Dr. Brandy Benson, PsyD, is a licensed clinical psychologist and the owner of Tampa Bay Psychology Associates in Clearwater, Florida. She specializes in the behavioral health and wellness of first responders and her clientele ranges between law enforcement, fire rescue, emergency medical personnel, dispatchers, federal agents and their family members.

Dr. Benson’s areas of service include crisis intervention, trauma therapy, and Employee Assistance Program (EAP) development and provision. She also specializes in fitness-for-duty, pre-employment, post-incident, and psychological clearance evaluations. Most recently, Dr. Benson has been hired by several agencies to assist with consultation and development of Officer Wellness and Safety programs to support increased utilization of mental health services by employees, as well as overall resiliency and prevention efforts of PTSD, Suicide, and other psychological conditions impacting the first responder communities.

Welcome to our Community Education Series, hosted by the IAFF Center of Excellence for Behavioral Health Treatment and Recovery.

Kelly:
Hello and welcome. It is 12 P.M. eastern time, so we are going to go ahead and get started. Thank you all so much for joining us. I see we’ve already got about 140 people on, so we’re really excited about that. For those of you who might be joining us again, you might know our team here, but if you are new, we are so glad you’re here. My name is Kelly Savage. I’m one of the community outreach directors for the IAFF Center of Excellence. My co-director, Myrrhanda Jones, is joining us from Alaska. Myrrhanda’s joining from the super-west coast; it’s a little earlier for her, but she’s a trooper. Makes it through to join us all the way from nearly Russia. 

So, a few housekeeping items before we go ahead and get started. For those of you who might not be as familiar with the IAFF Center of Excellence, we are an inpatient treatment center that is dually licensed for mental health and substance use treatment. We are exclusive to members of the International Association of Fire Fighters, so that is what we do on campus. We treat firefighters, paramedics and dispatchers, and have seen about 1,400 members in the last three-and-a-half years. So, this is our life’s work, and we’re so passionate about it. Part of that is providing education to the fire service community and beyond on really important topics. September, as many of you may know, is suicide prevention month. So, no time like today to cover a very important topic, being suicide in the fire service. 

Before we get started and introduce our speaker, just wanted to review a few things for participation. I see many of you have already kicked off the chat. You guys know the drill, thank you so much. We’d love to know where you’re joining us from. We’ve had people from pretty much every state in America, Canada, Africa. I think the Netherlands was on here a few weeks ago, so it’s really neat to see where everyone’s coming in from. And we appreciate you all joining us from all sorts of different time zones. You will also find, at the bottom of your screen, a Q and A box. We would love to take your questions. We’re going to make some time, I think, a little bit during the presentation and then also afterwards. So, if you have questions, please drop them in the Q and A box. We would love to address them. 

Do not put them in the chat because as you can see right now, it moves really quickly. We don’t want to miss anything, and it helps to stay organized if you drop those questions in the Q and A so we can make sure we get to them. So, before I turn it over to my lovely colleague Molly, our clinical coordinator at the Center of Excellence, we’re going to do a poll to see everybody’s primary role. Now, I know many people have multiple roles, but for the purposes of this training, we’re interested to know what your relationship is to the fire service. So, take a look at that poll. Please chime in. And as you participate, I’m going to turn it over to Molly to introduce herself and our speaker for today.

Molly:
Thanks, Kelly, and thank you all for joining us today. I am the clinical outreach coordinator for the Center of Excellence, as Kelly mentioned. I’m also a social worker. So, I received my master’s in social work from the University of Oklahoma and have since moved out to Colorado and did some direct practice work. Moved into this role and feel really grateful to be here with you all today. Part of my role as the clinical outreach coordinator is to bring education to the community like what we’re doing today, but also bringing it to unions, fire departments, other treatment providers, just trying to increase awareness around the behavioral health issues that are most prevalent in this community. And figure out ways that we can combat things like stigma and normalize what fire service members tend to go through just because of the nature of their job. So, that’s a really cool thing that I get to do. 

And then I also do outreach with other treatment providers to, quote unquote, “vet them” and make sure that they are culturally aware of the fire service and understand different intricacies of this population. That they know what comes with the job, like shift work and sleep deprivation, and just kind of some things that you really can’t get around in this line of work. Then also, of course, making sure that they are effective in their treatment of trauma and can really provide some different approaches to treatment to be able to serve the whole person and get fire service members back to the level of functioning that they hope to be at. Through that outreach, I had the privilege of meeting our guest speaker today, Dr. Benson. And Dr. Benson is a licensed clinical psychologist and the owner of Tampa Bay Psychology Associates in Clearwater, Florida. 

She specializes in the behavioral health and wellness of first responders, and her clientele ranges between law enforcement, fire rescue, emergency medical personnel, dispatchers, federal agents and their family members. So, she definitely sees a wide array of different types of folks. Her areas of service include crisis intervention, trauma therapy and employee assistant program development and provision. She also specializes in the fitness for duty pre-employment posts, incident and psychological clearance evaluations, and most recently, Dr. Benson has been hired by several agencies to assist with consultation and development of officer wellness and safety programs to support increased utilization of mental health services by employees, as well as overall resiliency and prevention efforts for PTSD, suicide and other psychological conditions impacting the first responder communities. Needless to say, she’s a busy gal, but we are super excited to have her on with us today. I’m gonna toss it over to Kelly real quick. She’s going to review this poll and then Dr. Benson will go ahead and get started. Awesome. 

Kelly:
I think everyone can see the results of the poll. So, I’m really excited to have 80 fire service members here. Good, really good number of doctors and clinicians, some health care professionals, administrators, chaplains — a little bit of everything. So definitely, I think we’re seeing 53% of firefighters and paramedics, but we’ve got a great, diverse group today. We really appreciate you all being here and participating. And without further ado, we will let Dr. Benson take it away. 

Dr. Benson:
Thanks, ladies. Hi, I hope everyone’s doing well. This is a little different for me to do trainings. I’m one of those people that really thrives off of interacting with people and actually being immersed with my participants, so I appreciate you guys indulging me and doing a webinar. It is definitely a learning curve. I keep looking over at the screen ‘cause the only face I see is mine and I’m trying to, like, connect with human beings. So, looking at my slides, which I’ve already shared with you guys — and one of my fellow associates helped me develop these slides, Dr. Kristin Klimley, so you’ll see her name on there. Yes, Molly gave me a very generous introduction, but in brief and not to detract too much time from what we’re going to talk about today. 

Just to give you a little synopsis of who I am and why I do this and why I’m so passionate about this field: Yes, I am a clinical psychologist, and from the inception of my education, I have worked with first responders. Admittedly, my career started with law enforcement, but obviously that’s just such a natural segue to get into fire, EMT and then other public safety professions. Part of me just fell into this role and there was something about working with this group of people. Not only was there a great personality match, and I think that’s so critical and I am going to get to that at some point. That personality match being a sense of humor, a sense of levity. Also, the ability to take on serious concepts without being too emotionally distraught by them. Being able to have that organic sort of flexibility that you need. Also too, I’ve just really noticed with both law enforcement and firefighters that they are dramatically misunderstood.

Where we think of classic mental health disorders, such as PTSD, depression, anxiety, panic attacks, we have a certain model that comes up for us. And yet, those models never apply neatly to our first responders. Particularly — let’s go with just firefighters because that’s who we’re focusing on today. Those don’t neatly apply. Depression looks totally different among firefighters than it does the average individual in society. And more to the point, suicide. Suicide also is an extremely dynamic process when we talk about first responders. So, when Molly and Kelly approached me about what sort of training we can do, I, of course, have done many of the other ones that a lot of other mental health professionals have done that are competent with this particular group. You know, PTSD or other peer support, peer support trainings or other behavioral measures. And the one thing that I’ve noticed has been super helpful is really to have a discussion about suicide and how it presents really uniquely. 

