By Brandon K. Dreiman
I teach peer support and behavioral health classes to firefighters across the United States. At some point during every class, I ask the audience to raise their hands if they know a firefighter who has committed suicide. Without exception, anywhere from 80 to 100 percent of the class will raise their hands. And I raise my hand with them. In the past eight years, I have known four firefighters who committed suicide. If I asked you, the reader, to raise your hand if you know a firefighter who has committed suicide, I can almost bet that your hand would be up right now, too. The ability to confidently predict that such a high percentage of any firefighter audience will have this shared experience tells us there is a problem. And the current state of affairs clearly indicates that suicide is getting worse.
The Suicide Crisis
From 2013 to 2015, annual firefighter suicides were 70, 112, and 132, respectively. One can reasonably ask, “Why are we seeing such an increase in firefighter suicide?” (especially in light of the successes we are having with programs like peer support). While it is difficult to pinpoint exactly why this increase is occurring, I will offer a theory on why I believe firefighter suicide is on the rise, anecdotal as it may be.
I can vividly recall when I became involved in fire and emergency medical services back in 1991. In those days, we rarely heard about firefighter line-of-duty deaths (LODDs). They were certainly occurring – we just didn’t really hear about them. Maybe we would see something in a trade journal, in a newspaper, or on a newscast or perhaps hear about it on the radio, but even in those circumstances, unless it was a large loss of life, we would only hear about LODDs close to home.
Contrast that environment with the electronic media world in which we now live. We are exposed to constant footage and newsfeeds that could impact mental health. Think about the firefighter injuries and deaths you are exposed to via social media, e-mail, and online news sources during a typical week. We can watch phone video of firefighters falling through roofs, falling from ladders, bailing out of houses, and being involved in apparatus crashes. We can listen to audio of firefighters during fatal Mayday calls. When there is a firefighter LODD anywhere in the world, we can receive an e-mail notification. And it isn’t limited to simply observing trauma involving firefighters. There are readily and nearly instantly available videos of nonfirefighters suffering trauma from any number of methods, and it is all fed directly to our phones and tablets for continuous consumption. How does this help explain the continual increase in firefighter suicide? To help answer that, let’s examine vicarious trauma.
Vicarious trauma can be described as the emotions we feel from witnessing the pain and fear of trauma victims. Firefighters have always suffered from some degree of vicarious trauma simply by responding to traumatic calls. But our exposure is more magnified than ever because we are so consistently and intensely exposed to the trauma suffered by others (especially by our brothers and sisters) in the digital age. Firefighters are inherently empathetic, and it is very easy for us to put ourselves in our brothers’ and sisters’ boots. Because of our ability to deeply relate to those experiences, there is no doubt that, despite not suffering the trauma ourselves, we can be affected by these constant exposures.
As a result, the stress effects can be the same for us as if we actually experienced the trauma. While there are many risk factors associated with suicidality, one major factor is exposure to trauma. When we consider the exponential increase in exposure to vicarious trauma via social media and electronic communications, it is logical to conclude that suicides will increase as those exposures increase, and I submit for your consideration that that is exactly what is happening.
Hitting All The Markers
As noted previously, there is a long list of suicide risk factors, but among those of interest to firefighters are alcohol or drug use, divorce or separation, unresolved grief, exposure to trauma, and access to firearms. How many of us can look across the kitchen table at the firehouse and see a firefighter who meets some or all of those criteria? How many of us can look in a mirror and see the same thing? Think about those two questions; a genuine consideration of them may help you save a life – perhaps your own. When you consider the risk factors, it borders on terrifying just how many markers the average firefighter meets. Couple those risk factors with sleep deprivation, pain from injuries, legal problems, and financial concerns, and it is no wonder that we are suicide risks. Because of our higher-than-average risk, access to mental health professionals is crucial.
