It is difficult for a fire chief to acknowledge and seek help for his or her own mental health issues. Recognizing those issues in department members is a completely different, yet equally difficult, matter.

Susan Wilkie has been a practicing therapist for nearly 20 years, more than half of that time spent with firefighters. This has given her a pretty significant case load when it comes to firefighter mental health. She says that studies show that 37% of firefighters exhibit signs of post-traumatic stress syndrome.

“The difference between trauma and stress is that stress goes away the minute the situation ends, trauma doesn't — trauma stays,” she says. Trauma is an anxiety disorder in the mood disorder family and linked to biochemical shifts in the body. And like other medical conditions, such as a tumor or gangrene, anxiety left untreated gets progressively worse.

“Some people don't have the same biochemical resilience,” Wilkie says. “So after a stressor, their biochemistry doesn't bounce back. After 10 years of untreated depression and anxiety, that's tough, versus dealing with it when it first happens.”

The fire service culture often serves as a barrier to getting that help early on. The belief persists that admitting to mental health problems is akin to admitting to weakness. “In the culture of courage, bravery and heroics there is no room for fear and falling apart,” she says. “Another problem is that most firefighters are men, and men generally are more apprehensive and cynical than women when it comes to mental health.”

This is especially dangerous because of the high risk and high consequence of mental health problems for those in the fire service. Post-traumatic stress left untreated will have detrimental affects on a firefighter's home life and job performance. In many cases, it leads to suicide attempts, Wilkie says.

People want to think mental health is something that is in their control, Wilkie says. “They think they can't get in the shape of the guy in the hospital who wants to kill himself because it is all choice and within their control. But it is not.” She likens mental health to having fair skin. Wearing hats, sun block and being careful to cover up can reduce the risk of skin cancer. “We don't know which firefighters have fair skin and which don't. But we do know that all of them are living on the equator.”

And while the fire service may be a bit behind the general population in willingness to deal with mental health, the issue is largely societal. A major problem is that mental health is not as measurable as other medical conditions in terms of severity or recovery. There's also the perception that people will fake mental health problems to game the system.

“If a guy falls off of a ladder and hurts his back, it is so much easier for him to get disability,” Wilkie says. “This is invisible.”

One of Wilkie's patients was a 16-year veteran who was so overcome by post-traumatic stress that he lost his job, got divorced and attempted suicide. The man had to fight to get his disability pay and full pension. Will someone really go to that extreme to get disability pay, she asks?

The solution, as Wilkie sees it, is to make mental health as much a part of normal department operations as physical health. It is not enough to offer “if you need it, it is here” mental health services because given the prevailing culture, few will step forward for the services, she says. It also is not enough to sweep in with a team of therapists after a single traumatic event. There needs to be mandatory, preventive measures in place.

She recommends contracting with a therapist and requiring all firefighters have one-hour monthly sessions. After a few of these, it will become clear which firefighters need more attention and which need less. The cost of such a program would vary depending on the size of the department, insurance coverage and therapist fees. Wilkie says the going rate for a therapist with a Ph.D. is about $100 per hour — 50 firefighters each meeting one hour per month would cost $60,000 per year.

It may be difficult for a chief to spot indications of mental health problems in his or her personnel. Some signs to look for include increased substance abuse, marital problems and being withdrawn. Another telling sign is if someone overreacts to otherwise normal situations. A firefighter may react in a very angry or aggressive way to a situation that that person had dealt with 1,000 times before, she says.

If a chief suspects such problems exist, Wilkie says, he or she needs to address it with the firefighter. “Absolutely approach them,” she says. “It is always the biggest risk of regret and the biggest mistake not to say anything. You are not going to give someone an idea [such as harming himself] that he did not already have.”

Approaching those people is important, but so too is having a place for them to get help. If no preventive model exists, the chief needs someone trusted to send troubled firefighters to see. It also is important for the chief to talk about mental health in the course of routine business to erase the idea that it should be a hidden, shameful thing.

“Maybe you have to get the chief into therapy first,” Wilkie says.