighters Foundation. July 11- 12, 2011. http://lifesafetyinitiatives.com/13/depressionsuicide_summary.pdf.

2. Allen, Jane E. Firefighter PTSD, Depression and Suicide-Helping the Helpers. ABC News. September 9, 2011. http://abcnews.go.com/Health/MindMoodNews/firefighter-ptsd-suicide/story?id=14466320.

3. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. A report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. September 2012. www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf.

4. Firefighter Behavioral Health Alliance. Retrieved September 21, 2012. www.ffbha.org.

5. The White Paper Series-16 Firefighter Life Safety Initiatives. Initiative 13. National Fallen Firefighters Foundation. 2007. www.lifesafetyinitiatives.com/13/Initiative13.pdf.

6. Gist, PhD; Richard, Taylor, LCSW, Vickie H, and Raak, EMT-P, Scott. White Paper – Suicide Surveillance, Prevention, and Intervention Measures for the US Fire Service. Findings and Recommendations for the Suicide and Depression Summit. July 11-12, 2011. http://lifesafetyinitiatives.com/13/suicide_whitepaper.pdf.

7. Bledsoe, DO, EMT-P, Bryan E. Critical Incident Stress Management (CISM): Benefit or Risk for Emergency Services. Prehospital Emergency Care. Volume 7/Number 2. April/June 2003.

8. Mitchell, PhD, Jeffrey. Critical Incident Stress Debriefing. iTrauma. Retrieved September 15, 2012. www.info-trauma.org/flash/media-e/mitchellCriticalIncidentStressDebriefing.pdf.

9. What is PTSD? United States Department of Veteran Affairs. Retrieved August 15, 2012. www.ptsd.va.gov/public/pages/what-is-ptsd.asp.

10. Tull, PhD; Matthew. Rates of PTSD in Firefighters. About.com. January 23, 2012. http://ptsd.about.com/od/prevalence/a/Firefighters.htm.

11. PTSD. Firestrong.org. Retrieved September 1, 2012. www.firestrong.org/Default.asp?p=PTSD.

CONNIE PIGNATARO is a lieutenant for Oakland Park (FL) Fire Rescue (OPFR), where she has worked since 2002. In 2011, she was the first female to be promoted as an officer in the OPFR. Pignataro has a bachelor of applied science degree in public safety administration. She began her career in 1998 as a volunteer with her local community emergency response team.

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