There are a lot of places a firefighter can go for help, but one option I encourage all fire departments to explore is the employee assistance program (EAP). EAPs contract with a municipality or labor union to provide mental health and addiction counseling services to employees. One great thing about a lot of EAPs is that they aren’t limited only to diagnosable behavioral health problems. Many EAPs have financial planners, family counselors, and some even legal divisions. One caveat to EAPs is that the fire department needs to know how many visits a firefighter will get free of charge (some are extremely limited, which only causes disdain and distrust of the EAP). Another significant EAP consideration is whether the counselors have ever worked with firefighters. Any vetting process of an EAP must include an evaluation of how well the counselors will relate to firefighters. Firefighters are distrustful of outsiders, and having counselors who don’t understand the fire service will ruin any potential the EAP may have. Aside from those considerations, having an EAP available to personnel can make all the difference in getting our people healthy.
Peer support teams are another fantastic option. Many of us are familiar with the critical incident stress management (CISM) model of dealing with critical incidents through defusings and debriefings, but CISM should not be confused with peer support. CISM seeks to assist firefighters reactively by having them share their reactions to a traumatic event as part of a group. Peer support, on the other hand, seeks to assist firefighters proactively with education campaigns, station visits, stigma reduction, and personal requests for assistance as well reactively during one-on-one visits with firefighters after a critical incident. Peer support has been proven to be highly effective for getting firefighters assistance with behavioral health, financial, legal, and addiction services. Essentially, peer support acts as the bridge between the firefighter and all the other means of assistance available to the firefighter (something the CISM model is not designed to do). Peer support teams are trained in suicide awareness and assessment. They will be able to assess the level of suicide threat and will know who to call and how to get the firefighter into treatment (often without having to wait in a lobby at the receiving facility because of the relationships peer support teams develop with local providers). If peer support is available in your department or in your area, please invite them to your firehouse for a meet and greet. A firefighter doesn’t trust anyone like another firefighter, so use peer support anytime you can. It is frequently the best and most trusted option available.
The Toughest Question You’ll Ever Ask
Imagine you are sitting on a bench outside the firehouse with a fellow firefighter. You know that this firefighter is going through a divorce because of serious gambling debt and drinking too much. You also know that this firefighter is an avid hunter and has access to rifles and shotguns (probably with at least one of those in his truck in the parking lot). You ask the firefighter how he is doing with everything. His response, “I don’t know. I’m losing everything I ever loved, and I have less than nothing to show for my life now. My kids are ashamed of me, and I can’t face letting them down. I know the world would be a better place without me. I’m just done.” Worried yet? You should be. This is a firefighter who needs help. You know it, and he knows it. But what are you going to do? What do you need to ask?
We know the answer to that question, but it’s a difficult subject, even for those who deal with mental health issues every day. The toughest question you may ever have to ask is, “Are you thinking about killing yourself?” But I can tell you from experience that, in the end, asking the question is much easier than ignoring what you know to be a life-threatening situation. And as awkward as it seems, it is better for everyone simply to ask. If the person is not suicidal, he will simply say, “No.” I have never had anyone get offended when I have asked the question and they have not felt suicidal. On the other hand, if the person is contemplating suicide, asking the question may well be the life preserver he is desperately seeking.
We also have this idea (which is an avoidance mechanism) that even if we ask, the suicidal person will just lie to us, and we will both feel uncomfortable about it. However, people experiencing suicidal ideation are frequently very open about their intentions and are looking for someone to tell. Will some suicidal people lie to you and say they are okay? Certainly. But even if they lie to us, we don’t lose anything by asking, and considering the likelihood that we can get them help, we must try.
There is also a fear that by asking someone teetering on the edge if they are considering suicide we may put the idea in their head as a viable option. Rest assured that this concern has been thoroughly studied, and it has been unequivocally determined that asking the question will not lead someone to commit suicide. The inescapable bottom line is that you will never know one way or the other unless you ask. Consider how we react on an emergency call with a stranger who has taken too many pain pills. One of the first questions we will ask is, “Are you trying to kill yourself?” And we will ask it without a second thought. If we are willing to ask a stranger that question without hesitating, it is inexcusable that we would avoid asking a brother or sister the same thing. We must give our brothers and sisters the same chance for recovery that we give our patients.
