By Dena Ali
Suicide is a human tragedy that often results when the decedent incorrectly concludes that his death could be a service to others.1 It, unfortunately, is a permanent solution to a temporary problem. Only recently have mental health professionals begun to understand its traceable causes. Psychological autopsy studies of suicide decedents regularly return rates of mental health disorders above 90 percent; Dr. Thomas E. Joiner suspects that the true rate is closer to 100 percent.2 These mental health disorders include but are not limited to anxiety, depression, substance abuse, and post-traumatic stress disorder (PTSD).
If the disorders are diagnosed and addressed, a variety of treatments are available to alter an individual’s life trajectory to prevent suicide.3 (1) Although a person determined to complete suicide will prevail, hope lies in the fact that most people who desire to kill themselves at one time will feel differently after receiving help for their underlying problem. (1, p. 3) Mechanisms such as peer support have the potential to help a person cope with underlying problems when addressed early enough and not choose to die by suicide.
Risk factors associated with suicide in the fire service include illness, injury, substance abuse, depression, and trauma exposure.4 In recent years, suicide has become recognized as a significant health problem in the fire service.5 One explanation for the increased risk to firefighters is that depression, alcohol use disorders, and PTSD are co-occurring in this population. (5, p. 45) Firefighters have been found to use alcohol to cope with stress, and these comorbidities have frequently been associated with increased rates of suicide. (5, p. 45)
Suicide in the fire service is not a new phenomenon. Janet Savia, PhD, conducted a 15-year retrospective study of firefighter deaths in North Carolina from 1984-1999 and concluded that suicides occurred more than three times as often as line-of-duty deaths. (5, p. 51) What’s alarming about this statistic is that the true value could be much higher because there is no official tracking mechanism for firefighter suicide.6 In fact, some research has shown that the cause of death for police officers (who share many of the same risks for suicide as firefighters) was significantly more likely than nonpolice officers to be listed as “undetermined,” raising the question of whether suicide fatality rates were higher and not listed because of the associated stigma.7
Through public education efforts by organizations like the Florida Firefighters Safety and Health Collaborative, National Fallen Firefighters Foundation, Chicago Firefighters Union Local 2 Employee Assistance Program, Illinois Firefighter Peer Support, Firefighter Behavioral and Health Alliance, and the Pennwell Fire Group, the fire service is becoming educated on firefighter suicide and emotional health. These organizations are leading the way to understanding the causes of and ways to prevent firefighter suicide.
Fire Service Stigma
A key finding is that the stigma associated with suicide and mental health disorders has led firefighters to fear showing any sort of vulnerability.8-11 The feeling that they cannot reveal vulnerability to their peers can lead firefighters to experience a sense of isolation. This isolation, or sense of alienation, often is a contributor to suicidal intention. (11, p. 1)
Although there has been an increased focus on understanding suicide in the fire service, there is little empirical evidence on the effectiveness of prevention. The benefits of peer support are illustrated in the Interpersonal Psychological Theory of Suicide (IPTS) model, developed by Joiner in 2005. It provides a theoretical model of suicidal behavior while consolidating a broad range of suicide risk factors.12 Joiner’s model, which is discussed later, defines one common pathway all suicide decedents travel prior to their death and suggests that contributing and connecting are necessary for the will to live. The IPTS model has withstood up to 20 direct empirical tests.13 When properly trained and implemented, peer support teams can serve as a layer of defense to the firefighter population by removing one component of the IPTS model and helping to prevent members from completing suicide.
In addition to the cultural stigma attached to mental health disorders, another major contributing factor to the high suicide rate in the fire service is untreated mental health disorders. (10) (4) Although firefighters tend to perceive themselves as superhuman, they have the same susceptibility to mental health disorders as the remainder of the population and should not feel weak for seeking treatment.14
The data on suicide and mental health reveal the following:
- At any given time, 45 percent of the population is experiencing some sort of mental disorder, and five percent of the population is experiencing major depressive disorder.15
- More than 95 percent of suicide decedents had a diagnosable mental health disorder at the time of their death. (12, p. 577)
- Approximately 78 percent of inpatients report some regret about attempting suicide in the days immediately after their attempts. (2, p. 242)
- 90 percent of the 515 suicide attempters restrained by the California Highway Patrol at the Golden Gate Bridge did not go on to die by suicide in the decades after their intervention.16
- 98 percent of jumps from the Golden Gate Bridge are fatal. (16, p. 208)
There is hope for reducing rates of suicide in the fire service. Mental health disorders can be diagnosed and treated, and a suicidal crisis is often temporary. (16, p. 203) Intervention and prevention have the potential to reduce firefighters’ suicide rates. Untreated mental health disorders and the stigma attached to mental health are main contributors to completed suicide.
