Suicide. The very mention of the word creates uneasiness, fear and bewilderment for most individuals. The stigma and tragedy associated with suicide makes it one of those life events that we hope never happens to us, so we avoid learning about it and preparing for its occurrence.

Unfortunately, most fire departments also avoid the topic. We hate to think about even the possibility that one of our own might decide to take his or her life. Such a thought contradicts the very essence of what it takes to be a firefighter: courage, resilience, self-sacrifice, confidence and the ability to handle the most difficult situations.

In public safety literature, this subject is discussed mainly within the context of law enforcement professionals. Therefore, it's not surprising that the prevalence rate of suicide among firefighters is unknown. However, it's a subject that the fire service can't afford to avoid. A firefighter's suicide strikes at the very core value of the profession — teamwork — and despite the lack of research, many will agree that when a fire department experiences this tragedy, its impact can be emotionally and mentally debilitating for the personnel who are left behind to grieve.

Risk factors

Suicide, which is defined as intentional self-harm, is the 11th leading cause of death among Americans. The group that is most likely to die from suicide is white males, who account for 72% of all completed suicides. White males and females combined account for 90% of all suicides. Suicide is the second leading cause of death among white males ages 20 to 34, the fourth leading cause of death among white males between 35 to 44 and the fifth leading cause of death among white males ages 45 to 54. White males age 65 and over have the highest rate of completed suicides because they tend to use more lethal methods, and while it still is not a leading cause of death in this age group, it's increasing at alarming rates.

Non-demographic risk factors for suicide include alcohol abuse, mental illness, stressors, divorce or separation, and the presence of a firearm in the home. Of those who completed suicide, 70% to 80% were suffering from alcohol abuse and a mood disorder, such as major depression, bipolar disorder or dysthymia; 40% to 60% were intoxicated at the time of death; 60% previously had a mood disorder; and 56% used a firearm to carry out the suicide. The greater number of stressors result in higher suicide risk; the number of stressors exhibited is more important than the nature of the stressor. Finally, some studies have shown that the risk increases if the individual recently has divorced or separated from his or her spouse.

Demographic coincidences

One can't help but notice that the population group most likely to commit suicide mirrors the population of the fire service. Approximately 98% of firefighters are males, the vast majority are white, and fire departments are composed of all of the age groups in which suicide is a leading cause of death. Of the non-demographic risk factors, divorce, exposure to traumatic events and numerous stressors are associated directly with the occupation of firefighting. Studies involving firefighters have found a causal relationship between the occupation's high stress level and depressed mood.

Furthermore, fire service culture creates a strong potential for alcohol abuse and the presence of a firearm in the home. Social scientists have found a strong relationship between exposure to traumatic events and alcohol problems. Also, among some fire service professionals the cultural norm of heavy alcohol consumption during off-duty gatherings still is adhered to, along with the ownership of firearms.

It's said that every completed suicide results in a significant, negative impact on a minimum of six people. In the case of firefighter suicide, however, the camaraderie and teamwork significantly increases the number of people negatively affected. As most firefighters will attest, they are trained from their first day of the academy to look to each other first for assistance and to never leave or abandon their crew no matter what, and that action or inaction can determine the fate of other firefighters.

Therefore, for some a co-worker's suicide translates into a personal failure to take care of a fellow firefighter, which can result in guilt, shame and anger. The severity of these reactions will depend on how well the tragedy is managed by fire chiefs and their senior staff in terms of providing guidance, support and mental health services for bereaved firefighters.

Warning signs

The many similarities between fire service demographics and its occupational norms to suicide risk groups and factors suggest a greater potential for firefighter suicide. Therefore, departments should take a closer look at this topic and insist that commanding officers receive training to appropriately identify and assist suicidal members.

It's a myth that suicide happens without warning. The majority of those who commit suicide give definite signals of their intentions. These warning signs and clues are called suicidal communications and will be in the form of statements, expressed emotions or actions. In general, the more warning signs a person displays, the greater the risk for suicide.

