Health & Wellness: Firefighter Suicide: Risk Factors & Warning Signs

In 2016, the Round Rock, TX, Fire Department responded to a medical call for a reported suicide. The suicide was a firefighter who was employed by another department and lived in our response district. It was evident to the responding crews that there were no life-saving measures they could provide for the deceased firefighter.

This event caused concern and discussion in the department about the chances of this happening to one of our own firefighters. If this could happen in the other department, which appeared to have all the right resources available, then how susceptible were we to a firefighter suicide of one of our own? It was possible that some of the same stressors that haunted the firefighter from the other department were affecting some of our firefighters.

National problem

Suicide is a national problem; in fact, according to the American Foundation for Suicide Prevention, it is one of the top 10 causes of death in most age groups.¹ In 2016, 75 firefighters died in the line of duty, per National Fallen Firefighters Foundation (NFFF) statistics.² The Firefighter Behavioral Health Alliance reports that 139 were reported to have died from suicide³ in the same time period, and these numbers are likely under-reported due to the stigma surrounding suicide⁴ and because of the different ways in which deaths are categorized and reported.⁵ This means that firefighters were nearly 1.5 times more likely to die from suicide than they were to die in the line of duty.

Risk factors

Someone may experience a crisis that seems overwhelming or cause them to consider suicide. The most critical period is during the first 48 hours from the onset of the crisis, and proper intervention and support may allow the crisis to recede.⁶ Firefighters who understand the risk factors of suicide and suicide indicators are better prepared to assist themselves and others. Suicide prevention is possible and consists of effective intervention and controlling risk factors. 

The risk factors that most contribute to suicides can be categorized as external stressors, mental health, demographics, past exposure to suicides, and other non-categorized risk factors. 

External stressors include:

• Relationship issues^4,7
• Job-related issues^4,7
• Financial stress⁸
• Death of a loved one⁴
• Health issues⁸
• Other adverse life events^4,7

Mental health risk factors for firefighters include:

• Post-traumatic stress or critical incident stress^9,10
• Mental illness^4,7
• Depression⁷
• Loss of hope⁷
• Loss of self-esteem¹¹
• Physical or sexual abuse¹²
• The feeling of being a burden¹³
• Intent to die⁷

Other risk factors for suicide include:

• Health issues^4,7
• Access to lethal means^4,7
• Alcohol abuse^4,7

When a firefighter suicide occurs, peers often ask if there was a sign, a signal or a hint that would have allowed intervention and prevented the suicide. Those who attempt suicide are in such pain and desperation that it affects their ability to generate alternative solutions. They are feeling so much hurt, coupled with feeling like they are a burden, and are attempting to find a solution that will end their pain.¹² Fortunately, the fire service lends itself to camaraderie and a culture where firefighters refer to each other as brothers and sisters, and consider their peers to be their second family. This culture allows for firefighters to be in the best position to identify suicide indicators and to help each other.¹⁴

Warning signs

Many people who have committed suicide had given definitive signals or indicators that they intended to commit suicide. These indicators or warning signs are a considered suicidal communication and can be in the form of verbal statements, or expressed as emotions or actions. The more of these warning signs that are present, the higher the risk of suicide. Some warning signs are more serious, serve as a stronger indicator than others, and should receive greater attention.¹⁵         

Warning signs are changes in behavior that include:

• Isolation and withdrawal^4,7
• Aggression⁴
• Difficulty sleeping⁴
• Changes in mood¹⁵
• Loss of interest in activities⁴
• Acting reckless⁴
• Anxiety⁴
• Overreacting to criticism¹⁵
• Depression⁴
• Difficulties at work¹⁵
• Discipline issues⁸
• Giving away possessions⁴
• Ending significant relationships¹⁵
• Humiliation and irritability⁴
• Loss of confidence in abilities and skills⁸
• Retirement^8,16
• Tardiness, absenteeism and poor work performance⁹
• Neglecting appearance¹⁵
• Writing a will or buying insurance¹¹
• Making funeral arrangements¹⁵

