Suicide - A Look Into The Darkness

It is quite an honor to be asked to share my thoughts
on firefighter suicide with the readers of Firemanship. I have researched and studied suicide for the last three years, and while I don’t claim to be an expert, I can assure you that I have turned over many rocks in my quest to understand this profound human tragedy.

What I have learned is that suicide is a complicated subject for many, not just those in our profession. While researchers, experts, and clinicians are beginning to identify preventative factors and treatment methods, it is still difficult to recognize those at risk. I don’t have all the answers, and I haven’t found anybody who does.

My quest began as an action research assignment in 2015 for graduate school; the instructions were to find an area where current practices were not best practices, and research better practices.

Like many readers of this Journal, I wanted study an area of the fire service that I could improve upon, so I emailed our department’s safety officer and asked for recommendations. He asked me to research firefighter suicide. I’ll be honest; I was pretty shocked, as this is simply not a subject that was ever discussed around me or in my department. Like so many other people, I considered suicide a taboo topic and never discussed it openly.

Unbeknownst to my Safety Chief and all that knew me,
I had reached a point in life where I had become quite depressed, and suicide had crossed my mind. It had not reached a point where I made a plan for suicide, but it was to the point where the thought of suicide entered my mind often. I had become so depressed that I remember riding my road bike and having no fear of being hit by a car.

I recognized this was a problem, because typically cars that passed too closely scared the crap out of me. All of the sudden, however, my fear was gone. In my head, I felt that if it were to happen, so be it. These are the thoughts that led me to not only research firefighter suicide, but led me on a mission to understand suicide and suicide prevention.

As soon as I began researching firefighter suicide, I was shocked with what I learned. Suicide was a dark secret in the fire service and several organizations were already working to recognize the causes and prevent future suicides. In fact, in 2011, the National Fallen Firefighters Foundation (NFFF) held the first fire service suicide and depression summit.

One of the attendees, Chief Daniel DeGyrse, of the Chicago Fire Department was searching for solutions after CFD lost 7 firefighters to Suicide in an 18-month period. Another of the attendees, Captain Jeff Dill (ret), realized there was no official tracking mechanism or data available to quantifiably measure suicide in the fire service. He has since established the Firefighter Behavioral Health Alliance, http://www.ffbha.org/, an organization that tracks firefighter and EMS suicide.

Reporting to the FFBHA is completely voluntary and as a result, compliance is suspected by Dill to be around 40%. Yet, Captain Dill has validated more suicides each of the last four years than the U.S. Fire Administration has listed as line of duty deaths.

This mirrors findings from a 15-year retrospective
study conducted by Janet Savia, PhD, in 2007. She reviewed death certificates of all career firefighters in North Carolina between 1984-1999, and discovered that a firefighter was three times more likely to die by suicide than in the line of duty. What is even more alarming about this statistic is the fact that while she only looked at suicide of career firefighters, she included LODDs from both career and volunteer firefighters.

During the course of my research, I learned that firefighters have several protective factors that actually make them less likely to be at risk than the general population, but sadly, we also have quite a few risk factors that most civilians do not. Of the protective factors, positive social support from our crews is number one; and, of the risk factors, our poor sleep ranks high. One thing I have learned, though, is that somebody who is determined to complete suicide will most likely prevail. However, hope exists, because most people who desire to kill themselves at one time, will most likely feel differently after receiving help for their underlying problem.

Dr. Thomas Joiner, PhD, leading expert on suicide, lost his father to suicide while he was in graduate school nearly 30 years ago. He has since made it his mission to understand suicide and learn methods to combat what he calls a profound human tragedy.

Over the course of his work, he has found that nearly 100% of people who died by suicide had some sort of diagnosable and treatable mental health disorder at the time of their death. These people were not psychotic; they were sane, but suffering. Moreover, he indicates that at any given point, 25% of the population is suffering from some sort of mental health disorder.

Firefighters are not immune from these disorders that include, anxiety, depression, substance abuse, posttraumatic stress symptoms, posttraumatic stress disorder, and insomnia.

Often, when people think about mental health disorders, they think of psychosis, bipolar disorder, and other extreme mental health problems, and fail to account for other disorders that the general population is susceptible to.

In fact, Dr. Joiner believes that lifetime rates of mental health disorders are close to 50%. Again, firefighters are not immune, and we are more likely to suffer from certain mental health disorders such as:

• Depression

• Substance abuse

• Alcohol abuse

• Sleep disturbances
• Posttraumatic Stress Symptoms (PTSS) • Posttraumatic Stress Disorder (PTSD)

We are quick to blame firefighter suicide on Posttraumatic Stress Disorder (PTSD), and in doing so, inadvertently make the other causes more difficult to address.

Because of the long-standing stigma associated with mental health disorders and suicide, firefighters are reluctant to seek help when they find themselves suffering from any of the aforementioned. If they can’t attribute their depression, anxiety, or substance abuse to a traumatic call, they feel unworthy of seeking help.

Yet, in their review of over 2800 EAP contacts over 15 years in Chicago, Chief DeGryse found that relationship issues, substance abuse, and financial issues affected more members than did PTSS or PTSD.

In her research of firefighter suicide, Laura Willing found that, “feeling that they cannot reveal vulnerability to
their peers can lead to a sense of isolation. A sense of alienation or isolation is often a factor that contributes to suicidal intention.”

In fact, social isolation was found to be the greatest predictor of suicide. Additionally, several studies have determined that suppressing emotions or turning to maladaptive coping strategies, such as alcohol, can lead to major crisis.