Given that poll, I am very much going to try and cater my examples in our discussions to you guys and who you are. So, like our 80-plus participants that are actually firefighters EMTs. If you guys are part of peer support teams, or if you’re just here to get this additional knowledge to support your brothers and sisters in the service, then this is going to help you know how to ask certain questions or look for certain protective factors, look for risk factors, warning signs, or just understand the idea of suicide a little better when it comes specifically to firefighters. And then for those of you that are clinicians in this training, most of you have already been trained on how to do a formal suicide risk assessment. For all participants, a suicide risk assessment is actually a clinical tool. It is something that we document as an actual test that’s billable by insurance. It is a clinical service that is being rendered. So, we want to make sure that if you’re not a clinician, you’re not practicing outside your realm, but you can at least incorporate the education to be able to assess and know when to refer someone to more intense treatment or just to get additional help. 

For those of you that are clinicians, I do think a lot of you are going to see that a lot of this is overlapping, but hopefully I can provide some examples that really emphasize, again, why suicide in the fire service is a little bit more dynamic and not as cut and dry and also not typical for what we see with average civilians. I will be taking little check-in breaks with Molly; Molly’s going to be looking at the question board. I would rather do those check-ins for questions along the way, just ‘cause I want to make sure that if someone does have a question that relates to a particular topic that I’m discussing in real-time — that allows me to have a little more interaction with you guys. So, feel free to put those in there and I’ll try and answer those along the way, as opposed to all at the end so that we’re not losing track of information. So, cool. And I am learning how to share my slides. 

Okay, so I think most of this is going to be a review, or at least it’s information that you guys have seen before because a lot of this information does get repeated and cycled around across presenters. But in order for us to talk about suicide, we do need to understand national statistics. So, this is including everybody — not just our fire service, which is more unique. We do tend to see an average of 110 suicides per day. That’s a lot, right? That’s a lot. That’s across the nation, the continental United States. And also Hawaii and Alaska, forgive me — so, all of the United States. Most of them are by use of firearms. However, we are starting to see a trend where suicides are including other modalities, so we’re not seeing this predominant focus on firearms. But for all intents and purposes, when it does come to the fire service, firearms still is the predominant method of suicide. So, that is important to keep in mind when we talk about risk factors or how to protect people, how to intervene. 

So again, when it comes to national, we are starting to see other methodologies come into play. In the fire service, firearms still tend to be the predominant method. Pills is the secondary method, so keep that in mind. We are still seeing that men tend to have higher rates of successful suicide than females. Importantly, though, females tend to statistically have more frequent suicidal ideation. Now, what’s also important to know is that females also tend to be more inclined to seek out treatment. So, that’s a good thing, right? That’s one of those protective factors that we will talk about at some point — that although females report suicidal ideation at a higher level than men do, they are also more inclined to go seek treatment to address those issues. Now, one of the reasons that females might have more frequent suicidal thoughts than men, one hypothesis is whether or not men are actually reporting it because of stigma or this machismo or other reasons that might be withholding their actual candidate report. 

We do see that out of all ethnicities, white individuals or members of the white membership tend to have the highest rates of suicide. We also see that depression is most commonly associated with suicide. So, we do tend to see that. Now, amongst the fire service, alcoholism and PTSD are other diagnoses that we have to consider and look at. So, the rates of suicide in conjunction with PTSD is upwards of like 25% to 30%. And then certainly when it comes to alcoholism and suicides, we’re seeing about the 20% mark as well. Some interesting facts just to really kind of hone this in — if these are the national statistics, how does this relate specifically to the fire service? And we are seeing an increase in suicides among the fire service over time, and I think that’s why a lot of you are here. Unfortunately, research is still in its novice stage. So, we do have a lot of dedication to, let’s say, law enforcement suicide — the IAFF and National Fallen Firefighters Foundation. 

A lot of other organizations are starting to dedicate more efforts and research into looking at what’s the actual number, but it’s still just — it’s not always conjecture, but they’re still not always accurately reported. There are still instances where suicides are being concealed or not disclosed for a variety of reasons. So, just to kind of give you the impact, suicides have raised — the last figures that I had, and these might be a little dated, but they’re the last that I’ve looked at in terms of published research — in 2013, there were 69 suicides in the fire service. And then it raised 112 in 2014 and then 117 in 2015. So, we’re just seeing this giant trend. Certainly, we do also see that there are other agencies that are really starting to experience the significant impacts of suicide. Good example: The Phoenix, Arizona, fire department had four firefighters commit suicide in a span of seven months. And the Chicago fire department — they had, in the span of 18 months, seven suicides. 

Now, some things to keep in mind when we talk about those figures is, obviously, Chicago is a highly populated area. So, we might see a higher figure happening because they have more employees. But more to the point, what you have to keep in mind is that we’re having suicides occur in a tiny population of people, which is a fire department. So, regardless of how many employees they have, we are seeing that there’s a phenomenon happening where individuals are taking their own lives. And again, just for all to kind of, like, make the point of how serious this is: Firefighters are four times more likely to die by suicide than a line of duty death. 

When I go into departments, I love to tell that statistic, not because it’s all positive or uplifting, but really, what I like to point out is that cities invest so much money to keeping our firefighters and emergency medical personnel safe. We invest millions of dollars so their risk of physical harm is dramatically reduced. It doesn’t mean that the job doesn’t take a physical wear and tear on the body over time. Like, obviously, sleep deprivation does affect the heart, smoke inhalation, or also just muscle aches and muscle pains. So, the job does take its toll, but in terms of a line of duty death or the risk of that, we invest so much money to protect them physically, but we’re not investing a lot of money to protect our people mentally and emotionally. And the psychological risk that is posed to our firefighters is significantly greater, such that they’re now four times more likely to die by suicide than they are in the line of duty. So, that’s just a really kind of sobering thought to hold on to. 

So now, specific to firefighters, let’s talk about how serious this scope is. Over a career, 49% of fighter firefighters admit that they have experienced suicidal ideation. That’s insane. That means half of our firefighters at any point in their career, even if it was just once, has actually thought about, “Hmm, what would it be like if I wasn’t here anymore?” Or maybe they’ve actually gone a step further and they’ve started thinking about, “What would it be like if I was dead? How would that benefit my family? Would anyone care about me? How would I do it?” So, the ideation part — about 50% of our people, our employees, have actually had these thoughts at some point in their career. Now, of all the firefighters, almost 20% have actually gone as far as to develop a plan. So, now we’re getting more serious, right? 

So, this is where we’re actually seeing people are starting to develop thoughts. Most likely, they’re reoccurring thoughts, and then they’re taking it to the point of having thoughts of how they would actually execute the plan of committing suicide. Now, one thing I do want to point out for those of you that are clinicians in the room — we obviously have always been trained that ideation is the lowest. Now, remember ideation is a symptom. So, someone could have suicidal thoughts and not always be at that highest risk level that they’re ready for hospitalization. Suicidal thoughts, thoughts of death and dying — that’s a common symptom of depression. We commonly see that in anxiety. It’s also really not uncommon to see that in PTSD. One reason ideation is pretty high in the fire service is because of those immense exposures to death. Think about it: If you are consistently exposed to death on a daily or weekly basis, depending on what the demands and the calls of your specific department are, don’t you think that’s going to be a thought that’s kind of at the forefront of your mind? 

Just because someone thinks of death and dying doesn’t always make it the most extreme, “Oh my gosh, quick, let’s react.” Sometimes, that’s just the nature of what the calls have put to the forefront of a firefighter’s mind. So yes, they are thinking about it. Now, please keep in mind that does make a risk factor for the future, but it doesn’t always make it a risk factor that they are going to hurt themselves. So, then that’s where we take it a little further. About 20% of firefighters have actually thought of a plan of how to harm themselves. Now, again, that sounds really serious and it is; those are definitely the people that we’re getting a little bit more concerned about. And if we’re not a little bit more concerned, we’re a lot more concerned. ‘Cause maybe we’re seeing some risk factors or we’re seeing some other, like, red flags that are happening. But it’s also not uncommon for people in the fire service or any first responder, really, to think about methodologies of dying. 

