Post -Traumatic Stress Disorder (PTSD) and firefighter suicide have unfortunately become common terminology in fire departments and police departments. Mental health studies cited PTSD and depression stemming from exposure to trauma as significant factors that contributed to the higher-than-usual suicide rates. First responders, including police officers and firefighters, are more likely to die from suicide than in the line of duty, according to a new study. In 2017, at least 103 firefighters and 140 police officers took their own lives, compared to the 93 firefighters and 129 police officers who died in the line of duty, per the Ruderman Family Foundation. Additionally, the recorded rates of suicide among first responders could be artificially low—the Firefighter Behavioral Health Alliance estimates that approximately 40% of firefighter suicides are actually reported. This could make the actual number of suicides in 2017 closer to 257—more than twice the number of firefighters who died in the line of duty. Clinical studies are finding that PTSD is associated with an elevated risk for suicidal behaviors; therefor it is important to understand the underlying mechanism linking PTSD to such suicidal behaviors.
Many fire service organizations are facing challenges of suicidal ideation and suicide. As organizations begin to look at a paradigm shift toward providing services to treat and assist firefighters to understand the significance of educating themselves to recognize signs and symptoms, it is imperative that mental wellness and health elevate to a level in which fiscal support for education and training becomes a normalcy for all fire organizations. It is no secret that first responders are reluctant to speak publicly about their mental health struggles. Although there is improvement in this dynamic it seems that there are still expressed concerns that openly addressing the topic might negatively impact their careers or their working relationships. In addition to the everyday exposure to the trauma of our jobs, we also experience personal related stress and trauma just like everyone else. There are also additional factors to consider regarding suicide and suicidal ideation among first responders such as:
• Physical injuries that include pain medications
• Emotional trauma that includes antidepressants
• Substance abuse
• Personal issues contributing to the traumatic cycle
Factors such as depression, internalized anger, self-hatred, and perceived burdensomeness have been identified as mediating factors between PTSD and suicide risk. It is therefore important to assess members not only for presence of PTSD, but also for these intermediary factors.
BACKGROUND AND SIGNIFICANCE
Post-traumatic stress can occur because of direct exposure to traumatic events whether one is a victim, witness to the event, first response professional or vicariously as off-site participants. Traumatic events can be spontaneous or planned events spawned by natural causes or by human intervention whether accidental or deliberate, but regardless of the cause people who are exposed to the events can develop symptoms of post-traumatic stress and the symptoms can either present immediately after the exposure or can accrue through consistent exposure to those types of environments and suicidal ideation can be attributed to prolonged exposure to those stressors. Human responses to exposure from such events are considered to be normal and can vary depending on the person, but prolonged exposure along with inability or unwillingness to address it can cause the symptoms to become worse over time and eventually evolve into suicidal ideation. Members of professional response agencies are consistently exposed to their fight or flight response because of the nature of their job duties and their immersion and exposure to trauma-related events on a daily basis.
In 1980 The American Psychological Association developed diagnosis and recognition for Post-Traumatic Stress Disorder as an official mental disorder classification. Post-Traumatic Stress Disorder is no longer categorized as “anxiety disorder” although anxiety is one of the symptoms. In the year 2000 the prevalence of Post-Traumatic Stress Disorder was 3.6% and 9.7% respectively in American men and women. In the year 2013 Post-Traumatic Stress Disorder is recognized as a DSM-5 diagnosis, criteria to include direct exposure to a catastrophic event involving actual or threatened death or injury (including sexual violence), indirect exposure of a loved one’s experience, and repeated exposure by either actual or electronic related means due to one’s professional responsibilities: military personnel, emergency responders, police officers and emergency health care workers. When symptoms of Post-Traumatic Stress occur during or after one’s encounter with a catastrophic event or duty-related experiences it will be important to recognize and identify the contributing factors associated with the symptoms. This also includes the perceptions and interpretations of other outside factors which may cause additional stress or create added stress such as: organizational expectations of the employees, roles and responsibilities of the responders to their organization, to their peers, and to the public. This is especially significant when the individuals are operating in environments which lack adequate leadership and direction because it generates feelings of insecurity and uncertainty, thereby compounding the symptoms of stress.