Although other contributing causes to firefighter suicide like marital problems have been identified, little empirical evidence or research exists on suicide specific to fire department personnel. (9, p. 1) After the Chicago (IL) Fire Department (CFD) experienced seven firefighter suicides in an 18-month period, it was compelled to examine data within its department to determine if suicide rates specific to fire department personnel are higher than those of the general population and if working in the fire department contributes to thoughts or acts of suicide. (9, p. 1) The conclusion of the study indicated that the department experienced suicide at a rate more than twice that of the national average over a 20-year period. But, because the CFD demographics do not mirror society, the results are considered speculative. (9, p. 1)
One key finding during the Chicago study was that “suicide is one outcome of serious, internal struggles for an individual that can manifest for some time before the individual reaches the decision to die by suicide.” (9, p. 2) The consensus among researchers is that we must break the silence surrounding suicide. Joiner views suicide as a tragedy that has tractable causes that can be understood and counteracted only if the causes are not hidden or kept silent.17
One signal commonly seen among firefighters who commit suicide is silence once they have begun to contemplate suicide. (8-10) The silence is compounded in the fire service because of the stigma associated with suicide and help-seeking behavior—a combination of fear and ignorance. (17, p. 272) The fear of suicide is healthy and necessary; the problem is the ignorance that flows into disgust, contempt, and lack of compassion. (17, p. 272) These negative connotations have made suicide prevention difficult to research and understand.
Joiner’s Interpersonal Psychological Theory of Suicide
After the loss of his father to suicide while he was in graduate school, Joiner made it his life’s work to understand suicide and determine how to prevent future suicide. His IPTS model states: There are several chains of causation in suicide, but there is only one common pathway to suicide that all varying trajectories travel through. (2, p. 240) This final pathway consists of three components that can be easily understood and recognized: (a) acquired ability to enact lethal self-injury (fearlessness), (b) perceived loss of a sense of competence or effectiveness (burdensomeness), and (c) perceived loss of a sense of connectedness (loneliness or thwarted belongingness). (4, p. 26) The presence of loneliness and a perceived burdensomeness for a long enough time is sufficient to produce the desire to die. Fortunately, this desire is not sufficient to translate into the ability to enact lethal self-injury. The capability to engage in suicide requires a third element, the acquired ability to overcome a natural human instinct for self-preservation and enact lethal self-injury. (12, p. 576) More simply stated, connecting and contributing are necessary for the will to live; loss of both for a long enough time can lead to suicide, but only in the presence of an acquired fearlessness of death.
Acquired Ability to Enact Lethal Self-Injury
Peer support can reestablish the perceived loss of belongingness (connectedness). If a person has not acquired the ability to enact lethal self-injury, he will be unable to overcome the instinct of self-preservation and to enact his own death. (6, p. 13) In fact, the capability for suicide is generally a limiting factor in enacting one’s death. (6, p. 13) A person works up to the act of lethal self-injury over time by gradually accumulating experiences and habituations that reduce the fear of self-harm. (6, p. 3). Fearlessness can be developed through repeated exposure to painful and traumatic experiences that accumulate over time. (13, p. 36) Having had multiple past suicide attempts is perhaps the clearest marker of the acquired ability for lethal self-injury because through multiple attempts, one can develop a sense of courage, competence, and the fearlessness necessary to commit suicide. (17, p. 207)
The painful and provocative events inherent to firefighting help firefighters develop fearlessness, which can place them at a greater risk for suicide.18 (2) (5) These events include mangled bodies from vehicle collisions, burned victims, assault victims, and incidents involving children. The work involved in firefighting may lower one’s fear of death and elevate the physical pain tolerance through the course of the firefighter’s career. (18, p. 163) Firefighting is difficult work that necessitates strength, endurance, and courage. Moreover, firefighters often are the first to respond to tragedy.
