Firefighter Behavioral Health — A Five Alarm Fire

One thing that has not changed in the fire service during this pandemic is the decline in firefighter behavioral health.  We are still losing more firefighters to suicide than we are in the line of duty each year and I wish it would stop.  Two firefighter suicides “close to home” in the last couple of months have really made me want to revisit this issue.  Allow me, if you will, to explain our position.

I joined the fire service the same way many of you did.  I was attracted to the excitement and thought that my involvement in the fire service would only require a knowledge of how to turn the lights and sirens on in the engine and where to point the nozzles — toward the flames.  I was REALLY wrong.  My fire service education has taken me through building construction, pump operation, technical rescue, hazardous materials, pre-hospital medicine and so on.  When I first joined the fire service, I was young and likely lacked the level of empathy that I have now.  This is to say that I have formed a new respect for the tragedy we see every day.  That tragedy comes in many forms and can be anything from an individual’s poor living conditions to seeing a child die from traumatic injuries.  I’ve felt that it is much harder to witness those tragedies now, after 30 years, than when I started.  I’ve attended many classes on firefighter behavioral health and hear often about a firefighter’s file folder or bad-call tank.  This is the place where we store all of the tragedies we have experienced or witnessed.  Perhaps mine is full and that is why I feel differently about the tragedies I see today than 30 years ago.

Let’s start there.  When we join the fire service, we commit to operating at tragic scenes in a professional manner.  Those that call us, demand that we put our emotions aside and go about solving their problem in a systematic and non-emotional manner.  Make no mistake, not everyone can be you.  The fire service is a job where you are called without notice to operate in a foreign environment under dangerous conditions and make split second decisions that carry with them the potential for catastrophic consequences.  There are not many other professions that operate in this manner.  Many of us have long resigned ourselves to the possibility of giving our lives to save another person.  To continue to operate in an environment that could potentially cost you your life requires bravery, a suppression of your survival instinct, and what some would consider a sense of fearlessness.  It is this suppression of emotions and fearlessness, both requirements of our occupation, that pre-disposes us to having poor mental health.  We’ll come back to that in a minute.

Next, we need to understand the context of a firefighter suicide.  I often hear other firefighters say that they think the firefighter that committed suicide left their family, their station, their shift, and their department and that it was an incredibly selfish thing for that firefighter to do.  Since firefighters have been conditioned to suppress their emotions in this occupation, we do not typically respond to a co-worker who asks us how we are doing with, “Well, I’m really lonely and I feel as if I am a burden on my family and my department and I’m thinking about killing myself.”  Nevertheless, this is how some firefighters feel.  Behavioral health specialists suggest that when a firefighter commits suicide, they oftentimes view it as a selfless act, relieving their family and department of the burden that they believe they are.   This context is something that we need to understand because if we label each firefighter that commits suicide as selfish, we are not beginning to understand the problem.

Next, we need to understand who possesses the ability to commit suicide.  Research suggests that the ability to complete suicide is developed through repeated exposure to painful or fearsome events.  Abused children and victims of physical or sexual abuse often have these experiences.  However, firefighters, law enforcement, EMS, and even dispatchers share these experiences.  This post-traumatic stress is common among military members committing suicide and has just recently been explored in the fire service.

So, if you take an individual who has expressions of loneliness or burdensomeness, add the ability to complete suicide — which is achieved through repeated exposure to trauma — and add to it a sense of fearlessness and a loss of survival instinct, you will have a high-risk individual.  The math version of that is Loneliness + Repeated Trauma + Fearlessness = Firefighter (High-Risk Individual).  In this equation, we cannot remove the repeated trauma or the fearlessness that is sometimes required — not always.  However, we can battle the loneliness.  We should effort to identify any of our firefighters who seem socially withdrawn.  There is also a myriad of external factors that can contribute to our loneliness —divorce, anxiety, depression, alcohol/drugs, feeling of hopelessness, financial problems — and these are all high-risk indicators.