So, for those 80 participants here — maybe there are more right now that are actually in the fire service — I’m sure you have seen suicided bodies at some point. And don’t think it hasn’t been past a lot of my clientele, whether they’re my patients or they’re really just part of my cities where I go in and visit with them. But they’ve said things like, “Well, that guy screwed it up, they should have done it like this,” or, “Nah, If I were to do it, I would do it like this.” This statistic right here, it is referring to someone that intentionally is actually starting to think of how they would harm themselves — not just that passive sort of, ethereal thoughts of ways to die. Now, again, someone that is entertaining those thoughts — that might be a risk factor, or it might not. We have to kind of look at it dynamically based on that person and some other things that they’re working with. 

So, moving along with something that is actually a little bit more sobering is that about 15% or 16% of the fire service has actually attempted suicide at some point. Now, this could have been jumping off a bridge. Actually pulling the trigger on an unloaded firearm. This could also include taking a loaded firearm, putting it in their mouth and just holding it there. This could include taking pills. I’ve also had other people describe things — that they’ve gotten severely intoxicated and they’ve walked into the ocean, ‘cause I’m in Florida, by the way, if you guys don’t remember from my intro. Walking into the ocean, hoping that they’re going to drown because they’re just going to fall asleep and they won’t be able to swim or have enough energy to get to shore. So, about 16% of our fire service has actually attempted suicide at some point in their careers. It’s pretty sobering. And then a comparable figure to that is that about 16% have engaged in self-harm. 

Now, for any of the clinicians that are here, if any of you guys have worked with fire service before, some examples of self-harm from my clientele that I’ve worked with has been cutting. Cutting is a huge one, and I know that also seems like a very teenage girl thing to do that is distressed. And I don’t mean to make light or levity of it, but usually, a lot of my clients underestimate that self-injury can include cutting, and it tends to be on the thighs or the upper arms, like, areas that they are hidden. So, individuals in the fire service that do engage in self-injury are very mindful of concealing their injurious wounds, their self-inflicted wounds. So, they’re not always going to be red flags that you see, unless you’re noticing them working out and they’re wearing clothing, like a t-shirt that may be exposed, in shorts that expose them a little more. Another one that I’ve also seen is burning. So, using lighters or cigarettes or cigars or different methodologies to burn their skin. And again, it’s doing it in areas that are easily concealed. So, those aren’t always red flags that are easily seen, but they can’t be okay. 

Alright, so let’s talk about why firefighters may not seek help. I think a lot of these won’t come as a stranger to anybody, but the biggest thing is stigma, right? And that stigma can be self-imposed or it can be work-imposed. So, the most obvious thing that we always talk about is why people don’t actually seek help. And by the way, suicide is usually the last stage of someone’s emotional distress. So, a firefighter doesn’t go into a call is bad, and then they go straight from zero to suicide — that’s not how it works. No, most firefighters walk in after fire academy, get their job, they get their new uniform. They look super cute in it. They can’t wait to go out. They eventually get married or have kids, or they get into their career and, like, things are going good. They’re getting different calls and some bother them, but most of them don’t. But over time, it compounds. Then they get part of the culture and they might learn maladaptive behavioral strategies to cope with things, whether it be influenced by their peers or it be something that they learn on their own. So, that could be like alcohol use — that is one of our more common ones — or maybe it’s infidelity. Maybe it’s other impulsive actions, such as excessive spending on your days off. Even avoidance is another maladaptive one. 

Over time, these issues aren’t getting addressed, and this is where depression starts to creep in. Or maybe it is undiagnosed trauma symptomology that creeps in, or maybe it is anxiety over time. And then the lack of sleep just makes that worse. So, we don’t get straight from zero to suicide. It does build over time, but that stigma of not seeking help exists the entirety of someone’s career. So a lot of times, it can be because, “Yes, I don’t want to get in trouble with admin.” Now, I am going to tell you, recently — and this was so bad, and luckily the department subsequently called me to consult so they never did it again — but a firefighter reached out for help. Reached down to their district chief rather than a lieutenant or, like, anyone directly above them. Reached out to a district chief, said, “What’s the EAP number?” That was the only question that was asked. And honestly, the gentleman was really just going to work on some complicated grief issues after losing a parent; they weren’t at the highest risk, but they wanted to take care of themselves. 

Well, all of a sudden, the district chief knows about it — that you’re going to EAP, which is a service that’s offered to you. And now, this poor person has to go for a fitness for duty. They can’t go back to work until they get cleared when, really, there was nothing wrong with the guy. The guy just wanted to take care of himself. So unfortunately, ill-informed administration does compound this fear that, “If I seek out help, it’s going to work against me. I won’t be able to work or I’ll lose my job.” So certainly, that stigma has been there for a while. I think the one that I have to fight the most is the self-imposed stigma. Now, the workplace stigma of peers judging you, that is there. Certainly, a lot of peers just minimizing, saying, “Get over it. It is what it is. It’s just another call.” I’m not seeing that as much at this point in time, but that certainly still does exist. No one wants to be seen as the weak guy or gal, no one wants to be seen as the only one affected by this call and can’t get it together. So yes, that does exist, but I am seeing that more and more firefighters have been craving someone and, really, just all of society to recognize, like, “God, this job sucks sometimes. It’s really hard on us, so someone just throw us a bone once in a while.” 

When they see one of their brothers or sisters struggling, I am finding that peers are being a little bit more supportive. The hope is also, with the implementation of peer support teams, that people are starting to build more of a sensitivity and a willingness to refer or discuss things that are bothering their peers. But that self-imposed stigma — that’s more of that judgment of oneself. Seeing one as weak, seeing one as not being able to solve their own problems. This is my best way of getting you guys to understand it: First responders, firefighters in particular, have high tolerances for misery. What that means is they can keep going and going and going and going, and they can just ignore what’s hurting them on the inside because they might not even recognize it as hurting. They might notice something bothers them, but they might not appreciate the whole toll of it. Why? Because they got other things to do. They got other people to take care of. And it’s not always just at work with their patients or citizens. They got to go home, they got to go home and they got to take care of stuff there. And they can’t tell their parents or their significant others what’s bothering them because they don’t want to worry them. Because again, they’re always the caretaker, they’re always coming in and being the helper. 

I don’t necessarily want to say the word hero. I know that’s the spirit of it, but it’s, like, they’re always the one managing and problem-solving everything. So, they have that high tolerance for misery that they often ignore. And then that contributes to the stigma of, “I don’t want to seek out help because I don’t have time to do that. I don’t have the ability to be weak,” or they start judging themselves that they can’t solve their own problem. The other note — minimizing. Minimization is a huge thing, and denial. That call — if something about that call bothered you and it’s sticking with you, a lot of people just going, “Hmm, it’s just another call. I’ll get over it soon.” But that’s not always the case. Sometimes, they stick with you a little longer than others. I do know; I was just talking to a firefighter that had been on for umpteen zillion years. I mean, he is as old as Methuselah and still in the fire service. And one thing that he was telling me was, at first, the calls didn’t bother him, but then eventually, the calls just started compounding. The thing that bothered him the most was obviously the kid calls and the idea that he couldn’t get the Johnson’s baby soap smell out of his head. When his grandchildren were being born, his first thought was, “I’m scared that I won’t be able to hold my grandchildren because the smell of the baby shampoo is going to upset me too much.” 