However, some warning signs are stronger indicators than others and are given greater priority. Some action-oriented warning signs include having difficulties at work or changing work habits, neglecting appearance, losing interest in activities, dropping out of activities, relapsing into drug or alcohol use after a period of recovery, displaying anger and rage, giving away possessions, making final or funeral arrangements, ending significant relationships, improving in mood suddenly, having a suicide plan, overreacting to criticism, self-imposing isolation from others, being overly self-critical, collecting means or tools to commit suicide, and taking unnecessary risks beyond acceptable safety standards in the fire service.

Emotional warning signs include feeling depressed, hopeless, helpless, pessimistic about life and the future, meaningless, restless, agitated, and preoccupied with failures. Warning statements can be direct or indirect. Indirect statements include, “My family would be better off without me,” “I'm tired of life,” or “Take this [belonging]. I won't be needing it anymore.” Direct statements include, “I wish I were dead,” “I'm going to end it all” or “I'm going to commit suicide.”

While the large amount of time firefighters spend together at the fire station and the close-knit nature of the environment provide opportunity to recognize personnel who may be suicidal and prevent such a tragedy, it's very unlikely that a firefighter will seek help openly if he is having suicidal thoughts. Although some progress has been made, emotional problems still are associated with personal weakness in the fire service culture. Firefighters experiencing such problems often are embarrassed or afraid of being perceived as unable to handle personal affairs. Unfortunately, such cultural norms deter members from seeking help. These firefighters may fear negative repercussions concerning promotion and duty assignments and believe that no one will help.

Department outreach

There's a general lack of knowledge among commanding officers regarding helping resources. Consequently, the basic goals of a suicide prevention and intervention should consist of identifying at-risk firefighters and providing them with support and assistance. The program must remove the stigma and fear of seeking help. It also must instill in its commanding officers confidence in their ability to handle such a situation and provide them with a concise, effective strategy for helping a firefighter experiencing a suicidal crisis.

One option to achieve these objectives is the QPR suicide prevention/intervention model. Designed for non — mental health professionals and commonly used in law enforcement, the model suggests basic training in suicide awareness, the warning signs and the three basic intervention steps:

1. Questioning the meaning of warning signs or suicidal communications,

2. Persuading the person to accept help and

3. Referring the person to an appropriate mental health professional.

Making such training routine for commanding officers sends a clear message to personnel that seeking help is not a sign of weakness, that the department is concerned about the emotional well-being of its members and that such problems should not be ignored. More information about the QPR program can be obtained at www.qprinstitute.com.

Another option for fire departments simply is having a mental health professional conduct a basic suicide prevention training program. Whichever option is selected, fire departments will need to have policy and procedures in place that outline the appropriate steps for ensuring confidentiality, notifying superiors and making mental health referrals.

Conducting interventions

Contrary to the myth, talking about suicide will not cause a person to attempt it. If a commanding officer suspects a firefighter might be at risk for suicide, the officer should communicate those concerns to that firefighter. During the conversation, the commanding officer should ask the firefighter directly, “Are you thinking about committing suicide?”

If the answer is yes, the commanding officer should ask the firefighter if he has a plan and the means for carrying out the plan. For example, if the firefighter states he intends to shoot himself, ask if he owns or has access to a gun. Don't leave him alone and immediately make arrangements for him to see a mental health professional. Also make arrangements for him to be released to the care of a family member or significant other. Never allow a suicidal firefighter to just leave with a promise that he is not going to hurt himself.

Some things commanding officers should not do if a firefighter acknowledges that he is thinking about suicide are lecture, place blame or criticize. Although to you these problems do not appear distressing enough to warrant suicide, they are to the distressed firefighter. Don't debate the pros and cons of suicide, nor discredit suicidal ideas. Finally, don't be fooled by the firefighter telling you the crisis has passed.

