By Dr. Beth L. Murphy
The phone rings in your office or home. It’s a call delivering the horrible news that one of your firefighters has committed suicide. This is a horrific event for anyone, and your department has training to help others in trouble; but when it comes to the loss of one of your own, you’re at a loss. What follows are confusion, numbness, a bunch of ‘what ifs’ and “I should have knowns,” and other assorted self-flagellation. What could you or the other members of the fire department have done? What signs did you miss? Was the firefighter continually late for work; sleeping all of the time at the station; having decreasing performance; increased use of sick leave; looking hung-over at work; marital discord; increased use of medications or frequent doctor visits? What did you miss? What has been going on with your firefighter? How long has this been going on? There are thousands of questions and very few answers.
You then begin to reflect on the missed opportunities where you may have intervened. What did it look like? You then ask, how would I really know, I’m not a psychologist? If I did notice something was wrong, what would I say, how would I say it, and what resources do we have to help?
Mental health and suicide is a mental health issue that has confronted our society for many years. In the fire service, much like the military, this is a condition not discussed in the open or adequately treated. The mere mention that “I am having some mental health struggles” or “I have a problem,” creates a perceived sign of a weakness that carries a stigma; it signifies to most people weakness or fragility. Too many people with mental health issues are confronted with statements like, “Toughen up; don’t be a wimp,” or “Get over it.” This is especially true in the military where mental health issues are not to be talked about and suicides are nearing epidemic proportions. The past Secretary of Defense Leon Panetta stated in response to the growing epidemic, “Leaders throughout the department (military) must make it understood that seeking help is a sign of strength, not a sign of weakness; it is a sign of strength and courage. We’ve got to do all we can to remove the stigma that still too often surrounds mental health care issues.”
The fire service is not much different from the military. Firefighters help others, they don’t need help, nor do they ask for help. Too often, firefighters have turned to suicide to resolve their problems, and survivors in the department don’t know what to do or how to help. The fire service has developed into an industry in which every firefighter injured or killed in the line of duty triggers an investigation to look at conduct by fire personnel, training, leadership, fireground operations, policies, and the overall department operations to prevent the problem from happening again. What if the death or injury is from the firefighter who attempts or commits suicide? Do we reevaluate our own human condition and perform a mental health assessment on ourselves or our brother and sister firefighters? Probably not, as we feel very uncomfortable intervening into someone else’s life to say, “What is going on, and how can I help?”
In the general population, suicide is the 10th leading cause of death; on average, one person every 13.7 minutes dies by suicide. Suicide among males is approximately four times higher than for females, and approximately 56 percent of suicides are committed using firearms, followed by 24.7 percent, hanging/suffocation. Statistics also indicate 33.3 percent of suicide decedents tested positive for alcohol, 23 percent% for antidepressants, and 20.8 percent for opiates, and there is one suicide for every 25 attempts. [i]
The National Mental Illness Statistics indicate several mental illnesses are strongly associated with suicide including: depression, bipolar disorder, anxiety disorder, schizophrenia, substance use disorder, eating disorders, and conduct disorders. Their studies indicate that major depressive disorder affects approximately 14.8 million American adults and is 70 percent more prevalent in women than men.
The statistics for firefighters are not well known. There is virtually no research on firefighter suicides, although many articles citing anecdotal evidence have been written by firefighters and a handful of mental health professionals connected with the fire service. Scant research has been conducted on factors of stress and stress response, and more research has been conducted on physical stressors and responses such as heart disease, stroke, and cancer. The harsh truth is there is more focus on the firefighters’ physical health because of the high percentage of cardiac events among the firefighters, but we do not address the issue of mental health and suicide with the same urgency.
National Fallen Firefighters Foundation, National Volunteer Fire Council, and Dr. Gist, along with Dr. Joiner, Dr. Nock and Dr. Berman. These individuals and groups are beginning to provide crucial statistics and understanding of suicide and mental health issues in the fire service and are bringing hope for change. However, despite the information being provided by these individuals, the actual dissemination of information and policy making based on this information are not happening. I believe this is related to the aversion to “intruding” into another person’s life and intimating that he or she may be struggling with mental illness. There is some movement toward supporting the mental health of the firefighters, but it is slow and not enough. To be blunt, firefighters’ mental health needs to be prioritized with policy, assessments, and ongoing monitoring, in line with what has been done for physical fitness. Talking about suicide will not cause someone to attempt suicide, but it may save someone from suicide.