But he never got help ‘cause he said you don’t have time to do that. He had to go home and go right to a family to take care of. So now, again, undiagnosed mental health disorders. That’s just one of those risk factors that comes into play. Again, with that high tolerance for misery, individuals tend to ignore symptoms that they should probably be addressing, and then it compounds and builds over time. Lack of resources, that’s also another one. EAP programs — I’m not gonna knock them all, but by and large, EAP does not have a great history in the fire service. Whether the individual doesn’t understand the culture, doesn’t understand the language. Maybe there’s a personality mismatch. Maybe the individual’s a little bit more sensitive. There’s a lack of responsivity. So, the key for administrators is making sure resources are readily available, and are they responsive? The fire service is 24 hours a day. My practice, at least we do, we are 24 hours a day. So, we always have doctors managing the on-call phone. Not every doctor or clinician can be like that, which is fine, but are you responsive to the best of your ability and communicate expectations to your clientele so that they can rely on you? And then also too — I mean, I can’t train you on personality, I can’t train you on humor — but also making sure that whoever is working in terms of a clinician for these individuals can be flexible, can be funny, can relate, can identify and not try too hard. 

I will admit, guys, I’ve never been in the fire service. The only reason I actually have knowledge of this is because of working. So, I never try and impress you with my knowledge. I just go in and we talk and, you know, I know what I know, and then you inform me sometimes too. But in terms of resources, making sure that they’re readily available and confidential. That’s the other thing — making sure that they’re confidential so that people are likely to use them. So, for our peer support team that’s in here or any fire service individuals that are doing this training so that you can inform your department, find a professional, use the IAFF resources, find someone like another mental health professional, interview them, be open with them, ask them their knowledge about the fire service. And if you can hand out their card and keep that on you, that’s fantastic. That’s how a suicidal person or someone that’s thinking about it — or just anybody in an early stage of distress — is likely to use the resources. 

Can I stop and ask you a few questions? 

Absolutely. I was actually gonna say I’m about to do that. 

So, the first question I have for you is what advice do you have for individuals who haven’t found success in treatment? 

That’s a good one. So, we’re referring specifically to fire service. My advice is don’t give up, and I say that because the likelihood is you did not find there were two things happening for you. One, you didn’t find a clinician that was a good fit for you, that you related to, that they gave you advice and therapeutic techniques that were helpful and applicable and something you could do. Maybe, again, that personality match, or maybe the clinician didn’t match because they just didn’t have the level of care that you needed or that specific intervention and you just needed something different. The other thing is to keep in mind — maybe it was a personal barrier. Maybe you weren’t quite ready for change. There is a difference between wanting to change and readiness to change. Doesn’t make you a bad person if you’re not ready to change; I’m going to tell you right now, change is so hard. When we think about alcohol use, why does — and Molly, I promise I’m gonna make this a short answer, but I want to make sure you guys understand what I’m saying. 

When someone starts to use alcohol in the fire service, they’re doing it to treat something, they’re doing it to treat fatigue. They just want to go to bed and they can’t. They’re doing it to treat and get away from recurring thoughts that are causing them anxiety or panic or just distress, or they’re doing it to treat anger, depression, all these negative emotional states that are just drowning them. So, when you go to a clinician and they ask you about trying to curb your alcohol use, in your head, that’s effective. That’s actually effective in getting rid of those things in the short-term, and the long-term causes other consequences and risks for things. So, you may want to change because you know that that’s not healthy for you and you know it’s causing other problems, but you may not be ready to because that’s a big issue for you as well. What else would you replace it with? So, for someone that has not had success in treatment, don’t give up. Let’s try and find you a better clinician, like, one that fits with you better — not necessarily better skill-wise but fits better with you. And also, someone that can maybe push you to a state of change and want to change, not just a desire to change if you weren’t already there. 

So, the next question I have for you is: Do you think that there can be multiple people affected in one agency by a single event? 

Oh, absolutely. And what will be so different is they’re all affected in different ways. You can have the young buck that just got on and he’s, like, 20-something years old. And he’s affected by this call, like, let’s say it’s a kid call. Let’s say it’s a kid drowning or a baby and a mom rolled over on the baby. And that 20-year-old had to do CPR on an infant with blood coming out of its mouth. And smelling that Johnson soap and having the chaos around them, that individual is going to be totally affected in a different way than someone that’s 20 or 30 years on. Now, I am going to tell you, I recently did a debriefing at a local department that did have a kid’s call, and one of the firefighters that responded actually experienced his own losses of children. So, when they responded to this call, he’s relating back to his own hurt, his personal pain. And then you’ve got this young guy who’s relating to, “Oh my God, this sucks. This is my first kid call. I’ve never experienced anything like this in my life. I don’t even have children.” 

So, I do think multiple people can be affected at the same time, but for peer supporters and clinicians — and then just those peers that are here that want to just support each other or chaplains — what I’m going to tell you is you can’t look at the broad group. Like, if you’re going in and doing a debriefing and assume everyone needs the same exact intervention, you really have to go in and be able to do a broad intervention to meet the general need, but then be able to look at each individual and try and help them on an individual level or if they reach out to you. 

So, a lot of contextual factors at play, a lot of personal differences that you have to consider when thinking about how different people are going to be affected. We’ll move on to risk factors and protective factors, and then we can take a short break right after that. And I can throw some more questions at you.

So, risk factors. This is actually going to be — I think a lot of you guys know what this is, but obviously the stressful jobs, the excessive use of alcohol, hiding feelings, seeking help as signs of weakness. To be honest, I just reviewed most of these in what we’ve already talked about. Here’s one point I do want to make with respect to traumatic exposures: Please remember that firefighters are asked to do something that’s completely abnormal to the human psyche. The human psyche, who is also an animal as a human, we’re built to survive. We are built to seek out pleasure. So, when we put a firefighter in a position of doing their job, we’re basically saying, “We want you to fight your basic animal instincts to survive and your basic human psyche instincts to seek out pleasure. So, when there’s the burning building and there’s someone dying and there’s all of this, we want you to run straight for it.” 

I’m gonna tell you right now, I was walking my dog this morning. She saw a dead bird on the sidewalk. My dog goes and smells it and then goes, “Oh, hell no,” and then walks away. Why? Because my dog wants to survive, and what she just confirmed for herself was, “Oh, I don’t know what happened here, but it wasn’t good. And I don’t want to be around in case it comes back.” So, we are consistently asking our fire service to expose themselves to things that are abnormal. Now, most of our fire service does have high pools of resiliency — that they’re prepared mentally to deal with that. But that does take a toll over time. Why? Because it is artificial and it is contradictory to your basic animal instincts to survive and your basic human psyche to seek out pleasure. So, that’s something to keep in mind. 

In terms of the stressful jobs, we know all of these things; we know the bells, we know the lack of sleep, the idea that when you clock out, you don’t just always get to go home and go to bed. You’re going home to do more things, like mow the lawn, and all those to-do list items at home always follow you into work because you didn’t get to do them ‘cause you were too tired. Just a lot of things like that. And now, some other things that are coming up are like dynamics in station houses specifically. So, we can have dynamic complex between people, all of this social craziness that’s happening now can create more social conflict amongst employees in your own station house. If there is a lack of family vibing in your particular shift with your people, that can also cause stress. So on that note, Molly, if you don’t mind, I just want to say this one real quick and then we’ll take that break.

Highest-risk personnel out of everybody in the fire service: lower ranking people, less years experience, history of exposure to suicide and anyone that’s military like veterans or active duty or reserves, that sort of thing. So, that is our highest-risk group, and I think a lot of you guys should be mindful of that — that where we really need to dedicate a lot of suicide prevention efforts are at the beginning of someone’s career. And if we do that at the beginning of someone’s career, how is that going to be positive for the longevity of not only their mental wellness, but also their career itself? We don’t want to ignore our retirees. We don’t want to ignore our senior people. They’re still there. But if we start now at the beginning, we’re going to catch our highest-risk group and we’re going to set them off on a good path. 

You mentioned retirees just then — do you think that retirees, just in general, maybe have a higher risk than someone who’s still on the job? 