Another risk factor that exacerbates a firefighter’s acquired ability to enact self-injury is consuming alcohol to cope with stress. (4) (5) (8) (10) Depression, PTSD, and alcohol use disorders frequently co-occur. (5, p. 45) Because PTSD and depressive symptoms are associated with suicide, alcohol use may indirectly be associated with suicide when used as a coping mechanism. (5, p. 45) Prolonged substance abuse can deteriorate social capital (leading to low belonging) and diminish feelings of overall effectiveness (producing a perceived burdensomeness. (17, p. 194) Research on alcohol abuse and loneliness revealed that alcohol abusers experience more loneliness than do members of most other groups. (17, p. 194) (5) Estimates suggest that approximately 50 percent of firefighters report excessive drinking,19 and one-third engage in heavy drinking, defined as consuming more than five beverages on one occasion. (5, pp. 44-45)
Perceived Loss of Competence or Effectiveness (Burdensomeness)
The second component of Joiner’s model is the perceived loss of a sense of competence or effectiveness (perceived burdensomeness). In a study of suicide notes, perceived burdensomeness emerged as the only unique predictor of death by suicide as compared with other effects such as hopelessness and emotional pain. (17, p. 107)
People sometimes consider suicide decedents as selfish, but “it’s sadder than that: Those who die by suicide have concluded that they are bereft and that their deaths will be a service to others.” (1, p. 42) Their perception of burdensome often is perceived and mistaken. (17, p. 99) This miscalculation is tragic among eventual suicide decedents as they sense their death could possibly be worth more than their life by removing from others financial, physical, and emotional costs and hardships. (2, p. 243) People who are contemplating suicide see themselves as a burden and feel their current state is permanent and that death is the only solution. (17, p. 98)
A lifesaving method to counteract this mistaken view is for the person to feel effective and see himself as a contributor instead of as a burden. (17, p. 100) Simply stated, our sense of effectiveness can be life sustaining.
Many avenues can lead firefighters to a point where they perceive themselves as a burden. As mentioned earlier, substance abuse can diminish feelings of overall effectiveness. Firefighters are extraordinarily committed to their jobs and the roles they represent because of a strong belief in the value of their service to others. (6, p. 14) Firefighters enter the service because they have a desire to save lives; when they are unable to save a life or when they make an error that jeopardizes a life, they can develop a sense of failure and helplessness. (4, p. 30) Additionally, PTSD, injury, and illness can cause a firefighter to feel as if he is no longer contributing. (4, p. 28). In addition, in the firefighter population, depression and post-traumatic stress have been found to account for a 14 percent increased variance in suicide risk above that accounted for by alcohol dependence. (5, p. 49)
Personal problems occurring outside of work have also been attributed to a firefighter’s loss of self-efficacy. Research has found that biometric changes occurring during disrupted sleep cycles can lead to mental and physical illness. In addition, the demands of firefighter duties may strain family-marital relationships and lead to a higher rate of suicide attempts by married firefighters. (18, p. 169)
Perceived Loss of Connectedness (Loneliness)
The final component of the IPTS is a perceived loss of connectedness or loneliness. “The need to belong is so powerful that, when satisfied, it can prevent suicide even when perceived burdensomeness and the acquired ability to enact lethal self-injury are in place,” explains Joiner. (17, p. 118)
This mirrors a key finding by Willing: “Well-connected people with good support systems can feel desperate too, but they usually don’t kill themselves. They can see other ways of dealing with difficult situations and have confidence that they will have support in doing so.” (11, p. 1) In fact, social isolation is the strongest and most reliable predictor of suicide. (12, p. 577) These reasons explain why focusing on a sense of connectedness should have the greatest impact on prevention.
