It is a grim but telling statistic that, in America, firefighters are more likely to die by their own hand than their job. Though little talked about, firefighters and EMS personnel, the people whom society counts on to handle its crises, are among the highest at-risk groups for severe depression, a kind of personal crisis. Their rates of suicide are ten times the national average. Last year, 92 firefighters and 17 EMS workers took their own lives, compared to 93 who died in the line of duty. Despite this, less than 2% of fire and EMS stations have a truly defined behavioral health program. The job is demanding, physically as well as emotionally and encountering death or violent injury is commonplace. Years of such work can take its toll on the psyche. But it is more than mere exposure. It is also a culture of machismo and expectations of superhuman endurance that has kept the mental health crisis among firefighters and EMS workers silently burning.

That’s what Jeff Dill wants to change. The former firefighter captain and licensed therapist is the founder of Firefighter Behavioral Health Alliance (FBHA), a non-profit which educates firefighters and EMS personnel on behavioral health issues. Workshops, which he gives to stations across the country, touch on topics that have long been taboo in the community: depression, PTSD, anxiety, addictions; human weakness. He shows them how to notice the warning signs, in themselves and others. Above all, he stresses the importance of asking for help. Along with such training, Dill’s group also offers support and other resources to the families of suicide victims, much of the money which comes from his workshops (in the past couple of years, they have been able to provide four educational scholarships for children of suicide victims).

A major aspect of the group’s work involves collecting data on firefighter and EMS suicides. They are currently the only organization which does so (the earliest case they’ve validated involved a fire chief in New York in 1880). Data isn’t easy to come by, and largely comes through a confidential online reporting system. A decade later, the database stands as a grim motivator for Dill. In his research, he estimates that he has spoken to over 1,100 fire and EMS workers about their general mental health, as well as 500 directly struggling with PTSD or thoughts of suicide. The knowledge collected in those interviews has shaped the seven workshops which he offers to stations.

A culture of machismo and expectations of superhuman endurance that has kept the mental health crisis among firefighters and EMS workers silently burning.

Lately, he says, demand is high. Stations typically come to him requesting training. This is a major change from the beginning, says Dill, when trying to get folks to talk about these issues was a challenge. Of his first-ever workshop, in Philadelphia, Dill recalls, “You’d have thought I had leprosy.” Now the group is expanding, hosting workshops abroad, bringing on new volunteers and even planning a cross-country tour in a camper. “Finally, people are talking about it and we’re seeing a lot more proactive action,” Dill says. “But we still have a long way to go.” We reached out to hear more.

How did you get started in all this?

I spent 26 years in the fire service in the northwest suburbs of Chicago. I retired as a fire captain. In 2007, when I was a battalion chief, I went back to school and got my masters, becoming a licensed counselor. Because of Hurricane Katrina, I wanted to work with fire and EMS personnel. Division One out of Chicago sent down numerous firefighters including ones from our department. When they came back they said, ‘We saw some horrific things Jeff. We were picking up bodies in the streets.’ They went to see their Employee Assistance Program. But E.A.P., though good people, didn’t have any clue as to what our culture is in the fire service. That’s when I decided to get my masters. In 2009, I founded Counseling Services for Firefighters to train counselors and chaplains. If you want to work with us you need to understand us. When I started receiving phone calls and emails from around the world asking if I knew anything about firefighter suicides, I said, ‘I didn’t know we had a problem’. I called all the major players in the fire service and no one kept any data. In 2011 I founded FBHA, and we are the only organization in the US that tracks and validates firefighter and EMS suicides.

When I started receiving phone calls and emails from around the world asking if I knew anything about firefighter suicides, I said, ‘I didn’t know we had a problem’.

Why is this such a prevalent issue?

We have validated 1,060 fire and EMS suicides. I travel about 130,000 air miles every year across US and Canada. I’ve spoken to well over 15,000 firefighters. With those suicides which we have validated, the number one known reason was marital and family relationships. That’s followed by depression, then medical conditions. Number four was addictions and five was diagnosed with PTSD. Are these all interactive? Absolutely.