Furthermore, we must fight the temptation to soften the question. We may want to ask, “Are you thinking about harming yourself?” or “You’re not planning on killing yourself, are you?” Both approaches are set up for failure. The first one asks the wrong question, and the second one conveys that you really don’t want to know. The easy rule to remember is to be direct and to keep it simple. “Are you thinking about killing yourself?” is the best way to ask – clear and concise. But your inquiry cannot stop there if the answer is that he is considering suicide. You must then ask if he has a plan and if that plan involves anyone else (some people may be considering murder-suicide). If he has a plan, you must ask if he has taken any steps toward completing the plan. Another crucial question is to ask if he has attempted suicide in the past. Why are these follow-up questions so important? They are important because a person who has formulated a plan is considerably more likely to attempt suicide than someone who has no plan. Similarly, a person with a history of attempted suicide is far more likely to attempt it again than someone who has never attempted suicide. As such, the answers to these questions will tell you how immediate the threat is and what sort of timeframe you have to get intervention. The more immediate the threat, the less time you can wait for others to assist you.
What Next?
Regardless of how immediate the threat is, if the person tells you he is thinking about suicide, you must understand that you are in over your head. Simply put, this is not a situation you can handle alone. But whom do you contact? I first determine whether the person already has a therapist. If so, I tell him we need to call his therapist on speakerphone so we can all be part of finding answers. Understand though that calling a therapist during business hours may result in getting voice mail. If there is an immediate threat, you may not be able to wait for a call back. Another option is to contact your EAP. A good EAP will have 24-hour counselors available to talk to a suicidal firefighter – use that service. If you don’t have access to an EAP, you can call the National Suicide Prevention Lifeline at 800-273-8255. Before you read any further, put that number in your phone (as well as the number for your EAP if applicable). The absolute worst time to search for numbers is right after a brother has confided in you that he is suicidal, so have these numbers readily available the moment you need them. You should also consider reaching out to your peer support team. Peer supporters are trained to serve as the bridge between the firefighter and behavioral health providers. If time allows, a lot of peer support teams will send a peer supporter to your location so that you are not alone. At the very least, the peer supporter can speak to you and the suicidal firefighter on the phone to start developing an action plan. Peer support teams are a great resource because they understand how to access needed services, and they are immediately trusted more than most other resources simply because they are firefighters.
But what if you are in a worst-case scenario? What if the firefighter states he is ready to commit suicide now? We will assume that you don’t have time to wait for a therapist and you don’t have an EAP or a peer support team. Who would you call? The answer: 911. This is tough because we know from working prehospital what this means for the firefighter. It means law enforcement will respond. It means that other firefighters and ambulance personnel who the firefighter probably knows will be responding. We understand that the firefighter will likely be involuntarily placed on a hold at the hospital until things can be evaluated. But even with all those things in mind, it is 100 percent appropriate to call 911 if you feel that the person is an immediate threat to himself or others and you do not have time to wait for other means of assistance.
The final concern is to separate the firefighter from any lethal means he can use to complete the suicide. In our case, we know the firefighter has access to firearms, and statistically most firefighters will have access to guns. We need to talk to the firefighter about having a family member or another firefighter secure those guns and keep them somewhere away from the firefighter during this crisis. Assure the firefighter that he will eventually have the chance to get the guns back but that right now everyone needs to be safe.