Firefighters, unlike other professionals, operate as a team, which should buffer them from suicide. (4, p. 27) However, because of the stigma associated with help-seeking behavior, firefighters are reluctant to discuss stress or mental health problems with their team. (10, p. 5) The firefighter culture leads members to fear admitting any sort of weakness because doing so may lead them to being considered a risk to the crew when on calls. (10, p. 5)
Additionally, because firefighters are predominantly white males, women and ethnic minorities do not always feel a sense of inclusion. (4, p. 27) Numerous incidents of harassment, ostracism, discrimination, and workplace violence have been documented throughout the fire service, and significant research suggests that conflict with coworkers is positively correlated with stress. (4, p. 27) In April 2016, Fairfax County, Virginia, Firefighter Nicole Middendorftt committed suicide. An investigation uncovered that she had been the victim of cyber bullying by other firefighters.19
A loss of connectedness can result from an injury, an illness, or early retirement; unfortunately, these conditions also lead to a loss of self-efficacy. (4, p. 29) A risk factor often overlooked is the transfer of a firefighter from one station to another, which produces a loss of the sense of affiliation and a need to earn acceptance in a new group. When combined with other stressors, this type of loss may overwhelm an individual’s ability to cope and can lead to depression and increased substance use. (4, p. 29)
Peer Support as a Protective Factor
The combination of unique stressors, isolation, and maladaptive coping strategies contribute to suicide ideation and suicide completion for firefighters. (10, p. 2) Positive social support can serve as a protective factor against the loss of social support that is a major risk factor for mental health disorders and suicide. (8, p. 3) Peer support is one layer of protection, and it helps responders to feel comfortable opening up to their peers.
An effective model of peer support raises awareness of suicide risk and protective factors; lets others know they are not alone; and develops a more educated, understanding, and supportive work environment. (10, p. 9) “It is important that departments develop strong relationships with employee assistance programs (EAPs), local mental health centers, universities, and licensed clinicians for avenues of intervention.” (10, p. 9) It is equally important that departments establish policies and procedures that encourage help-seeking behaviors, provide a safe environment for disclosure without recourse, and allow personnel to receive the needed resources and services while continuing to serve their department. (10, p. 10)
An example of the potential benefit of a working peer support team is the Houston (TX) Fire Department Suicide Prevention Program, which was implemented after seven suicides in a six-year period. (10, p. 10) In 2007, 10 Houston firefighters were trained by their department’s psychologist to identify, assess, and deal with crisis situations so that their peers could use them as a resource. (10, p. 11) After implementation of the program, Houston experienced a five-year period with no deaths by suicide. (10, p. 11)
In 2013, a mental health counselor and a group of firefighters established the Illinois Firefighter Peer Support (ILFFPS) Team in the basement of the Bolingbrook (IL) Fire Department. Matt Olson, one of the founders, felt compelled to do something for the fire service after he found himself depressed, confused by his emotions, and struggling at home and work (14, p. 1) The group discussed ways to facilitate firefighters being there for each other, make it safe to ask for help, share stories, and listen to one another. Olson said they recognized the need for something more than critical incident stress debriefing. A culture change was needed. Today, the ILFFPS Team is available to any emergency responder who calls a toll-free number or sends an e-mail request. Olson states: “We have made it policy for a member of ILFFPS intake members to respond to any inquiry within 24 hours and usually much sooner. Our intake coordinators gather some background information, listen to the firefighters’ stories, validate their feelings, and provide reassurance that they are safe and not alone! They then send a message to the entire team of 100-plus trained peer supporters across Illinois with some general information about the request to see who can help.” (14, p. 1)
Since its inception, the ILFFPS has expanded to become one of the nation’s premier educators on peer support.20 Olson’s team travels across the nation to teach all aspects of the program from training to implementation. Olson teaches to listen, relate, and validate. Peer supporters are not substitutes for therapeutic services; they are not trained as mental health professionals. During training, peers are taught best practices and educated on high-risk behaviors that necessitate referral to a counseling professional.
The ILFFPS serves as an effective protective factor by ensuring that any member who reaches out receives assistance, is validated, and is not alone—therefore satisfying the need for belongingness in the IPTS model. Efforts that enhance belongingness and efficacy can be protective, says Joiner. (17, 219) People can be brought back from a break; but to bring them back, they have to be detected, understood, and accepted, he stresses. (1, p. 110) The ILFFPS is an effective model for enhancing connectedness in the fire service.
The ILFFPS team travels the nation teaching its two-day course. Information is at http://www.ilffps.org/register.