Additionally, while alcohol is a risk factor, alcohol use may also serve as a warning sign.⁴

While most of these indicators need no explanation, retirement as an indicator deserves a little more explanation. Firefighters’ memories remain long after they are no longer closely connected to their fire service support system or network—groups that firefighters have historically relied upon to help deal with the issues. The status of “inactive firefighter” gets internalized and interpreted to a status of ignored or irrelevant. It is sometimes when things start to slow down in a firefighter’s life that some of the memories begin to come back—and sometimes without warning.¹⁶ 

Verbal communications and topics that the firefighter talks about can also provide suicide indicators. These verbal indicators include:

• Statements about being a burden to others⁴
• Statements about feeling hopeless or no reason to live^4,7
• Statements about feeling trapped or being in unbearable pain⁴
• Statements about a lack of support or belief in the system⁷
• Dwelling on problems with no apparent solution⁷ 
• Lastly, the most significant suicide indicators can be in the form of a suicide plan, such as:
• Searching online for ways to commit suicide or collecting tools to commit suicide^4,7
• Tidying things up⁷
• Visiting or calling people to say goodbye⁴

The list of warning signs is very extensive. A single warning sign does not usually mean the firefighter is contemplating suicide, but a firefighter exhibiting numerous signs is at a higher risk for suicide.¹¹ The death of a loved one may seem overwhelming but can be manageable with a good support system. A firefighter who comes into work hungover one day out of the year may not be anything more than someone who went to a late party. A firefighter coming to work hungover each shift should be a concern to everyone on the crew. In this regard, it is essential to look for pattern.^8,17 Small changes in a firefighter’s behavior may be an early warning sign.⁹

Taking action

It is important that observed indicators are addressed early and often. Supervisors may be accustomed to correcting unsafe behavior problems in the fire service that are a result of lack of training, but often cringe at the task of having a difficult conversation with a firefighter who is not focused because of a personal problem.

An effective initial intervention consists of active listening, being empathetic and being non-judgmental.¹⁸ Many people avoid talking about suicide for various reasons.¹⁹ Asking a fellow firefighter if they are considering suicide, or otherwise talking about suicide, will provide a starting point for identifying solutions. To determine a firefighter’s intent on suicide, ask questions about if the firefighter has access to lethal means, if the firefighter has a plan on how to commit suicide, and if the firefighter has determined when to commit suicide.⁷ Early intervention provides the best chances of success and allows someone to get help before a point of crisis is reached.²⁰ 

The NFFF has created “ACT Now! Ask. Care. Take” as part of their efforts to support its Initiative 13: Psychological Support, which is one of the 16 Firefighter Life Safety Initiatives to reduce firefighter fatalities.²¹ Until one can attend a suicide awareness and intervention training program, firefighters can do the following for a firefighter in need⁶:

• Listen carefully
• Assess the situation sufficiently to avoid under or overreacting
• Offer friendship and understanding
• Suggest alternatives to suicide
• Suggest professional assistance
• Remove any stressful obstacles
• Validate his or her feelings: “I know that given the conditions you are against, people may consider suicide. Let’s work on some alternative options for you.”
• Remove the person who has serious suicidal tendencies from the workplace
• Call the police or bring the distressed person to a hospital, if necessary
• Do whatever is needed if a life is on the line

The NFFF suggests that the fire service should consider including suicide or mental health identification curriculum and should consider including depression screening as a part of a firefighter’s annual physical.²²

Self-check

The Firefighter Behavioral Health Alliance created a short 16 questions self-screening questionnaire for firefighters to determine how they are doing and if they need counseling or assistance.²³ At the end of the 16 yes or no questions are specific recommendations based on the answers. Visit ffbha.org for the survey, and do a personal mental check-up for yourself, and follow the recommendations. It may just save your life.  