So, not a lot of research has actually been dedicated to retirees. Unfortunately, like, once they retire, they become this long-forgotten group. There’s about one or two studies. And sometimes, you can even look at law enforcement retiree studies too, which is pretty minimal as well. Retirees definitely do have — they are at suicide risk. What I noticed that they are at suicide risk for is because they might have health problems that are just accumulating and becoming worse and worse and worse because the assumption is that they’re more senior in age. But the other part, which is most critical, is they’ve lost their identity. So, similar to a midlife crisis or similar to entering into that next stage of life. 

A lot of people are losing their identity when they leave the fire service. You’ve also lost your family, if you will. You’ve lost the group of people that you used to go home with. And I don’t know how many of you sometimes feel like a stranger in your own home, and sometimes, your station house with your brothers and sisters is more like your family and you feel more comfortable and authentic there, but that happens too. So, there’s where our big retiree risk comes from. So, a lot of times when I get people exiting their careers, I really try and do some retirement counseling prior to them going into it to make sure they’re set. Research does show though that right now, our younger personnel that’s active duty is at the highest risk for suicide than retirees. But I think that’s just based on the minimal research done.

So, same kind of question but for the newbies. We had a question come through: Someone’s going to be meeting with new recruits in the next couple of days and talking about their experience with treatment and mental health and substance abuse. Do you think that there’s anything that you would recommend to tell them so that way they know it’s okay to ask for help? 

Oh, that’s a great question. I love the idea that if this individual is meeting with these newbies, and if you have your own personal experience, you’re very much going to be able to normalize and say, like, “Look, I just want to tell you this was helpful. Don’t try and be the hero. Don’t try and be the man. At some point, something’s going to suck. Be okay to go because you still have a job to do. You still have to come in and take care of your patients, but you also have to be able to go home and take care of your people there. If you’re not right, you can’t do anything, so don’t try and be the man and the hero. Something bothers you, don’t even ignore it — just go in, talk it out, get it out, done.” 

That’s usually, honestly, when I sign new contracts with agencies and then every year afterwards, I go into the different stations and I just say, “Hey, how are you guys?” Like, I go talk to them. And when I’m trying to tell them about how to seek out counseling and treatment, I tell them, “Look, guys, it’s like a professional football player. They only get a short amount of time in their career, so they wanted to do this their entire lives. What do you do to keep yourself in the game? You do weight training, you do yoga, you do acupuncture, you do massage therapy. You kind of need to think about mental health treatment as keeping yourself in the game. You can only take so much of this in that head of yours. Get it out and then keep it moving.” That’s the idea. You’re not broken if you go to counseling; it’s more of mental training with first responders. That’s the way at least I present it. 

We hear that backpack analogy all the time, the rocks in the backpack. And I think really what you’re saying is stop and unload that backpack. I’ve got one last question for you: Why are members of the fire service with prior military service at higher risk? 

Just from the increased exposures that they likely experienced. That tends to be one interesting statistic to see. You guys know first responders actually have a higher incidence rate of PTSD than combat-exposed veterans. Very interesting. Combat-exposed veterans have an incidence rate of PTSD of 30%; firefighters, police and other public safety, it’s up to 35% and it’s even higher than that, we think, because it’s a little different presentation. Usually — military individuals — it’s because they’ve had additional exposures that are even in excess of what you get on the homefront. Now, one thing I do want to say is there should be no minimization or comparison between traumatic combat exposures versus homefront traumatic exposures. What you really need to think about is homefront traumatic exposures. 

Those sometimes relate a little bit more personally, whereas if you’re in the military, you’re deployed, you’re getting some sort of combat traumatic exposure. You at least get to go into soldier mode, where you potentially depersonalize a little better. One of the other issues is reintegration is huge. So, veterans are consistently having high rates of suicide during the reintegration process if it’s unsuccessful. So, if we have someone that’s having to go through reintegration, and yet they’re going right back to active duty in the fire service. This is where we may see some adjustment issues, and part of that tends to be because they can’t correct for the homefront; maybe there’s relationship conflicts or their kids aren’t listening ‘cause they haven’t had a parent there for a while, so on and so forth. 

Thank you for elaborating there. So, we’re getting close to the one o’clock mark and I know we have a lot to still get through, so I’m going to toss it over to you so we can be sure to hit those strategies. 

Thank you. Okay, perfect. So, I’m going to go over this really quickly. When we think about a suicide risk assessment, my best explanation is that you need to look at risk factors versus protective factors, right? So, we just got done talking a lot about that — different risk factors. We are going to review a few more coming up, but when we talk about protective factors, some general things to look for — that social support, that belongingness. I always try and ask and assess for, basically, who does this person connect with? Do they have a sense of responsibility to their kids, to their spouse, to their parents, to their brothers and sisters in terms of the fire service? Do they have a sense of connection with people? Because what that’s going to do is it’s going to cause the person to want to stick around because they don’t want to disappoint them. They don’t want to hurt those people. 

Now, again, if someone escalates to a point of suicide, that might not always be enough. So, we have plenty of people that have unfortunately committed suicide, where they had lots of people around them that love them, talk to them all the time. And yet, because they were so entrenched in their depression and what issues were present for them and starting to feel that hopelessness, helplessness, not even connection was key. Now, that is important to keep in mind too. Are we starting to see, like, one sort of warning sign? Are we seeing someone that used to be so friendly — so bubbly, always the jokester, always getting into the mix of things — are we starting to see them become a little more disconnected? A little more jaded, a little quieter? This is the person we want to start watching. Not because they’re necessarily at a suicidal state, but they’re definitely starting to experience some things that, again, if left untreated, can push them to that more severe place. 

Sense of religion. I will tell you this: I’ve always found religion to be one of the most effective protective strategies. Why? Because it helps you explain the things that can’t be explained. That’s where a lot of people use, “Well, God wanted it this way,” or, “God would only make it happen if it was supposed to happen.” Even if it’s not religion, like a formal religion, and it’s just a spiritual sort of idea of how the universe works or “it is what it is” and all things happen the way they’re supposed to mean to do — more general versus this deity. But I do find people that can make sense of bad things that are relatively out of our control. They have one of the most effective protective mechanisms against getting to a higher state of distress. 

Obviously, fear of pain, and I did add fear of judgment. The idea of, like, would someone judge me? Any sort of engagement in physical activities or hobbies? Are we seeing that someone has a sense of plan for their life? Like, they’re talking about their retirement home that they’re going to buy? They can’t wait to go out on the boat on their day off and go fishing? Is this also a person that’s willing to talk or has expressed a hope that treatment is actually gonna work? Like, they’re holding onto that last-ditch effort that maybe this is the thing that works? And the one other protective mechanism that I think is super great is a sense of self-efficacy. Self-efficacy relates to a degree of confidence in oneself for their abilities or their ability to solve their problems or their ability to get out of this at some point. Maybe they just need a little bit more help. So, those are protective factors that I look for when talking to someone.

Some suicidal commonalities to keep in mind — these are some of those risk factors. And I’m so sorry; my little notes have gotten a little wonky on me over here, but threat of lost relationships. So, if you’re looking for some major sort of warning signs of things, keep in mind marital issues, relationship issues, any sort of signs of domestic violence. Now, here’s the problem. People know how to keep things close to the chest. So, you may not always know what’s happening in the home life. But at some point, fire service — they’re living together, so at some point, some sort of blip is going to be observed. Now, it’s normal to fight in marriages. It’s normal to have issues here and there, but is it something that’s really starting to creep in? Be a little bit more present in the individual, and also, are you observing that in addition to some other warning signs or risk factors that are happening? Custody problems are another one I’ve noticed a lot. Having the cops call because someone was intoxicated and it just became a verbal altercation that resulted in law enforcement being involved. 