Acute Suicidal Affective Disorder
It is imperative to understand that prevention efforts such as peer support are effective only if introduced and used early enough. Peer supporters can function to validate an individual’s thoughts and help the person cope with his circumstances. However, if peer supporters are not involved early enough and the individual chooses maladaptive coping strategies, that person can become a high risk for suicide and require professional assistance beyond the capabilities of peer supporters.
Three of the most significant warning signs for risk of suicide are expressing feelings of hopelessness and helplessness, feeling as though you are a burden, and having made previous suicide attempts. (10, 7) In addition, overarousal states and insomnia increase the risk for suicide. (2, 240) A study in Finland showed that those who reported having frequent nightmares were 105 percent more likely to have died by suicide.21
After extensive case study, Joiner has identified what he has termed “acute suicidal affective disturbance.” It presents a clinical picture of a person in the hours and days before death by suicide. It consists of the following manifestations:
- A geometric increase in suicidal intent or planning (gathering of materials for an attempt) over the course of hours or days.
- Alienation, demonstrated by withdrawal, disgust, or perceptions that one is a burden.
- A belief that suicidal intent and alienation are intractable.
- Overarousal symptoms, including agitation, marked irritability, nightmares, and insomnia. (2, p. 239)
Recommendations for Implementation
Among the most commonly expressed reasons leaders give for failing to initiate a behavioral health, peer support, or suicide prevention program is a lack of knowledge. When Olson of the ILFFPS teaches peer support, he explains that it is not complicated and it is something that has been done in firehouses for years. It is simply “making it safe” or facilitating a culture in public safety that allows members to talk to one another and ask for help when it’s needed.
Members must be able to admit when they become confused by their emotions or are not emotionally well without fear of repercussion. Peer support helps responders recognize their emotions are normal, even when they’re uncomfortable or overpowering. Olson teaches peers to listen, relate, and validate. Their job is not to solve a problem or counsel but to be present and offer an ear. (20, p. 1)
CFD Battalion Chief Dan DeGryse also teaches peer support to fire departments across the nation through the International Association of Fire Fighters (IAFF), http://www.iaff.org/behavioralhealth. Members in public safety already have skills intervening with people in crisis, he explains, so DeGryse expands that knowledge. DeGryse and other IAFF Master Trainers teach students the signs and symptoms of substance abuse and mental health issues so they can better identify these issues and intervene appropriately.
“You don’t have to know everything,” DeGryse says, “but you have to have some knowledge of mental health disorders and be comfortable talking to your personnel. We’ll ask tough questions on an EMS call when we’re worried that a person may be suicidal,” DeGryse says, “but we’re uncomfortable asking those same questions with our coworkers.”
The IAFF Peer Support Program is an awareness-level class focusing on the signs and symptoms to watch for in our peers. After completing the training, members become IAFF Trained Peer Supporters.
The course is taught over two days and includes interaction with the instructor and opportunities for role-playing, which helps firefighters get past the stigma and fear of asking coworkers tough questions. DeGryse compares the class to the hands-on training firefighters are required to complete before graduating an academy. “It’s like opening a roof for the first time; you’re not sure how it’s going to work until you get up there to open it,” he adds. The program helps members to gain hands-on experience so they can better serve as a bridge between department members and resources available within the department and the community. Additional information on the program is at http://www.iaff.org/behavioralhealth.
Another resource is the QPR Institute, which has been providing suicide prevention training since 1999 and works closely with the American Association of Suicidology. QPR stands for Question, Persuade, and Refer, the three simple steps anyone can learn to help save a life from suicide. Additional information is at https://www.qprinstitute.com/about-qpr. Finally, LivingWorks is a national leader in suicide prevention training; additional information is at https://www.livingworks.net/.
1. Joiner, TE. (2010). Myths about suicide. Cambridge, MA: Harvard University Press, 42. Dr. Joiner is considered the premier researcher and educator on suicide. His knowledge and experience include personal-, scholarly-, and research-based understanding.
2. Joiner, TE, Hom, MA, Hagan, CR, & Silva, C. (2016). “Suicide as a derangement of the self-sacrificial aspect of eusociality,” Psychological Review, 123(3), 242. doi:10.1037/rev0000020.