We also know that a common method for attempting suicide is via poisoning, usually from a medication overdose. Therefore, we also must ask the firefighter about medications at the firehouse and at the firefighter’s residence. Again, we will need to employ outside help to secure medications. You need to ask a family member or someone else the firefighter trusts to take control of medications in the home to ensure that no lethal doses are kept in the home and that any expired or unnecessary medications are removed. Get in the habit now to ask about both categories. Most firefighters will have access to one or the other means (and many will have access to both). Remember that our goal is to remove options for completing suicide. This can also mean having things like rope removed from the home. There are clearly many options to complete suicide, but by removing the most lethal means available we increase the likelihood that if suicide is attempted it will be by a less effective means, which increases the chances that rescuers will be able to save the firefighter.
Prepare To Travel The Long Road
Firefighter suicide and its tremendous increase in recent years seem overwhelming. But, while it will won’t happen overnight, rest assured that we will get a handle on this crisis. Why am I so optimistic about such a dismal topic? Because I have seen the fire service change paradigms before, and it will do it again. For example, let’s consider the development of rapid intervention teams (RIT). When RIT was introduced to me in the late ’90s, most firefighters thought the idea of having a company of firefighters standing in the front yard waiting to assist other firefighters was a crazy concept. Now, firefighters think the idea of NOT having a company of firefighters standing in the yard waiting to assist other firefighters is a crazy concept. How did the fire service do that? How did it get such complete buy in and force a 180-degree turnaround? The answer is through education – again and again and again. It started with reeducating veteran firefighters about the proper tactics on the fireground, demonstrating their value, and insisting on their implementation. Over time, we saw more and more veteran firefighters accept the idea of RIT. Implementation also involved adding RIT to recruit training. By implementing it early in firefighter careers, class after class accepted the idea as a basic tenet of firefighting without ever realizing that it was a revolutionary concept. Eventually, it became just another accepted practice.
The same model can be applied to behavioral health, keeping in mind that gaining the upper hand on firefighter suicide will require more than just education about suicide awareness. After all, suicide is not the behavioral health issue that needs to be treated. Rather, suicide is the result of an underlying behavioral health issue, whether it be post-traumatic stress disorder, depression, bipolar disorder, addiction, or psychosis. By educating firefighters about all these issues, we will make prevention and seeking treatment for them the new paradigm.
In my department, we have a week-long class for all newly promoted officers. I have secured time during this training to talk to the new officers about behavioral health, peer support, and what to do when confronted with these issues. As a result, I have seen a tremendous increase in the number of officers who reach out to peer support for assistance. I also worked to initially get one hour to present behavioral health information to our recruit classes. Through consistency and perseverance, I now receive four hours to teach our recruits about these concepts in the fire academy. Just like with RIT, recruits accept that seeking help for behavioral health issues is commonplace and expected in the fire service without ever considering that it is still a relatively new concept. It may take five to 10 years for it really to take hold, but if we are vigilant and remind ourselves how important behavioral health is we will come out on top. We have seen dramatic reductions in LODDs because of Mayday training, better physicals, and smoking cessation and dietary programs; we can do the same thing for behavioral health if we have the courage and fortitude to stick it out until practicing resiliency methods and reaching out for help become the norm.
Like you, I don’t want to bury another brother or sister who has committed suicide. Unfortunately, I know that we will. We need to be realistic and realize that a quick solution to this problem doesn’t exist. But with that in mind, we must do better, and I have no doubt that we will. Please be my partner – be part of the solution – and have the courage to stand up and say “Enough!” and then see to it that our brothers and sisters receive the training they need. It is well past time that we start to care for our minds the same way we care for our bodies. Effective models for achieving our goals are out there. We did it with RIT, and we will do it with suicide prevention. Nobody perseveres and stands up for their brothers and sisters like firefighters do.
This our fight. Let’s go to work!
Brandon K. Dreiman is a 15-year veteran of the fire service and a firefighter/paramedic with the Indianapolis (IN) Fire Department (IFD). He is the coordinator of the IFD/Local 416 Peer Support Group, an IAFF-certified peer support master instructor, an FDIC International HOT instructor, and an AHA-certified BLS instructor. Dreiman is an attorney, and prior to joining the fire service he worked as deputy prosecutor in southern Indiana.