Why are family relationships number one? Is it difficult for firefighters to sustain relationships?

It’s difficult in that we don’t tell people what we see and do. That burden is in your mind. It starts changing you. Any firefighter that says they haven’t changed because of the job is not telling you the whole truth. Because it does change you. How can it not? It is not only the things that we see and do but all that’s expected out of us, from the community, our brothers and sisters, and even history dictates how we’re supposed to act. You live it 24/7, so all the sudden, now you’re isolating at home, you bring a lot of anger home, you’re not as communicative as you should be. All of these are very detrimental to relationships.

You’ve talked before about “cultural brainwashing.” What is that?

Any firefighter that says they haven’t changed because of the job is not telling you the whole truth.

I don’t use it as a bad term. It’s just that we have always been taught to handle all of our issues on our own. ‘Don’t bother anyone else and don’t be the weak link of the company.’ When you’re battling issues, personally or professionally, and you’re not supposed to turn to anyone and handle them yourself, well, the easiest thing to do is go down to the liquor store and pick up a six-pack. Maybe you’re having night terrors and not sleeping well. Before you know it, you’re hooked. It doesn’t make us bad people. We were always just told to handle things on your own.

How dangerous is the job?

In reality, the traumatic calls are very minimal compared to the average calls: the car accidents where there’s really not a serious injury and the medical calls. In most departments, 70% are medical runs. When you start talking about tragic calls, it also depends upon the volume of calls. In some cities they run a lot of calls and they see a lot of things. But each place is different. Maybe one station has expressways going through their district and they’re seeing a lot of serious crashes. It really depends.

Looking back on your own career, what were some personal difficulties you encountered?

In 2011, my granddaughter, at 22 months, lost her right eye to cancer. I was in fire service at this time. It was a struggle and I didn’t realize it. I began to isolate. It’s amazing how it affects you and you don’t even realize it. My crew knew what had happened but I didn’t tell them how much it affected me. We had a video of her playing in the nursing station before the surgery. I would go home on my off days and watch that video on my computer, sitting in tears every night. Looking back I can’t believe, that wow, why didn’t I reach out for help? I was a battalion chief, so you’re supposed to have your men and women look up to you. Now I think it would have been a lot easier if I had just said, ‘Hey man, I’m struggling with this.’ If I am, and I’m in this business, then guess what, someone else might be too.

It’s amazing how [depression] affects you and you don’t even realize it. Looking back I can’t believe, that wow, why didn’t I reach out for help?

What are some tips for dealing with stuff?

We have our top five warning signs. Recklessness and impulsiveness. Anger’s a big one–you’ll see a lot of fire and EMS struggle with anger. Isolation is one as well. Loss of confidence in their skills and abilities, because their head’s just not in the game. And of course the last one is sleep deprivation. That’s a real huge one. The schedule, even for volunteers, is rough. You’re woken up in the middle of the night. One warning sign we’re really seeing grow among retirees is that they’ve lost their sense of humor. Humor for us in the fire service is our coping mechanism. For those retirees, that’s a big one. We tell families to watch out for that.

Have you found any regional differences in your work?

Our whole job is predicated on helping those who call for help, so where did it go wrong so that we can’t ask for help?

Absolutely. Ninety percent of our workshops are from Pennsylvania south and to the west. The northeast is a very difficult nut to crack. They’re very tight. The history of the fire service is deep. I have some great friends in New York and Boston who talk about their great-great-great-grandfather being a firefighter, their uncle, brother, etc. It’s an eye opener but we’re starting to see some movement up there as well. Because I have data on some our brothers and sisters who have taken their lives there. Other states are more open to changes. And they are making them.

What kinds of reactions have you received?

Early on no one wanted to hear about what we did. When you start talking about that people start looking at themselves; they don’t want to admit that maybe they’ve been struggling. That’s always perplexed me, though, because our whole job is predicated on helping those who call for help, so where did it go wrong so that we can’t ask for help? But it’s changing. We now have bookings through 2019 for our workshops. So you see, it’s changing.