3. Sher, L. (2004). “Preventing Suicide.” QJM Quarterly Journal of Medicine, 97(10), 677-680. doi:10.1093/qjmed/hch106.
4. Savia, JS. (2008) Suicide among North Carolina professional firefighters: 1984-1999. Dissertation Abstracts International, 69, 1.
5. Martin, CE, Vujanovic, AA, Paulus, DJ, Bartlett, B, Gallagher, MW, & Tran, JK. (2017). “Alcohol use and suicidality in firefighters: Associations with depressive symptoms and posttraumatic stress,” Comprehensive Psychiatry, 74, 44. doi:10.1016/j.comppsych.2017.01.002.
6. Gist, R, Taylor, V, & Raak, S. (2011). Suicide Surveillance, Prevention, and Intervention Measures for the US Fire Service (11, White Paper). Baltimore, MD: National Fallen Firefighters Foundation.
7. Violanti, JM. (2010). “Suicide or undetermined? A national assessment of police suicide death classification,” International Journal of Mental Health & Human Resilience, 12, 89.
8. Antonellis, PJ & Thompson, D. (2012). “A Firefighter’s Silent Killer: Suicide,” Fire Engineering”; 16(12):69-76.
9. DeGryse, D. (2012, August 14). Chicago Union EAP Embarks on Firefighter Suicide Study. Retrieved October 11, 2015, from http://firechief.com/suicide/chicago-union-eap-embarks-firefighter-suicide-study/.
10. Henderson, SN, Hasselt, VB, Leduc, TJ, & Couwels, J. (2016). “Firefighter suicide: Understanding cultural challenges for mental health professionals,” Professional Psychology: Research and Practice, 47(3), 224-230.
11. Willing, J. (2011, July 18). Firefighter suicide prevention: The company officer’s role. Retrieved May 21, 2017, from https://www.firerescue1.com/cod-company-officer-development/articles/1080052-Firefighter-suicide-prevention-The-company-officers-role.
12. Van Orden, KA, Witte TK, Cukrowicz KC, Braithwaite S, Selby EA, Joiner TE. “The Interpersonal Theory of Suicide,” Psychological Review. 2010;117(2):575. doi:10.1037/a0018697.
13. Ma, J, Batterham, PJ, Calear, AL, & Han, J. (2016). “A systematic review of the predictions of the Interpersonal–Psychological Theory of Suicidal Behavior,” Clinical Psychology Review, 46: 35.
14. Olson, M. (2016, August 01). “Creating the Illinois Fire Fighter Peer Support Team,” Retrieved May 25, 2017, from http://www.firerescuemagazine.com/articles/print/volume-11/issue-8/firefighter-safety-and-health/creating-the-illinois-fire-fighter-peer-support-team.html.
15. Joiner, T. (2009, June). The Interpersonal-Psychological Theory of Suicidal Behavior: Current Empirical Status. Retrieved May 23, 2017, from http://www.apa.org/science/about/psa/2009/06/sci-brief.aspx/.
16. Seiden, RH. (1978) “Where Are They Now? A Follow-Up Study of Suicide Attempters from the Golden Gate Bridge,” Suicide and Life-Threatening Behavior; 8(4): 215.
17. Joiner, T. (2007). Why people die by suicide. Cambridge, MA: Harvard University Press, 11.
18. Stanley, IH, Hom, MA, Hagan, CR, & Joiner, TE. (2015). “Career prevalence and correlates of suicidal thoughts and behaviors among firefighters,” Journal of Affective Disorders, 187, 163-171. doi:10.1016/j.jad.2015.08.007.
19. Jouvenal, J. (2017, February 15). “Bullying, harassment a problem in parts of Fairfax fire department, report says,” Retrieved May 23, 2017, from https://www.washingtonpost.com/local/public-safety/report-finds-bullying-harassment-a-problem-in-parts-of-fairfax-fire-department/2017/02/15/c7c4be80-e52a-4bce-bf63-e135654d63bb_story.html?utm_term=.9100809eff00.
20. Ali, Dena. “A Culture of Acceptance: Up Close with the Rosecrance Florian Program,” Fire Engineering, May 2017. Web.
21. Tanskanen et al., (2001). “Nightmares as predictors of suicide,” Sleep, 24, 844.
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.