Interior Attack: The Secret Fight Your Brothers and Sisters are Fighting

Firefighters operate in minimum crews of two when in atmospheres that are immediately dangerous to life or health; meaning that in most traumatic situations, firefighters should not be working alone.

A different fire is set ablaze in fire stations all across the United States, however, involving a different kind of “interior attack” than most are familiar with. There is little protection from this fire and oftentimes no training. Firefighter suicide is a raging inferno that is spreading uncontrolled through the fire service today. More than running into burning buildings and dealing with wrecks on interstates, more than early flashover or becoming disoriented inside a fire, more than structural collapse or vehicle accidents, and more than cardiac events; firefighters fall more often to stress and PTSD than all of the above factors combined. Many are uninformed, undereducated, or are completely unfamiliar with the severity of the problem. Suicide is real and suicide is serious. Preventative efforts in the fire service still focus on line of duty death, but numbers are indicating that line of duty death has been dethroned.

Suicide among public safety personnel is nothing new. Suicide first became prevalent in public safety in the 1970s, with the highest rates of suicide coming from law enforcement personnel. This doesn’t necessarily mean these were the first suicides; this was simply the first time that someone noticed an upward trend. Suicide became noticed specifically within the fire service in the mid-1990s and has since grown tremendously. Today, law enforcement officers experience a suicide rate that doubles or triples the rate of line of duty deaths. It seems that the fire service is trailing just two decades behind.

What causes this?

Many believe stress is to blame. Stress took the blame back in the 70s and is believed to remain the leading cause of suicides today. As defined in the Merriam Webster dictionary, stress is “a physical, chemical, or emotional force or influence, that creates bodily or mental tension and may factor into causation of disease.”

The way stress affects humans is similar to the way an injury affects a professional athlete; a football player, for example. Normal levels of stress endured at home and at work are analogous to the forces absorbed by muscles, joints, etc. of a football player while training and practicing. While these normal levels of stress are part of life, they have much greater impacts when an athlete is injured. Following injuries, the affected area must be effectively treated and rested before it can be expected to function normally again. Sometimes an injury develops over time without a single instance to blame; ironically, a “stress” fracture would be an example of this.

Ultimately, stress is caused by changes. Even small changes such as adjustments in eating habits or the planning of a vacation can cause stress. For those of us that are “physics-minded,” stress can be thought of in the same way as pressure. In physics, the same force exerted over a smaller surface area creates more pressure. Likewise, even small changes create large amounts of stress if implemented in a small amount of time. Stress is maximized when large changes occur over small amounts of time. This phenomenon embodies the job of a firefighter, either volunteer or career.

On the job, firefighters perform many activities of lesser intensity; things such as station duties, maintaining equipment, exercising, resting, training and etc. These activities make up a large majority of a firefighter’s time spent on duty. Other time on the clock is spent responding to emergencies — swiftly introducing high intensity activities in a high stress environment. The fast-paced nature of the job further intensifies tasks that are stressful to begin with. It’s not just what the job requires, but how it’s required. This effect is even further heightened for volunteer firefighters that respond from their jobs or their homes.

In addition to the intensity levels of the tasks at hand and the rapid onset of such activities, another contributing factor is exposure to traumatic events. Firefighters are generally the first responders to arrive on the scenes of severe vehicle accidents, violent situations and mass casualty incidents. Firefighters work in the heat of battle; extricating victims, extinguishing fires, de-escalating hostile environments, and helping families — and friends — cope with loss. While firefighters are able to function on the battlefield, the things they see and the actions they take can haunt them well into the future. Critical incident stress debriefings are common in the fire service. All too often, they are downplayed or even not conducted at all. While the intentions are good, they are clearly not being utilized to their full potential.

Just as there are direct job factors that contribute to firefighter stress, there are also indirect factors that can produce stress. The work schedule alone creates an impact on firefighter marriages that rivals those of military personnel. Reports show that more than 60 percent of full-time firefighters work a second job, and nearly 12 percent work a third job. Obviously these extra hours worked increases stress levels and tensions with family.

Combined, these factors produce levels of stress that are typically uncontested outside of the military or other public safety organizations. Going back to the football analogy, the normal stress involved with the day-to-day life of a firefighter is like practice or training to an athlete. When a firefighter is exposed to elevated stress over time or experiences an acute exposure to extreme stress, they suffer a mental injury. Like the football player, they must be allowed to rest and recover. Particularly in the economic “slump” we find ourselves in today, many fire departments are tight on money, short on staffing, and cannot allow or do not allow firefighters the time needed to recover. Since firefighters respond to a wide variety of incidents, each one will react differently according to the situation. Diagnosing the resulting mental injury can be extremely difficult.

All of these elements come together to create a “perfect storm” in which suicide thrives. Starting with the stresses of the job, add a good working knowledge of human anatomy — obtained through training and years of experience; then mix in the lack of awareness and prevention. The result is an ever-increasing number of successful suicide attempts.

While suicide is often passed off as an escape of conflict for the weak, psychologists believe that this is not the case. Suicide is a direct contradiction to mankind’s most prominent instinct; survival. Rather than categorizing those that attempt suicide as weak, we should instead think of them as strong enough to want to override their very own existence. While there is a small fraction of firefighter suicides that are unsuccessful, those that survive attempted suicide should be considered a wealth of information. With all of the alternatives available for dealing with stress, we need to determine what it is that makes death the most appealing option.