Emotional aftermath

In the unfortunate event that a firefighter attempts or completes suicide, departments must be prepared to manage the reactions. Often relatives are members of the same department, so it's very likely that some personnel will experience the event as both a co-worker and survivor. It's also possible that firefighters may find themselves in the difficult situation of responding to and providing emergency medical care for their co-worker. These situations present greater challenges to recovery.

Therefore, fire departments must ensure commanding officers have a general awareness of common reactions to a co-worker's suicide, common survivor's responses, strategies for helping bereaved co-workers, and hindrances and aids to survivors' recovery. If a fire department underestimates the impact of a co-worker's death, it may provide inadequate and inappropriate response, which can be quite costly as an employer.

Some of the common reactions to a co-worker's suicide include shock or disbelief, anger, and guilt. The shock or disbelief may be expressed by work absenteeism, dazed withdrawal or violent outburst. The anger may be directed at other co-workers, management or the dead firefighter. This can involve surviving firefighters expressing anger that the deceased firefighter did not let them know how desperate he was and how much he was hurting, or anger at commanding officers' or other firefighters' inability to prevent the suicide.

The guilt may be over things that surviving firefighters may or may not have done or said to the deceased firefighter. Sometimes the guilt is associated with regret regarding inadequate concern or care for the deceased firefighter. This inadequacy can be the result of the teasing, joking environment that still exists in many fire departments, which sometimes can be quite harsh. This may leave many firefighters struggling with tremendous guilt and regret.

If a co-worker is a relative of the deceased firefighter, he or she also will most likely be experiencing survivor grief responses. Some of the common survivor grief responses are mental lapses, a lack of or decrease in energy, inability to make decisions, inability to concentrate, and anxiety. All of this is further complicated by the professional expectation that bereaved firefighters will continue to function in a professional and proficient manner.

Support groups

There are several actions that fire departments can take to help bereaved firefighters. Assemble a meeting of the senior staff to clarify the facts and allow them to express their feelings. This information should be disseminated to commanding officers, and similar meetings should be held with their crews.

Firefighters who ask should be allowed time off for the funeral or memorial service. This may require some additional logistical coordination with neighboring departments to fill in at stations if numerous firefighters make this request.

Departments also should be aware that some bereaved firefighters might require more time off than others or more than departmental policy allows. These situations will require flexibility and creativity on the part of commanding officers and senior staff in meeting this need. Additionally, printed informational pamphlets concerning grief and suicide survivors should be available for firefighters who want it. Likewise, referral information to community agencies and mental health professionals should be available.

Finally, the department should be prepared to offer critical-incident stress debriefing. These steps will help to prevent the actions that hinder survivors of suicide from healing. Some of these actions include denying that suicide was the cause of death, rushing people through the grieving process, placing blame, and using alcohol or drugs as a coping strategy.

Conversely, if a firefighter attempts suicide and, after appropriate mental health interventions, is found fit to return to duty, a fire department must take steps to ease that individual's return to the workplace. These include safeguarding confidentiality while managing rumor control; ensuring other personnel understand that gossip, off-colored jokes and insinuations are not appropriate; providing an atmosphere in which the individual can openly talk about his or her attempt if they choose to; and modifying a duty assignment.

The similarities between fire service demographics and suicide risk groups should raise some concern. Denying that it could ever happen to your department does a disservice to suffering firefighters and often to those who are left behind to grieve.

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Portia Rawles serves as an assistant professor in the Doctor of Psychology program at Regent University in Virginia Beach, Va. Prior to becoming a licensed clinical psychologist, Rawles served 13 years with Norfolk (Va.) Fire and Paramedical Services, now Norfolk Fire and Rescue. She retired as a captain. Rawles continues to serve locally on the regional CISM team and consults with public safety agencies. Write to her at Regent University, School of Psychology and Counseling, 1000 University Drive, CRB 215, Virginia Beach, Va., 23464; or e-mail portraw@regent.edu.