Financial stress is another one I’ve noticed quite a bit as pushing people to a more severe stage. Again, one of those warning signs and one of those maladaptive coping mechanisms for emotional distress is excessive spending. So, someone is really quite miserable at their job. What do they do when they go home, where they don’t always feel connected either? They go spend things. Why? Because buying things makes you feel good and you get new toys, and that’s exciting. So, look out for someone that’s all of a sudden making a lot of big purchases, like new car, new boat, new house, new this, and they seem to always be buying something. So, either financial stress is going to be a contributing factor later, or the excessive spending related to feeling emotional distress. Also, history of attempts at self-harm. Again, we can see the cutting. If anything, I don’t find that people in the fire service always have family histories of suicide. Although with the general population, that is something that is a risk factor. If anything, I find the excessive exposures to death and dying to be a greater risk factor for eventually someone breaching into suicide. And then, of course, untreated mental health. 

So, how does it look a little different amongst the groups? Someone at the most severe stage of suicide as an average civilian is typically going to present as sad, depressed, cheerful, crying, withdrawn. So, that really sort of morose individual, very retarded in functioning, super slowed down, very sedentary. They tend to be the ones that are rather disheveled. They’re not investing a lot of time and care into their hygiene. Their homes tend to be rather messy too, but you’re looking at them and they look sad and depressed. So, when they commit suicide, it’s somewhat unsurprising. Now, when a firefighter commits suicide, it usually throws everyone. And there’s a lot of people saying, “I never saw it coming.” After the initial shock has worn off, that’s when people start kind of doing that forensic sort of examination — that, “Oh, I can see some of the red flags now.” 

So, firefighters tend to have more irritability, anger, aggression — that’s depression in the fire service. First responders don’t tend to have the sad depression at first. It tends to be more of an agitated depression. Irritable, and then that mood flipping as well. It doesn’t mean that they don’t get sad. They don’t have periods where they’re just quiet and withdrawn and into themselves and feel miserable. But by and large, the moment they feel that, they reactivate to anger and hostility and irritability. Also too, firefighters tend to — when they are depressed — project the blame onto other people. They don’t often recognize that what they’re experiencing are depressive symptoms ‘cause it doesn’t look depressed, it looks angry. So, how do you justify anger? Well, it’s someone else’s fault, right? So, it’s because I can’t get sleep, it’s because of the station, it’s because of my wife. It’s because of admin making stupid choices. It’s because of all, you know, the world and the way it is. And 2020 — it has sucked. Well, that’s a big problem because then nobody’s really taking accountability of what they do to correct it. 

Now, some other things that we’ve noticed — obviously, the increased alcohol use. Again, alcohol is a mechanism of avoidance, treating negative emotional straits, treating fatigue. The risk-taking behaviors can be a little odd for people. That can be hard for people to understand. So, I’ve actually have had several firefighters at this point that have gotten arrested for stealing. They’ve engaged in impulsive behaviors, testing the limits, testing life itself, just to see, “Can I invoke some sort of emotional reaction other than sad, depressed or angry? Can I feel excited or enthralled?” So, they’ll steal something to try and get a rush. 

This is also where people do start to engage in infidelity as well — might be one of the risk-taking behaviors. I’ve even had someone that engaged in looking at pornography at work, just to get some sort of something. Some more classic ones too — the reckless driving is another one. Testing the limits of life. At some point, if you really don’t care so much about your own life, or you’re not really sure if yours is worth living, maybe you don’t even want to die. Maybe you have no plan for dying. You just have the general thoughts of suicide of, like, “What would it be like if I wasn’t here?” You might actually test the limits by engaging in reckless behaviors that puts your physical person at risk, just to see, “Does it make me have a flash of fear and confirm that I want to live, or do I see the white, bright lights at the end of the tunnel and know that there’s something better for me?”

One last thing, and I do want to check in with Molly after this, just to make sure. And then we’re going to go into the actual assessment procedures. Aversion theory is what I was really trying to speak to in terms of what increases a firefighter’s risk to suicide if the mental health issues, if other risk factors are also present. The idea is that someone has become habituated to the idea of death. This is where that idea of death is at the front of someone’s mind because they’re always seeing it, whether it just be the old person that died naturally, it be the obese person that died from a heart attack, or it be the kid that got rolled over or drowned in a pool, or someone that actually did hang themselves, or carbon monoxide poisoning. Whatever it may be, first responders are exposed to a high number of situations where there’s death, dying, suicide or just physical harm to people. Arm being torn off after a motorcycle accident. Someone’s had the chainsaw from the tree rip off a foot. I mean, there’s a high number of exposure to blood, guts, gore. 

At some point, in order for you to keep doing this job and to not be destroyed every day, you have to develop mechanisms that help you just tolerate that. So, you come habituated. This is where that sense of humor comes in, where you distort what’s happening so that you can find humor in what most people would vomit over or become horrified over. But how that relates to someone that’s actually in a state of distress is that they do start to just become used to the idea that death will happen at some point. Death could happen at any point. “Death can happen if I want it to and death can happen if I don’t want it to, so I guess I should just accept that life maybe is not all worth living.” And then little thoughts like that is what starts the snowball effect of someone that’s actually in a state of distress — someone that is maybe very symptomatic with trauma and someone that is drinking because home life is not good. So, that’s what we call aversion theory. Molly, just want to check in with you. Are there any questions after that? 

Not that I relate to those slides. We do have a number of really good questions that I think we can address towards the end of the presentation. I just want to make sure that we’re able to get to that assessment piece. So, I’ll let you go; take it away. 

So, some warning signs. This is what’s all going into the assessment. This is what you would do and look for before you’re going into actually asking questions. So, look for people that all of a sudden have a change in mood. What I find more often than not with firefighters is we’ll actually see a levity in mood, so we’ll see a brightness that happens. Why? Someone that has gotten to the point of suicidal — they have, for so long, not been able to figure out their problems. They’ve become hopeless and helpless. Now, all of a sudden, the idea of suicide comes in, and they think about it and they think about it and they develop a plan. Now, all of a sudden, it’s starting to make sense and, “Oh my God, I might have the solution for my problem. It might be it.” So, you actually might see a sudden change in mood after a period of irritability, anger, frustration and then that moroseness, and then that would be something that would be, like, “What happened to that guy? Who gave him a pot of gold instead of Cheerios this morning?” Again, if you’ve noticed some other warning signs along the way and all of a sudden you see this bright mood, I would pause them, talk to them. 

Now, obviously, the giving away possessions — this could be your favorite coffee cup. This could be a home. This could be getting rid of your car or your boat because you don’t want to clean it anymore. And that’s what you tell people ‘cause that sounds reasonable, but giving away things that were actually rather meaningful for you. Again, the anxious and agitated behavior, acting recklessly, some things I would encourage you to listen out for. I’m trying to get to these verbal signs; I’m going to track back to those other slides. Listen out for someone that all of a sudden becomes preoccupied with the idea of death. So, we did have — one of my departments had a firefighter that every time they responded to a death call, they would always want to talk about those calls. And it was weird because everyone else could move on, and he kept wanting, “What do you think that family thought? What do you think they’re going to do? What do you think was in that guy’s head?” So, almost connecting with the person that just died, particularly if it was from unnatural causes, to try and understand death a little more. 

Listen out for verbalizations of hopelessness: “I’m not sure if this is going to get better. I don’t know.” That’s part of that self-advocacy piece. If someone starts to complain about some pretty big financial issues or relationship issues, and then they’re seemingly hopeless on how to fix them or not connecting with hope for the future that it’s going to get better — those are going to be those indirect verbal cues that you should listen out for. If someone’s going, “What is the meaning of life?” or, “I’m not sure if life really has much meaning.” Saying things like, “You guys would be better off without me.” Those are all those indirect verbal cues to listen for. Now, direct verbal cues are obviously saying, “I’m going to kill myself. Might as well be dead.” Now, when I get those verbal cues and treatment, someone is just trying to express, “I hate this stuff. I can’t stand it. Kill me now. I don’t want to work with this chief anymore,” something to that effect. So, you do got to take things with a grain of salt. 