What are some of the signs to look for in your firefighters? They include feelings of helplessness and hopelessness; loss of interest in daily activities; loss of the ability to feel joy and pleasure; decrease in appetite or weight changes; and changes in sleep patterns to include insomnia or waking in the early hours of the morning. Also included are anger or irritability; loss of energy; and feeling fatigued, sluggish, and physically drained. What is most important on the fireground is that these firefighters may have an increase in reckless behavior and freelancing, endangering themselves and their fellow firefighters. Many individuals finding themselves in this situation may begin to use alcohol in situations where it’s physically dangerous or mixing alcohol with prescription to blunt the effects of the symptoms noted above.
In addition to the symptoms above, Dr. Joiner indicates other significant signs of suicide are thwarted belongingness, perceived burdensome, and capability for suicide. Thwarted belongingness is a belief that you are alone, isolated, and not part of your family, friends, or work. Perceived burdensomeness is the feeling that everyone would be better off without you. Capability for suicide is a combination of disposition and experience that overrides your aversion to pain and suffering.[iii]
Some risk factors for suicide are white, male, and an older age, although suicide in the age groups between 25-45 years of age accounts for the second and fourth leading causes of death; a higher rate of divorce or separation or early widowhood; prior suicide ideation, threats, and attempts; history of trauma; history of reckless and/or violent behavior or traumatic brain injury; other severe injury; and chronic pain
If you are concerned about someone you supervise or work with, ask yourself the following questions: What did you see? What are your concerns? What would you do?
The most important thing anyone can do is “Have the tough conversation, and dare to intrude.” You have the most important tool already within your possession, and you use it every day as part of your job–Compassion. Talking to someone in trouble doesn’t require any special training. Do a size-up, observe, listen, and refer to a qualified mental health professional. There are many quality resources available–for example, peer support; employee assistance programs (EAP); chaplains; community mental health providers; hospitals and crisis lines, to name a few.
The department should develop a policy that outlines the signs and symptoms and the course of action, similar to the drug and alcohol program your department may already have in place. Most importantly, the policy should not be punitive, but supportive. Further, any policy should include the EAP number if you have one, the crisis line number, peer support group member if you have one, and contact information for the chaplain if you have one.[iv] Then develop a comprehensive mental wellness program that includes all of the above resources, and provide Psychological First Aid [v]for all of your employees and firefighters. Also contract with or hire a qualified psychologist and provide ongoing training in mental health and suicide prevention for your firefighters.
Here are some resources for your use in managing the stress occurring in the workplace or at home:
Crisis Lines and Online Supports.
First Responder specific, Safe Call Now- safecallnow.org, 206-459-3020
Firestrong, firefighter online- www.firestrong.org
National Programs on Suicide: www.suicide.org or 1-800-SUICIDE
National suicide prevention lifeline- 800-273-8255
Resources and Sources of Information
Substance Abuse and Mental Health Services Administration – http://www.samhsa.gov
National Center for PTSD *- http://www.ptsd.va.gov
American Psychological Association- www.apa.org
National Fallen Firefighters Foundation: www.firehero.org
National Volunteer Fire Council: www.nvfc.org
Mental Health Recovery-military program
Ask Care Escort, online screening tools and fact sheets. http://www.mentalhealth.va.gov/index.asp
Beth L. Murphy, PsyD, is a licensed clinical ppsychologist and a retired firefighter/EMT in Washington State. She provides therapy for individuals, couples, and families struggling with a range of difficulties from severe mental health issues to minor adjustment issues due to expected and unexpected life changes. Her specialty is in trauma and traumatic stress as well as chronic illness, such as cancer. She works with a diverse population and uses her experience and knowledge from being a firefighter to provide services for fire and police personnel and their families. She provides psychological assessments for firefighter prehire testing, promotional evaluations, and forensic work for attorneys.