Early on Sept. 17, as the sun rose in South Florida and morning traffic began thickening into rush-hour knots, a firefighter with a gun stood in the sand of Miami’s Hobie Beach. He was in uniform but wouldn’t make it to work that day. Just before 8 a.m., just off the busy toll road to Key Biscayne, he shot himself. Distraught colleagues flocked to the scene and draped a flag over his body before escorting him away.

Two days later, on the other side of the country, police in Lodi, CA, announced that a death previously thought suspicious had turned out to be a suicide as well. The body of retired city battalion chief Gary Duck, killed by a gunshot, had been found in a park on Sept. 6. Though no gun was located, forensics revealed his death was self-inflicted. Police speculated a passerby took the weapon.

Members of an elite fraternity of rescuers in life, Duck and his unnamed Miami counterpart became in death part of a cohort that is troublingly well-populated: emergency professionals who take their own lives. Comprehensive statistics are hard to come by, but it’s neither a new phenomenon nor much of a secret: A lot of fire, EMS and law providers kill themselves.

In Canada, as of Oct. 10, 25 first responders were known to have died by suicide in the preceding five-plus months. By the end of September, the U.S. had around 58 documented fire/EMS suicides in 2014 (likely only a fraction of the actual count, says the guy devoted to tracking them). The Chicago Fire Department saw clusters of seven in 18 months in 2008–09 and four in five months in 2010; other cities have seen clusters too. A 2012 report from the Chicago FD’s IAFF Local 2 counted 41 suicides of active and retired members between 1990–2010 and concluded its members had a suicide risk 25 times that of the wider population. In alarming data reported in October, 27%–28% of Canadian paramedics had considered ending their lives.

You won’t find paramedic or firefighter among NIOSH data on jobs most linked to suicide (though you will find other healthcare professions; physicians outpace almost everyone). But our numbers seem uncomfortably high and persistent, and in a profession fond of boasting that no brother gets left behind, we don’t do a very good job of supporting our brethren in their times of emotional and psychological vulnerability.

What Goes Into That?

The horrors public-safety providers see surely create fertile ground for the development of negative sequelae. Operational stress injuries (i.e., psychological problems that result from mental or emotional trauma) can be acute or cumulative and take a variety of forms. The worst is post-traumatic stress disorder (PTSD), but there are lesser degrees of suffering and diagnosis that affect many more.

PTSD raises a sufferer’s suicide risk, but even less-severe injuries can contribute to woes like personal anxiety and poor health, family problems, abuse of alcohol and drugs, withdrawal, depression and burnout. These can be minor and isolated or coexisting and mutually exacerbating. It’s hard to generalize. Some people will develop problems following traumatic events, some won’t. Some do but aren’t diagnosed. Everybody’s formulative experiences and coping capabilities and cracking points are different.

“There’s much more variance between individuals than there is consistency in terms of who’s affected by what,” says Lori Gray, PhD, a clinical, rehabilitation and forensic psychologist and staff psychologist for Toronto Paramedic Services. “Take a multiple-casualty incident, for example, where people might be shot. Some people might come out just fine from that incident, and others may be affected. Similarly, one individual may have responded to a call of that nature previously, but then something’s different in the dynamic on the later call, and they’re affected by the subsequent one but not the initial one. It varies a lot.”

Compounding problems that stem from the trauma in which we traffic is our frequent refusal to ask for help. We see horrible things but try to shrug them off.

“We suffer what I call cultural brainwashing,” says Jeff Dill, a captain at the Palatine Rural Fire Protection District in Illinois and licensed counselor who runs the Firefighter Behavioral Health Alliance (FBHA), a nonprofit that tracks fire/EMS suicides and works to educate responders on the mental stressors that can impact their lives. “Once we put this uniform on, we’re expected to act a certain way: Be strong. Don’t show weakness. Don’t be the weak link of the company—we can handle problems on our own.