Unfortunately, alcohol is the most common coping mechanism firefighters use to deal with depression and mask the signs of stress. While alcohol is often seen as a temporary fix, its use often becomes constant; as a tolerance develops, use increases. Together, alcoholism and depression have been considered as deadly as the toxic twins, CO and HCN.

Constant use of alcohol leads to several negative outcomes, such as mood disorders, loss of health, loss of supportive relationships, and diminished thinking skills. During her research, Dr. Savia discovered that alcohol and depression are comorbid and their combination leads to an increase in suicidality. When alcoholism does not lead to suicide, it can still lead to death. In 2017, the fire service lost two amazing and talented fire instructors who died while driving impaired; Ej Mascaro and PJ Johnson.

The problem surrounding suicide in the fire service is fear of showing weakness to our peers, or fear of being deemed unfit for duty. I know for me, when I was most depressed,
I ensured nobody knew. I did not want to be seen as damaged and I did not want to be referred to EAP.

Sadly, most supervisors fail to realize that having open relationships with their subordinates is more productive than referring them to EAP. The ability to open up and share struggles in a meaningful and non-judgemental way is the most productive coping strategy.

In fact, multiple studies of suicide and PTSD have all discovered that the only variables that work for everybody are mindfulness and positive social support. There are several other treatment methods that include cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and medication, yet none of these have been found to work for all people all of the time. Furthermore, mindfulness and social support are protective factors that can be established long before one is in crisis.

The two coping strategies that work for everybody are oddly two of the easiest methods, yet the ones we shy away from them the most. I personally think that through understanding the combination of the prevalence of mental health disorders among all people and the high rates of suicide in the fire service, we can see the need for a shift in our opinions of the stigma behind mental health disorders. Through understanding that meaningful social connection and positive social support can prevent suicide, we hopefully can shift to a fire service that no longer fears help seeking behavior and no longer suffers in silence.

There are hundreds of risk factors that lead to suicide.

There are simply too many to memorize in an effort to help determine who may be at risk for suicide. Fortunately, Dr. Joiner created a model that explains suicidal behavior. His model posits that while there are several risks factors that lead to suicide, they all lead to one common final pathway that all suicide decedents travel. His model contains only three variables, and removal of any of the three variables is predicted to prevent suicide.

The model suggests that suicide occurs when three factors intersect: a low sense of belonging, a perception of burdensomeness, and the capacity to engage in lethal action. Dr. Joiner has found that the easiest of these three variables to alter is the low sense of belonging.

In fact, he says, among firefighters, social support and meaningful social connection is a primary protector against suicide risk. Joiner states, “the need to belong is so powerful that, when satisfied, it can prevent suicide even when perceived burdensomeness and the acquired ability to enact lethal self-injury are in place.”

Low belongingness is easy to understand; it simply means that one feels isolated. This isolation can occur even when one is surrounded by people. Because, when you feel that you are going through something that nobody else can understand, or something you are ashamed of, it is quite easy to feel isolated. Perceived burdensomeness is the idea that one’s existence is a burden to others. It can manifest into the idea that, “my death is worth more than my life.” The word perceived is included because quite simply it is an idea that is not true, but to the person who feels like a burden, they don’t realize that it’s untrue. Dr. Joiner conducted two studies of suicide notes and found that the perception of burdensomeness was the most common expression listed.

While connecting and contributing are necessary for the will to live, no matter how badly one may want to die, they will not be able to complete suicide without the last variable, the capacity to engage in lethal action.

This variable is often the limiting factor to suicide because quite simply, one must overcome the strongest natural instinct in order to enact their own death. They must overcome their instinct to survive. The survival instinct is autonomic just like our heart and lungs. We don’t control it, it simply operates when necessary.

However, the instinct to survive can be overcome through a habituation to painful and traumatic events. With repeat exposure to pain or trauma, one can become more fearless in the face of danger. In as much, multiple suicide attempts will eventually result in a completion of suicide.

Children who were abused have a greater sense of fearlessness, and thus are more able to complete suicide. People who have experienced painful or traumatic events become fearless, and firefighters, through the nature of our work, have to develop a sense of fearlessness. Once one becomes able to engage in lethal action, it generally cannot be changed.

Thus, efforts to reduce suicide must be directed
at the other two variables, low belongingness and burdensomeness. Dr. Joiner made a few fascinating findings during his research.

For example, while on average, every day, 90 people die by suicide, after 09/11, John F. Kennedy’s assassination, and the 1980 “Miracle on Ice,” suicide rates plummeted. In fact, we saw an all time low on 09/11/2001. Only 36 people completed suicide that day, and Dr. Joiner associates this with a coming together and sense of purpose. What’s fascinating is that suicide rates dropped both during days of national celebration and tragedy.

Through this, we learn that somebody who has made the decision to die by suicide can change his or her mind through appropriate intervention. What’s more powerful to learn is that over 90% of people who made a lethal suicide attempt (ex: jumped from the Golden Gate Bridge) and survived and received treatment, never attempted suicide again.

Treating the underlying cause of suicide can be lifesaving. Moreover, 95% of people who were simply restrained before jumping from the Golden Gate Bridge, never attempted suicide again. Intervention can be lifesaving, habituation is not.

People who are suicidal cannot live their lives like I did and fear seeking help or fear being discovered. They must recognize that it’s ok to not be ok, and it’s ok to open up and seek help.

I hope to follow this article up in the next issue of Firemanship with practical advice to members and departments on preventing suicide. A start to prevention is simply understanding. My hopes are that I have laid the groundwork to this understanding.