In addition to an already ripe environment for PTSD, and due to the nature of their job-related duties, firefighters and first responders are exposed to additional stresses brought about through the nature of their duties which can contribute to vicarious trauma and compassion fatigue.
Vicarious Trauma is a transformation within the self of a trauma worker which is the result of empathetic engagement with people who have or are experiencing trauma. It is actually a form of countertransference and firefighters engage in this every day.
Compassion Fatigue is also known as secondary trauma stress or STS, which is a condition characterized by a gradual lessening of compassion over time, both of these are seen most often in individuals who work directly with trauma victims, and this includes medical doctors, nurses, firefighters, paramedics, police officers, therapists and teachers.
Like visual and auditory memories of past traumatic experiences, both of the aforementioned stresses are cumulative in nature and intensify with repeated exposures as well. Individuals eventually present with signs of desensitization and outward hostility toward the people they serve which was called burnout but is now recognized as symptoms of PTSD. Front-line first responders, police officers, and medical professionals are not the only members of response organizations who are impacted by inherent stress. Emergency based dispatchers and call-takers consistently experience vicarious trauma and compassion fatigue because exposure to trauma is not only caused by physical presence but also because of visual and auditory exposure such as that which is incurred by call-takers, dispatchers, and those whose job it is to repeatedly review raw video footage and taped information from actual events.
For members of the fire service, events that are considered to have the potential of causing post-traumatic symptoms and undue stress are recognized as “critical incidents.” Examples of most notable “critical incidents” in the fire service: line of duty death, serious injury to a colleague, suicide of a colleague, responding to victims who are relatives or friends, mass casualty or multi-casualty event, traumatic events involving children, prolonged serious events with negative outcomes, events of considerable threat such as active shooter and victims are still exposed and wounded, and any event that overwhelms our ability to provide adequate services. Roles of firefighters, police officers, and emergency medical professionals have expanded in function so in addition to consistently participating in activities specific to mitigating any and all types of emergency situations, they are also expected to offer forms of consoling and accommodation in order to bring back a sense of security and normalcy to the victims who were impacted by the event. Emergency response-related providers are exposed continuously to stressful situations that will produce effects of post-traumatic stress, and when they are not engaged directly in the performance of their responsibilities such as having a day off, they are always in an emotional state of preparedness, which causes them to remain at a heightened state of hypervigilance and contributes to intensified symptoms of traumatic stress. Some individuals reach their maximum exposure rate quicker than others and that is when we witness the behavioral signs and symptoms of the accumulated stress up to and including suicidal ideation.
As a fire officer and leader, it is imperative that we understand and recognize some of the more obvious and common signs and symptoms of inherent job-related stressors that can contribute to PTSD and to accept reality of possibilities for firefighter suicidal ideation. The entire chain of command has an obligation to support and assist the members by ensuring that the member can feel comfortable and confident in expressing his or her concerns. Also important is promoting department-sponsored assistance from department psychologists, counselors, chaplains, and peer group advisors which will enhance an environment that is conducive to the member’s needs. This may include company closures, membership details or scheduling a visit from any one of the groups trained to assist with emotional wellbeing. As officers practice awareness they will get to know their members over time and will learn to embrace the member’s perception of the events that contribute to the symptoms of PTSD. Traditional thoughts that were present when we were young firefighters such as “hey get over it this is what we are trained to do,” maybe this isn’t the career for you,” or “forget about it there’s no time for tears we need to prepare for the next one” are not the sentiment now. In fact, through training and education, most organizations have developed systems which provide environments for recognition, acceptance and support of each other’s needs as they pertain to duty-related trauma. Since there is still some unwillingness of members to openly discuss and accept emotions and feelings, it is imperative that fire officers understand the reluctance of some members to objectively accept his or her emotional needs. These and other aspects of support can be accomplished by ensuring that the entire chain of command offer and support proper services and procedures for individual and group intervention. Sometimes it is enough just to hold consistent command briefings or post-incident critiques so that we can recognize and address needs of the individuals and the crew and then provide direction and support for the existing emotional wellness services available. When discussions are initiated facts and experiences will surface and further open discussion may reveal specific experiences of the event which might contribute to the development of traumatic memories leading to traumatic stress symptoms. It should transition to a more comprehensive and counselled conversation with trained members of the department’s psychologists and emotional support staff. As officers become more aware and observant in this type of engagement, they will develop skills to recognize signs and symptoms in members who are affected by trauma from specific events or the accumulation of trauma due to inherent daily stressors of their duties. In addition, it is important to encourage the members to attend and participate in educational and preventive treatment options provided by the department psychologist, chaplains or peer support teams and include yourselves.