Again, am I seeing other risk factors and other warning signs around this person? And then they’ve got plenty of protective factors that they’re compensating for that kind of wash that out. And I can tell that that’s a joke. However, please don’t put it past people. They will say direct comments like this. Now, what happens in the fire service? We make everything a joke, right? So, if some guy is just walking from the kitchen, through the TV room, back to their things, and there was a joke that everyone laughed at and this person didn’t happen to laugh, even though it wasn’t about them, and all of a sudden, “I don’t know, I might as well go kill myself,” and then they shock it up like that. That might not always be a joke. Think about what else is going on with that person. That is why it is so important to know your people. 

Okay, so I’m going to kind of go back a little bit. I’m so sorry. So, this checklist — again, very similar. Are we seeing some isolation? Are we seeing an increase in alcohol, drug use? Are we talking about being a burden to people? The rage? This is like a nice little checklist that peer supporters can kind of keep on you. And then just kind of check, check, check. Again, this is like looking for some of those warning signs. Now, if we’re talking about an actual assessment of suicide, this is where you use the “is path warm.” So, this model is taught a lot to new clinicians. A lot of our clinicians in this group and this webinar — you guys might have heard of this, you might not, but these are different things to look for. First, are we seeing ideation? Are there thoughts of suicide? Are there concerns? Second, and this is most important, why? Because it lowers inhibitions. 

A lot of our fire service individuals end up committing suicide under the influence of alcohol. So, are there substance abuse concerns? I know the few suicides that I’ve been involved in, alcohol was always implicated with our fire service people. Now, if we can eliminate or really start to control and treat for substance abuse, we dramatically improve the prevention of suicide. Purposelessness: Does this individual start to express things that they’re not really connected with life, they’re on the hamster wheel, they don’t know why life is worth living? They don’t know what their purpose is. Why? Because they go to work, they respond to a call, and the very next day, there’s another person dying of the same thing. And people just keep doing this. Or maybe it’s related to purposelessness and their home life, like they’ve lost their marriage or their kids don’t want to be around them anymore.

Anxiety, feeling trapped. That feeling trapped relates to that hopelessness and also helplessness feeling of when they feel trapped, or they find that there’s no way to change their situation. And then when you feel like you can’t change your situation, does that make you hopeless that it will ever get better? Or you are just bound to stay in this really crappy state for the rest of your life? Are they also starting to withdraw? Withdrawal doesn’t always happen immediately. Withdrawal tends to come towards the end. What I find most often is that’s either when someone’s really starting to think more and more and more, becoming more pensive and planning about suicide. But it also tends to be when people withdraw because they don’t want people to interfere with their planning. 

So, there are times that I think this is something we all have to keep in mind. As much as we talk about warning signs and risk factors and you can stop someone from committing suicide, there are some people that develop plans that leave you out of it. And they conceal things very well, so we do our best to be mindful and watchful of our people and be available. But if someone is concealing everything and then they never asked for help, even if it was offered to them, sometimes they end up still committing suicide very successfully. Recklessness — looking for that — and then, of course, the mood change. Like, are we seeing that immediate levity? Because that’s usually about the point where someone is about to commit suicide, unless it’s under the influence of substance abuse, which may occur in an immediate domestic incident. So again, keep in mind that substance abuse and that mood change may conflict with each other.

So, how to take action? This is where I’m going to kind of end it, and then just some things. If you are an employee, this is where you might want to consult with others. If you’re a peer supporter working with that person, making sure you have the resource of a mental health professional to refer them if you want to remain confidential. If not, get someone else involved — rather save that person’s life than save them being your friend at the end of it, right? Chaplains are always good. Don’t ever leave this person alone. Make sure to assess for firearms. Remember what I told you guys — that the majority, the overwhelming majority of suicides in the fire service are with firearms, and a ton of firefighters own firearms. Look for those different warning signs and cues. And I’m telling you guys from a clinician’s perspective that does this all the time, be flexible in the way you’re talking, be organic in it. So, when I say — let’s see, there we go — questions to ask, be direct. “Look, man, are you thinking about killing yourself?” Ask them those questions. You need to know the answers to that, but you don’t need to go down this little list with habit right here. “Excuse me, I need to ask you all these questions.” Firefighters don’t respond well to that. 

You know what firefighters respond well to? A conversation. That’s what they do good with. And in the midst of it, they are going to incorporate humor as a part of it. All of a sudden, you’re going to go from this person telling you, “Yes, I want to kill myself. I’ve definitely thought about it,” and then all of a sudden, they make a joke. Well, that joke probably has included their plan, you know, “Effing eat my gun, whatever,” and, “This has all happened to me.” So, as you’re tracking through this, this is where you have to be a part and not minimize that — overly engaged in the humor — that you’re not taking it seriously, but you also do have to be willing to track this person throughout the ways that they have to dispel their tension. Because the good thing is that they’re answering your questions and they’re talking to you. Along the way, they’re going to have to use their coping mechanisms to dispel that pressure, so that might include humor. You will never put the thought of suicide in someone’s head; it’s either there or it’s not. So, I promise you this: It is better to ask questions. 

Always ask. “Do you want to kill yourself? How long have you had these thoughts?” We want to know how long they have been going on. If they’re new, why are they new? “Yo man, what’s happening? What’s going on? Like, why, all of a sudden, is this coming up for you?” Okay, then go to the plan. Why? Because we want to know, “Oh, are they actually thinking about something that they could do?” And if they are, do they have access to that or have they actually thought about how they would do it? So, you want to ask them very specific questions. My best example is a firefighter that came to see me — a young guy — and just too much was going on for him. As we’re talking, he definitely is depressed and he’s making light of his depression along the way. And so I asked him, “How long have you had these thoughts?” I’ve had them for about a year now. “Okay, do you take antidepressants? What do you do with them?” I just ignore them. “Okay. Well, what have you thought about how would you do it?” Well, I’d probably just shoot myself. “Okay. Well, do you have guns at home?” Yeah, my roommate’s in the military, so he has guns. “Okay. Well look, man, I’m going to tell you this right now, we gotta get those out of. We gotta get those out of there because I don’t want you to hurt yourself. Like, I don’t want that to happen to you.” 

Now, clinicians, if you’ve got a firefighter that’s gotten to that point — with that particular individual, I told him, I was like, “Look, man, I can’t let you leave my office until we get this situation straightened out.” I very collaboratively worked with him. He had signed a release of information. We called his roommate. We didn’t overly disclose. I let him be in charge of it. But, you know, I talked to the roommate, I was like, “Look, man, can we get this out of the place? Can you secure these for me? Can you do this?” And then I followed him up the very next day and the very next day. If you guys are peer supporters or colleagues, see about referring them immediately to a mental health professional, or what can we do? Collaborate with the family member, or if you feel like the firefighter doesn’t want the family member to know, “Okay, look, I don’t want you to go back there, so that’s not good. Give me the guns. We’ll do this quietly. I’ll put them away. You can have them back. I’m not keeping them from you, but I just don’t want you to have them tonight. That makes me uncomfortable because I want you here, but I’m so glad you told me.” 

And then always follow up. I think that’s the one key thing that I’ve done with my firefighters is if they’ve started talking about suicidal thoughts, I always have them come back in the very next day — depending how severe they are — or they’re coming back in two days from then. Because a lot of times, what you’ll notice is a change, just by actually talking about suicide and then actually engaging in treatment. So, I know I kind of rushed through that a little bit, but I really wanted to give time for questions so I can answer anything else that comes up. 

Okay. I have a few questions for you already, but we’ll go ahead and just open it up for even more while we answer these ones that we already have. Can you elaborate on the relationship between complex PTSD and suicide? 