“Then when things go wrong, either on the job or because of the things we see or what’s going on in our personal lives, we try to handle everything on our own. That can include things like stress, anxiety, depression and post-traumatic stress. We forget we’re human beings first, and it becomes quite overwhelming.”

Many departments offer resources for their providers in need, but there can also still be a stigma attached to needing them.

“I’ve seen many cases of harassment and bullying among peers who will criticize someone who seeks help,” says Vince Savoia, a former paramedic who now directs Canada’s Tema Conter Memorial Trust, which works to help that country’s public safety personnel cope with the suffering they see. “We’re all very empathetic toward our patients, but how many show empathy toward our peers? We need to understand that it’s not a weakness to ask for help. In fact, it’s a strength—asking for help is a tool that allows us to do our job more effectively.”

How Does It Happen?

Savoia knows from his own battle with PTSD. Here’s how it happened:

In 1988 he responded to the murder of Tema Conter, the young woman whose name graces the organization he went on to found. Just 25, she was murdered with unusual savagery in her Toronto apartment. Savoia and his partner found her bound, gagged and nude; she’d been raped, beaten and stabbed 11 times.

The scene was especially jarring for Savoia: Conter looked just like his fiancée. “When I pulled back the sheets to see Tema, I thought it was my fiancée who had been murdered,” he recalls. “The physical resemblance was so uncanny that my partner said aloud, ‘Oh, my God, is this your fiancée?’”

Savoia composed himself, completed his scene duties and finished his shift. Driving home was when he lost it. “I had a total breakdown in the car,” he says. “I didn’t understand what was happening—I just didn’t make the correlation between the homicide and the way I was feeling.” At home he was greeted by that same fiancée, who innocently asked, “How was your day?” He lost it again.

Persistent feelings of helplessness and guilt followed. His job became harder. They married, but problems continued. Savoia left EMS but couldn’t stop thinking about Conter. It took him years to identify what was wrong.

“I was 27 at the time and didn’t understand what I was going through,” he says now. “I didn’t seek any sort of help. Three or four weeks later I still wasn’t sleeping, I was having nightmares and flashbacks. I went through three different psychologists over 12 years, and it wasn’t until about the 12th year that I received an official diagnosis of post-traumatic stress. It was still a relatively new thing back in ’88, and associated with the military. I don’t think anybody thought about how it affected emergency responders.”

Oh, but it does. A 2001 Toronto Star article recounting Savoia’s experience reported that 87% of the city’s medics, when questioned anonymously 24 hours after emergency calls, reported some form of critical-incident stress. A 2012 study noted that Canadian paramedics have a higher PTSD rate than other emergency workers; the Trust estimates 16%–24% of its country’s medics will be diagnosed with PTSD at some point. A 2014 study in BMC Emergency Medicine found 16% of South African paramedic trainees meeting PTSD criteria. A U.K. study of emergency responders pegged the number at 22%. In the U.S. some investigators have suggested rates as high as 37%. Per the American Psychiatric Association, by comparison, the general public’s rate is around 3.6%.

Particularly associated with developing problems are calls where a responder knows or identifies with a victim, as well as very violent incidents. Savoia’s was both.

“Typically we’d look at things like larger-scale abnormal circumstances,” says Gray. “We’d look at significant death or injury to a vulnerable person such as a child; a line-of-duty death or injury—any of those factors. But we’re also looking at the individual’s level of functioning, what’s their coping, and how have they reacted?”

Savoia ultimately helped ease his mind by founding the Trust in 2001 as an honor to Conter and way to help other first responders who struggle with the things they’ve seen. Others have benefited from PTSD treatments like cognitive processing therapy. But too many still don’t get help in time to avert the unthinkable.

It’s worth reiterating that not all post-incident stress becomes PTSD, not all PTSD leads to suicide, and we can’t get inside the minds of folks like Duck and his Miami counterpart or say what torments them before their final acts. But if we’re to intervene on the behalf of colleagues at risk, it has to be earlier than too late.