Above all, we — and I mean all of us — need to remove the stigma preventing firefighters from asking for help.  This stigma has existed since I joined the fire service and is rooted in fear and ignorance.  Firefighters are either afraid of being ridiculed if they ask for help or they do not know how to get help.  There are countless organizations that now exist to assist firefighters and other first responders with improving their behavioral health.  The National Fallen Firefighters Foundation (NFFF) website (www.everyonegoeshome.com) has links to state and local programs in your area.  As far as the fear of being ridiculed goes, those days are over.

I have seen countless firefighters over the years become very emotional after a call.  Sometimes, it is a particularly bad call and sometimes it is the accumulation of bad calls.  No one is immune.  Just a couple of years ago, I responded to an incident involving a deceased child.  Although it wasn’t a particularly graphic scene, the circumstances were unusual and sadly, I had seen a lot of deceased children before that call.  It wasn’t one of those calls that you walk away from thinking, “That’s the worst thing I’ve ever seen,” but it was certainly tragic.  I arrived home after that incident and had to call my wife to come out into the yard because I didn’t think I could make it into the house.  When she met me in the yard, I found that I couldn’t even talk about the incident.  Thankfully, my wife helped me through that difficult time.  In my career, that is not the first time that I have had a highly emotional response after an incident.  And you know what?  That is OK.  Let me make that clear.

Our great service requires, as our citizens demand, us to operate at incidents in a calm, professional and non-emotional manner.  However, and this is important, NO ONE should be ridiculed for being emotional AFTER a call has occurred.  We often deal with people on the worst day of their lives.  That is extremely sad.  If you have not felt sad for the people that you serve, it will eventually catch up to you.  I urge you to consider your own emotions before you end up pulling up in your yard and cannot make it inside.  The accumulation of post-traumatic stress, along with the above internal and external factors, can be detrimental to firefighter behavioral health if that accumulation is not routinely addressed.

So, what do we do?  Social support and social connection are the biggest preventers of firefighter suicide.  Our fire service family should be cared for just as our citizens are.  Many years ago, the fire service routinely used Critical Incident Stress Debriefings after a particularly bad incident.  These sessions got all of the responders and hospital staff together and allowed each attendee to talk about the incident, their role, what they witnessed, and how they felt about it.  Unfortunately, we learned that many either did not participate or otherwise found their participation not helpful.  Nevertheless, we must position ourselves to be able to talk about these critical incidents whether that is with our crew, shift, department, significant other, or professionals outside of the fire service when necessary.  Likewise, we should be able to talk to any individual in our fire service family that have withdrawn, are experiencing divorce, depression, alcohol/drug use or those that express feelings of isolation, hopelessness, anxiety, burdensomeness or display any of the other high-risk indicators.  The National Fallen Firefighters’ Foundation uses the acronym ACT to guide you in how you should approach a firefighter identified with one or more of the above.

Ask the Firefighter

First, you should “Ask the Firefighter.” You should ask, “Are you thinking of killing yourself?”  Many are hesitant to ask that question for fear that you may be planting the idea in the firefighter’s head.  You will not.  They either already have it in their head or will not give your question legitimate consideration pursuant to your question.  Any answer other than “No” to your question should warrant further attention and the second letter in the ACT acronym.

Care for the Firefighter

Next, you should “Care for the Firefighter.”  Talk more about their problems and tell them that you want to talk more because you care about them.  Try to identify if they have a plan to harm themselves and if they have a means to do so.  If this is the case, then you probably need to follow the last step in our acronym.  Otherwise, continual care may be required for an extended period of time.

Take the Firefighter

“Take the Firefighter.”  This will involve taking the firefighter to get the help they need from behavioral health professionals.  This will likely involve outside entities or people and while discretion should be used to the extent possible, protecting a firefighter’s health should be paramount.

Our fire service family demands that you “ACT” whenever necessary.  Firefighter behavioral health continues to be a struggle in our honored service.  I beg each of you, since you are part of my fire service family, to take care of everyone else in our fire service family.  The National Suicide Hotline is 800-273-8255 and the First Responder Crisis Support Helpline is 844-550-HERO (4376).  Put those numbers in your phone in case you or anyone else in our family needs them.  Not everyone can be part of our family, but all of us are charged with the responsibility of protecting our family members.

Be safe and do good.