Since 2012, the Firefighter Behavioral Health Alliance (FBHA), founded by Jeff Dill, has worked to collect info and further prevent firefighter suicides. The FBHA takes reports of suicides, verifies them, and coordinates prevention efforts. In 2012 there were 79 firefighter or EMT/Paramedic suicides reported to and confirmed by the FBHA. This number has steadily increased in 2015, surpassing Line of Duty Deaths in 2014 — estimated 95 suicides vs. 92 LODDs. Of the 755 total suicides reported and confirmed by FBHA, 660 (87.4 percent) were firefighters and 95 (12.6 percent) were EMT/Paramedics. If approximately 87.4 percent of the FF/EMT suicide rate is made up of firefighters, then it would be a logical estimate that somewhere around 98 firefighters deaths were due to suicide on 2015. This number easily exceeds the number of line of duty deaths from last year and continues to climb.

These numbers, as sobering as they are, actually underestimate the true number of firefighter suicides. Many are hidden or go unreported in order to maintain a positive public image. A number of additional suicides could potentially be staged as other means of death. It is also very likely that even more are not reported because personnel are not familiar with FBHA. The real number of firefighters that have committed suicide is impossible to know. The numbers presented by Captain Dill certainly offer a good starting point.

When compared with law enforcement and EMS, the fire service has a great advantage. Firefighting involves much more personal interaction and teamwork. Police officers are isolated in their cruisers for a large portion of their shift and often do not interact with other officers for hours at a time. The same goes for EMS workers, with the exception of the one other person who rides the unit with them. In the fire service, members live together and are typically in an environment with several other people. For volunteer firefighters, there are usually at least a good handful of other volunteers to interact with and confide in.

Firefighters operate in minimum crews of two when in atmospheres that are immediately dangerous to life or health; meaning that in most traumatic situations, firefighters should not be working alone. When firefighters experience traumatic incidents, they more often than not had a partner that went through the same experience with them.

The structure of the fire service allows members to get to know each other. Sometimes they know each other quite well. When a firefighter is showing signs of being under stress, there are many opportunities and many individuals in a position to acknowledge the situation and offer up support to them. Firefighters can tell when others are acting abnormally. It only takes one individual to intervene and make a difference. Every member of the fire service has an obligation to look out for his or her fellow firefighters. There is incredible potential for the fire service to greatly reduce suicide. Just as the fire service increased the use of seat belts and successfully improved levels of physical fitness, the fire service can greatly reduce suicides simply by increasing awareness and prevention.

The Houston Fire Department (HSD) has made great strides for suicide prevention and can serve as a model for many to follow. Following three firefighter suicides in the 2005 to 2007 time frame, the Houston Fire Department initiated a three-phase internal suicide prevention program.

Suicide Prevention Program

Phase I — Awareness

This involved introducing and educating all Houston firefighters about the issue of suicide in the fire service. The department began by gathering ideas from active duty firefighters about mental health. After ideas were drafted, a crew of nine active-duty firefighters developed a suicide prevention team. The team was then sent to a psychologist to receive further training. A presentation was created and the team then moved throughout the city to promote suicide awareness to all members and companies — including the airport firefighters, HAZMAT teams, and other special operations units. Approximately three months after the initial presentations, a second presentation was created that specifically addressed suicide history within the Houston Fire Department. This presentation featured an unscripted interview of crewmembers that had experienced the loss of a firefighter to suicide. After both presentations, there was a question and answer session performed by the team. Unanswered questions were forwarded to psychologists. At the conclusion of this awareness phase, surveys were sent to all members. These surveys analyzed mental health and confidentiality was maintained. The results were sent to the psychology department at the University of Houston. The final part of the awareness phase involved taking recommendations from all HFD personnel. Firefighters praised the suicide prevention team and wanted to keep it internal — not to just employees of the City of Houston, but specifically firefighters in the city of Houston. As a result of the awareness phase, a firefighter support network was created.

Phase II

The second phase of Houston Fire Department’s suicide prevention program touched on topics from the awareness phase, presented results from the surveys sent to the University of Houston, and brochures were circulated through the department that identified warning signs of suicide.

Phase III

The final phase of the program was officer development. A special presentation was given to officers that encouraged them to provide a culture of awareness and concern for the mental health of firefighters. Officers were given online training to teach them how to identify and mitigate potential mental crises in their firefighters.

Since the suicide prevention program was initiated in 2007, HFD has lost two additional firefighters to suicide but has averted three “near-certain suicides.” The suicide prevention team continues to make rounds as requested and also to assist crews recovering from the loss of a fellow crewmember. All Houston Fire Department cadets receive training on suicide prevention from the team and the team plans to extend services to the immediate family of HFD members in the future.

Like line of duty deaths, suicide prevention efforts cannot be expected to eliminate all suicides; prevention efforts serve to minimize the number of suicides in the fire service. It is imperative that we look out for our brothers and sisters in the fire service, being careful to note any signs or symptoms of mental distress or depression. The fire service has failed itself more than 660 times. Let’s be aware and be supportive of our fellow firefighters. Together, we can truly make a difference.