How Can We Help?

The Tema Conter Memorial Trust is trying. It started with a single award—a scholarship for the best student essay on critical-incident stress—and has grown into a comprehensive clearinghouse of research, education, training and help. Its offerings include peer support and family assistance, referral services, training, resources and scholarships worth $30,000 a year. In February it will host a weeklong educational event called “Common Threads” to spotlight the latest research and trends in dealing with acute, cumulative, vicarious and post-traumatic stress. That concludes with a tribute gala featuring actor Enrico Colantoni, who represents the Trust’s “Heroes Are Human” campaign.

In the U.S., the FBHA is trying too. It tallies and investigates fire and EMS suicides and works to educate providers and raise awareness of issues like depression, addiction and stress that can build to self-harm. It offers workshops around the country and a self-screening tool for suicide risk. In August it was recognized by FEMA with a grant that will let it bring free workshops to 25 departments.

At the department level, Toronto has had a dedicated staff psychologist since the 1980s; like many services it further supports its personnel with more typical mechanisms like a peer support team and employee assistance programs. Elsewhere across North America critical incident stress management (CISM) remains common but controversial; the Trust promotes an Australian-developed alternative called MANERS Psychological First Aid. Its acronymic components: minimize exposure; acknowledge the event; normalize the experience; educate as required; restore or refer to professional help; and self-care.

Certainly CISM is an article unto itself; for our purposes let’s just say there are roles for both clinical professionals and service colleagues in addressing providers’ distress.

“What we’ve found is that a lot of departments that implement CISM don’t implement it the way it’s supposed to be implemented,” says Savoia. “A lot of organizations rely on peers to do the psychological debriefs. The way CISM was designed to be implemented, the people who should be leading those debriefs are mental health professionals—clinical psychologists. I don’t think the model is flawed; I’ve been involved in debriefs done with a clinical psychologist leading, and they’ve worked wonders. Conversely, I’ve seen debriefings blow up because the peers running them just didn’t have the clinical skills to run a psychological working group.”

The FBHA’s workshops focus among other areas on EAPs. Many departments aren’t attentive enough to these, says Dill.

“We just kind of assume things will happen, and our villages and cities and fire districts will take care of the EAPs. But we need to get involved in them,” he says. “If we want to send our people to qualified help, we have to know something about our employee assistance programs. Know the counselors—have they ever worked with firefighters or EMTs? Most EAPs are awarded through low bid. Departments need to get involved and interview these people.”

Other tips: “Create a resource list of who’s available in your community. There are some very qualified counselors that have EMS or fire service experience. And don’t forget about chaplains. Invite these counselors and chaplains to train with you, to have some ride time. These are important issues to try to get everyone on the same page to work together.”

Along with intervening post-event to stop nascent problems from worsening, there’s an increasing recent focus on stopping problems before they start. In addition to early intervention and expedited treatment access, Toronto and an increasing number of others are emphasizing prevention efforts. Beyond just awareness training, that means building skills that allow us to withstand and rebound from operational stress injuries.

“I think that’s where we’re seeing the field heading,” says Gray. “Rather than a reactive approach, it involves more proactive care and prevention to build resiliency—things such as pre-incident education and what can be done to give people more skills for the types of situations we know can be difficult. For example, we’re seeing more training around delivering bad news and death notification, which can be difficult for some individuals.”

In trying to expedite treatment, there’s also a newer scrutiny on what early symptoms might portend bigger problems down the road. Short-term personal reactions may be able to predict eventual risk.

“What we’d look at could be things such as the quality of sleep within the first couple of nights, and whether that improves or continues to worsen,” says Gray. “Another cluster of higher-risk symptoms would be what we call derealization or depersonalization—things like feeling the event is happening in slow-motion, or like you’re standing there watching it happen. Those symptoms have been associated with more long-term and significant impact.”