References

1. American Foundation for Suicide Prevention. “Suicide: Texas 2017 Facts & Figures.” 2017. https://afsp.org/about-suicide/state-fact-sheets/#Texas.

2. National Fallen Firefighters Foundation. “Fallen Firefighters.” 2017. www.firehero.org/fallen-firefighters.

3. Dill, J. “What are these numbers?” 2017. Firefighter Behavioral Health Alliance. www.ffbha.org/what-are-these-numbers.

4. American Foundation for Suicide Prevention. “Risk Factors and Warning Signs.” 2017a. https://afsp.org/about-suicide/risk-factors-and-warning-signs.

5. Gist, Taylor, & Raak. “Suicide Surveillance, Prevention, and Intervention Measures for the US Fire Service” (white paper). 2011. www.everyonegoeshome.com/wp-content/uploads/2014/04/suicide_whitepaper.pdf.

6. Mitchell, J. T. “Medic Suicide. What Can be Done?” 1995. JEMS, 41–45.

7. World Health Organization. “Preventing Suicide. A Resource for Police, Firefighters, and Other First Line Responders.” 2009. Geneva, Switzerland.

8. Sivak, C. “Why Firefighters Take Their Own Lives.” 2016. Fire Chief. http://online.fliphtml5.com/jncs/vsfx/#p=7.

9. LeDuc, T. “Safety & Health Week 2013 Focuses on Firefighter Behavioral Health.” 2013. FireRescue. www.firerescuemagazine.com/articles/print/volume-8/issue-5/firefighter-safety-and-health/safety-health-week-2013-focuses-on-firefighter-behavioral-health.html.

10. Fire Chief. “Firefighter Suicide: 3 Things to Know and 3 Places to Get Help.” 2016.

11. Mitchell, J. T. “By Their Own Hand.” 1987. Chief Fire Executive, 48–59.

12. Harkavy-Friedman, J. “Ask Dr. Jill: The Connection Between Mental Health and Suicide.” 2017. https://afsp.org/ask-dr-jill-connection-mental-suicide.

13. Henderson, S., Leduc, T., Couwels, J., & Van Hasselt, V.B. “Firefighter Suicide: The Need to Examine Cultural Change.” 2015. Fire Engineering, 71–73.

14. Fennell, F. “Beyond the Yellow Bring Road.” 2013. FireRescue, 46-48.

15. Rawles, P. “Not Without Warning.” 2003. Fire Chief, 42–47.

16. Kenny, P. J. “There is no Such Thing as an Ex-Firefighter! Reaching Out to Retirees.” 2015. Fire Engineering, 81–84.

17. Willing, L. “The Fire Chief’s Role in Firefighter Mental Health.” 2016. Fire Chief, 15–17.

18. McDowell, A. E. “Confronting Behavioral Health Issues in the Firehouse.” 2013. FireRescue. www.firerescuemagazine.com/articles/print/volume-8/issue-8/firefighter-safety-and-health/confronting-behavioral-health-issues-in-the-firehouse.html.

19. Antonellis, P. J. & Thompson, D. “A Firefighter’s Silent Killer: Suicide.” 2012. Fire Engineering, 69–76.

20. Greenstein, L. “Opening up to Others About Your Mental Health.” 2017. www.afsp.org/opening-others-mental-health.

21. National Fallen Firefighters Foundation. “Firefighter Life Safety Initiatives.” 2017b. www.everyonegoeshome.com/16-initiatives/13-psychological-support.

22. National Fallen Firefighters Foundation. “Suicide: What You Need to Know. A Guide for Fire Chiefs.” 2013. www.everyonegoeshome.com/wp-content/uploads/sites/2/2014/01/SuicideGuide_Chiefs.pdf.

23. Firefighter Behavioral Health Alliance. “Firefighter/EMT Suicide Screening.” 2011. www.ffbha.org/resources/suicide-questionnaire.