Signs that may signal PTSD and possible suicidal ideation:
Abrupt change in work behavior – examples of this include: member who is normally detail-oriented about his or her duties suddenly becomes non-caring about the quality of his or her work, member is taking inordinate amount of time off with no apparent reason. Member is suddenly refusing to carry out assigned tasks or is argumentative about issues that do not warrant a refusal or disagreement.
Abrupt change in personal behavior – examples of this are: a member behaving or speaking in a manner contrary to his or her usual presentation, foul language, inappropriate humor, disrespect to supervisors and peers, hostility toward members of the public, lack of attention to personal hygiene.
Confusion or memory problems (amnesia in extreme cases) – examples include: member is not providing the normal level of care because he or she is forgetting proper procedural steps such as patient assessments or standard operating principles.
Feeling as if outside of oneself (detached) – examples include: member is referring to him or herself as a third-party participant during a critique of a recent incident rather than accepting of his or her role of actually being part of the incident (this is a quick one to pick up on during a post-incident critique), member is no longer participating in organized station activities such as company exercise, games for dishes or spontaneous mini-drills.
Depressed mood or anhedonia – examples include: member appears to be sad, diminished sense of self and well-being, stoic in response, past routines and activities that were once enjoyed are no longer desired, disheveled personal appearance, lacking in self-care and hygiene, lacking self-confidence, lacking self-discipline, lost pride in work ethic and continuously focuses on negative thoughts and lacks optimism.
Expresses feelings of guilt and shame – examples include: member appears to feel a sense of responsibility for the negative impact of an event or a situation, feelings of guilt or shame over outcome of an event that he or she had nothing to do with, feelings of guilt and resentment for not being able to respond and participate in particular events.
Expresses feelings of hopelessness – examples include: member expresses or insinuates that nothing he or she does is ever good enough, feels as if his or her contribution to the organization is unwanted and unappreciated, believes that their presence does not positively benefit the outcome of any response situation.
Unprovoked outbursts of anger or extreme melancholy – examples include: member is argumentative and angry over insignificant issues, angry outbursts directed at the public or peers.
Suicidal ideation – member may reference his or her death in a joking manner such as: you won’t miss me when I’m gone, or this place or my family would be better off without me. Member starts to give away what were once prized possessions, verbally makes amends for past history of events, or openly expresses a desire to harm him/herself.
PTSD is recognized as a real condition of survivors and witnesses to traumatic events and is recognized especially as a specific risk for members of the emergency service. Intermediary factors associated with PTSD include: self-hatred, high levels of depression, internal hostility and burdensomeness. Factors such as depression, internalized anger, self-hatred, and perceived burdensomeness have been identified as mediating factors between PTSD and suicide risk. It is therefore important to assess members not only for presence of PTSD, but also for these intermediary factors. Assessment and diagnosis are critical for providing the best possible intervention and treatment but more importantly each individual must be able to view themselves with objectivity that he or she is exposed to PTSD, and has a greater than average chance of accumulating some of the symptoms over the course of their careers. Officers and members of management should possess the ability to provide proper responses and support to the needs of their members. Chief Officers and Captains must create and provide an environment of trust and compassion so that the members foster a sense of security in knowing that they can openly discuss all issues regarding the exposures they encounter and that they have support resources available.