Resiliency, You Say?

Is it really possible to build skills and bolster defenses to prevent post-incident stress problems from occurring? In fact it may be.

A program developed for returning combat veterans has been adapted and tested successfully with emergency providers. It’s so promising that it will be incorporated into the next revision of the NAEMT’s acclaimed Safety Course.

“Our ultimate goal is to create resilient communities,” says Michael Marks, PhD, lead psychologist for the Southern Arizona VA Health Care System and a developer of the program. “We’re not going to be able to stop any natural disasters or crazy people from shooting up schools or theaters. But we can help people bounce back from those things.”

Marks and colleague Philip Callahan, PhD, a former paramedic and firefighter, initially developed a more extensive resiliency-based program to help manage stress and facilitate academic success for military members returning to college from Afghanistan and Iraq. That was successful, and they were approached about adapting the program for emergency personnel. The result was a compressed version called “First Response Resiliency.”The basic idea is that resiliency skills, bolstered by a strong social support system, can help prevent development of problems like PTSD.

The program was trialed in Aurora, Colo., with 25 responders (EMS and others) who’d had some part in the response to the notorious 2012 theater shooting. Their resiliency was tested before and after the class, and for 15 of them again six weeks later.

The results: Significant improvement from pretest to both post-test and the six-week follow-up. All but one recipient at the six-week mark reported the training improved their coping with stressful events.

The First Response Resiliency curriculum focuses on 12 skills:

• Goal setting;

• Nutrition;

• Exercise;

• Sleep;

• Relaxation;

• ABCs (activating events, beliefs and consequences);

• Perspective;

• Self-defeating thoughts;

• Empathy;

• Wins and losses;

• Reaching out; and

• Social support.

Some were addressed in class, others independently later, with an emphasis on social interaction as a means to develop the skill of social support. Not all students completed all the out-of-class work, but that didn’t appear to dampen the benefit much.

Those last two characteristics are of particular importance here. Asking for help, as noted, is something we’re not especially good at. And having a good social support system is a known protection against developing problems. The cohort-based approach promoted by both the military and emergency-services curricula builds on camaraderie.

The takeaway: Shutting up and shutting down doesn’t help. EMS providers need close confidants with whom they can share the experiences and emotions that come with their job.

“Part of where we’d like to see these resiliency trainings go, especially in the fire/EMS world, is to have the spouse there and go through the training too,” says Marks. “What all these skills really lead to is, the biggest protective factor against developing PTSD, even if you’ve been exposed to all kinds of trauma, is having a really good support system.

“Our ultimate goal is not only to have resilient families; firefighters and emergency medical providers are also in a perfect place to create resilient communities: to go out and teach these skills to kids and others through their regular community activities.”

Conclusion

If there’s a silver lining to all these recent emergency-responder deaths, it’s that there’s a lot of attention currently being paid to the issues of our job-related stress and suicide in emergency outlets and even the mainstream media. We may not all kill ourselves or develop problems, but none are immune to the risk.

“I preach in our workshops that if you’ve been on the job, EMS or fire, you suffer from some post-traumatic stress,” says Dill. “It might not be the disorder, but it will be some level of post-traumatic stress. I think it’s important to remember that whether firefighter or EMS, we’re human beings, and we developed our emotions long before we got into EMS or the fire service. We can’t just now shunt those emotions away because of the culture we live in.”

Work continues within emergency services and in the psychological community beyond to identify and improve tools to prevent and combat operational stress injuries. Our part of that, at the very least, starts with asking for help when we need it and caring for our colleagues as much as our patients.

“What we’d like to see is everybody being able to serve as a kind of peer counselor,” says Marks. “Ultimately, if everybody has certain basic resiliency skills, you can be driving back to the station and processing what happened on the run by yourselves: ‘OK, what skills do we need now to cope with this? How are you feeling?’ We could all have these skills and know how to use them on ourselves and each other.”