Common signals of distress are when we have unwanted or unregulated memories of past experiences to traumatic events and can include but are not limited to more prominent symptoms of PTSD:
– Bad dreams or nightmares relating to events one has witnessed, or distressing memories, images or thoughts of past events that cannot be controlled
– Physical distress such as heart pounding,body shakes, profuse sweating, hand tremors and twitches, and gastrointestinal distress when we experience triggers that remind us of past traumatic events (anxiety attack)
– Difficulty falling asleep or remaining asleep
– Hypervigilance when it is not necessary
– Easily startled by loud noises or sudden movements
– Overload of negative thoughts and outlook
– Shame that he or she is feeling emotions about the incident rather than just “shrugging it off”
– Difficulty in their marriage or other relationships, or difficulty getting along with colleagues
– Physical symptoms such as headaches,nausea, rashes, loss of coordination, and a spike in blood pressure
– Outward expression of anger toward, or loss of faith or belief in God
Subtle and less obvious signs and symptoms:
– Member appears hostile toward other members and/or toward the public
– Member forgets or refuses to follow direction and orders, is defiant toward commanding officer or senior members
– Member skips mess, inordinate time spent exercising or isolates him/herself
– Member becomes overly critical of others during routine training or over emphasizes importance of some training issues
– Hazing and practical jokes become incensed or personal and Gallo’s Humor is at a disturbing level
– Has difficulty remembering or performing basic tasks, is easily distracted, loses concentration easily
– Playing loud and angry music
Examples of more critical symptoms that require immediate attention and corrective action include:
– Excessive blood pressure, chest pain, difficulty breathing or collapse from exhaustion
– Suicidal ideation
– Mental confusion or disorientation, hallucinations, delusions and disordered thoughts
– Shock-like state or emotionally numb, exaggerated emotions or uncontrolled rage
– Extremely rapid or slurred speech
– Continuous rocking motions, facial tremors or body shakes
– Increased use of alcohol, substance abuse
Some self-assessment questions to consider:
1. Are you feeling like a burden to your family, friends, fire company or organization?
2. Do you feel the world would be a better place without you in it?
3. Have you started to isolate yourself from others in the station or at home?
4. Have you found yourself turning to alcohol or other addictive behaviors to make yourself feel better?
5. Have you or someone close to you noticed that your sleeping patterns have changed?
7. Do you find yourself thinking about or performing unnecessary risks while at a fire scene or on an emergency incident?
8. Have you found an increased or new interest in risky activities outside the firehouse?
9. Are you displaying unexplained angry emotions or have you been disciplined recently for anger towards other firefighters or the public?
10. Have you been told that “you have changed” by friends, family, fellow co-workers?
11. Does your family have a history of a suicide?
12. Do you have a history of feeling depressed?
13. Do you have feelings of hopelessness?
14. Do you feel like killing yourself?
15. Have you created plans to kill yourself?
16. Have you ever attempted to kill yourself?
If you or someone you know can answer yes to questions 11-16, please consider seeking professional assistance immediately.
About the Authors
Glenn is a retired Los Angeles City Fire Department Battalion Chief who served the City of Los Angeles for over 33 years. During his professional career he held the ranks of Firefighter, Apparatus Operator, Fire Captain I, Captain II, and Battalion Chief. As an officer he continued to endeavor into understanding the importance of leadership. He received his Doctor of Education Ed.D., from the University of Southern California (USC), and a Master of Arts in Leadership from Woodbury University. Glenn continues his lifelong passion to teach and advocate the principles of leadership, learning and performance.
John served 36 years on the Los Angeles City Fire Department and retired at the rank of Battalion Chief. During his career he held the ranks of Firefighter, Engineer, Fire Inspector, Helicopter Pilot Trainee, Captain I, Captain II, and Battalion Chief and he retained his POST certification as a Police Officer. He has earned graduate degrees in the fields of Fire Officer Leadership, Engineering and Social Work. John has established his own private practice in Nevada and is working to provide clinical psychotherapy as an LCSW in private practice. He specializes in diagnoses and treatment of post-traumatic stress in first responders.
by Dr. Glenn Miyagishima and John Potter LCSW
This document is property of Emotional Wellness for First responders L.L.C.
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