Well, complex PTSD would be that layered effect to PTSD over time, so multiple traumatic incidents. Usually, what happens with complex PTSD as it relates to suicide is that this individual has just accrued trauma after trauma after trauma and hasn’t addressed the trauma via treatment. They’ve addressed the trauma in ineffective or maladaptive ways, which has allowed them to continue experiencing more and more and more and yet not really get better. So, I always relate to it like a Jenga tower. Over time, every traumatic experience takes another block out of the Jenga tower. What eventually happens? It comes crashing down. 

Well, also what takes blocks out of the Jenga tower is when you use alcohol to treat it, or you use avoidance, you engage in fighting that causes a divorce. All of that causes these little towers to fall. So, our people that are at risk for suicide — that experienced complex trauma — are the ones that have ignored symptomology, and it’s just increased in frequency and severity. And then they’ve used maladaptive coping mechanisms to treat it and make it manageable for a certain amount of time. And then that’s caused other consequences, like losing your job, financial stressors or maybe marriage and divorce. And then at that point, the person just goes, “Well, what the hell is the point? Let’s cut my losses.” 

Awesome, thanks for answering that. What are your thoughts on using the word “completing suicide” versus “committing suicide?” 

I don’t know if I’m, like, partial to either. I understand that some people have a negative reaction to the word “committing suicide.” Personally, for me, I’ve used both. I’m sure you guys have heard me say that. I was trained with “committing suicide,” so that tends to be the rhetoric that I use, but “completing” isn’t. 

Yep, I dunno if I feel partial either way. More interchangeable from your perspective, I guess. 

From my personal perspective, yes. 

In regards to stigma, taking it kind of back to seeking out help, someone posted the question that many don’t go to counseling because they fear that their insurance company will provide them with the diagnosis and then that will then get to their employer or make it more difficult in the future for certain things. How would you encourage someone to work through that? 

Okay, so I will tell you: Suicide is not a diagnosis. Well, there’s the B code. Typically, clinicians don’t diagnose suicide itself. They’ll diagnose depression or what have you, but insurance companies still have to operate with protected health information. So, only certain individuals get access to your mental health notes or your actual diagnoses, so on and so forth. Now, can an employer see that insurance has been utilized? Yes. Can they necessarily see the specifics of it? No. Could they subsequently ask you, “What did you use this for?” Potentially. One thing I would encourage someone that’s interested in using their insurance to do is to actually call their insurance company. What you can do is, like, a clinician that’s on staff — like, a mental health clinician — they do have peer reviews of clinicians that bill the insurance. And you can say, “This is what I’m concerned about. What is considered protected health information?” Then you get it just straight from the source. 

So, that’s if you want to use your insurance. Now, I have some people that they’d rather play it way more safe than sorry, and so they always just self-pay for things that can be an expense if you have financial issues, but they just feel like it adds a layer of security for them. And it makes them engage in treatment more effectively. So, I’m going to tell you right now, if you can swing the funds to self-pay and you think that would just be one more layer of protection that would make you feel more comfortable going to treatment, do it. I would also encourage folks that if that’s the path they’re going to take or a route they want to take, ask the clinician if they offer sliding scale rates for first responders. A lot of them do, and it comes down to, like, the same price that you would pay for a copay. So, that’s another kind of way that you can maybe find even more options or make it even more kind of feasible. 

Alright, so another question that’s kind of got a little bit of a scenario, I’m going to read that for you. It’s coming from someone from a smaller department with less than a hundred members. They’ve had three suicides in the past 40 years, with the most recent just over a year ago. They’ve also had — this kind of goes back to that retiree question — but they’ve had a lot of drug and alcohol issues and PTSD in the recent years, most often occurring with retirees. What sort of advice would you have for them? I mean, you kind of touched on this already as far as maybe checking in with the retirees or preparing them for that, but do you have any extra insight there? 

If I were to think ideally what resources you could do is, yeah, do some pre-retirement counseling. We have an agency around here that actually kind of checks in in thirds over the course of a career. Early stage, mid-stage, late stage. And then also, are you circling back with your retirees? Do you guys have some sort of group membership that they can get together and connect and have war stories and all of that? Again, what I find a lot of is that loss of identity that has happened. We have attempted to try and start a retiree support group, at least in my area. It didn’t really take off, but that might be because we’re a little spaced out. Your department, being smaller — potentially, you create some sort of social events just to connect these retirees together. Maybe it’s once a month, maybe it’s just here and there and it’s a breakfast or something. Somehow, try and get them re-engaged with your department as well. So, are there opportunities for them as retirees to come back and be in the station and talk to new people? 

I think we can all agree — or hopefully — that a lot of healing starts with connection. And I think even just engaging retirees and a leisurely sort of activity would be great. Recently, I’ve seen a lot of different kinds of PDF flyers out there for golf tournaments, or golf meetups, or to go hunting, or different stuff like that. So, I think you’re right. Just kind of linking people together could be a huge kind of preventative measure to take. And you could always share — you could make peer supporters available for retirees too and let them know that. You could always share the resources as well of what mental health professionals are available to the employees. Now, maybe they don’t have the same benefits, but you can at least dispel the information. Like, I know our practice — the cities will pay for current employees but not retirees. So, what we do is we give retirees the sliding scale that we would give active people if they didn’t have any more sessions left. That’s what we do for our retirees, so you can always share those resources with them as well. 

We’re right at the 1:30 mark; are you good to keep going and answering a few more questions? Okay, great. So, hopefully everyone can stay on. We have still a good chunk of people on with us, so if you have questions, keep them coming. So, the next one that I have. You talked a little bit about humor and humor maybe being a protective factor — also maybe a desirable trait in a clinician that’s working with this population. But can you talk maybe about the flip side of how kind of deflecting with humor or really utilizing a dark sense of humor as a defense mechanism — how that could be detrimental? 

Ooh, yeah. I will tell you this right now: It happens a lot. And I think clinicians can walk into this trap of, “Okay, so they’re making light of things,” and I have had firefighters come in and say, “Well, the last therapist told me that I was good to go, so I stopped going.” Well, why are you scheduling it with me then? “Oh, because there’s still stuff wrong.” And what happens is that someone is using that humor to dispel the inner tension. Don’t get me wrong, I love to have a good time, like, in my daily life. So, someone joking in session is fun, but do you circle back to the issue? Do you allow them to do that sort of sense of humor, dispel that inner tension, recognize it for what it is? And then circle it back to, “Okay, but this is what you were talking about. Go back there.” That’s usually, like, I’m very direct with it. If someone’s talking to me, they’ll mention a topic, they’ll make a joke about the topic in a related way, and then I say, “Okay, alright.” Laugh about it. Circle back. “What were you trying to say with this? Let’s go back here. Let’s stop joking. I want to know.” 

Usually, people are super responsive to that. I will tell you too, in the humor, there can be information as well. That’s where you got to listen out for those indirect sort of verbal cues of, like, is someone making fun of themselves, which might be suggesting that they don’t have a lot of competence in themselves? Are they making a lot of jokes about death and dying, and maybe that’s actually where their focus is really at? Make sure that you’re not overlooking the humor as much as you’re being responsive, and be flexible with it. I think flexible is my best word of how you use that humor. You can get information out of it. It can be used as a tool to connect with the person and it can be used as a tool to avoid bigger issues too. 

So, what about — and this may not necessarily be humor — but kind of at the tail end of that question that was posed, it mentioned bullying and maybe some hazing as a way to kind of deflect and encourage people not to reach out. What advice do you have for kind of changing that culture within that? 

That’s hard because I’m also not in the agencies. Really, I pose that to the 80-plus members that are here that are actually in the agencies, and it takes one person to start change. Really, firefighters are going to be more apt to seek out treatment if they see that their brothers and their sisters are open to do it too. So, normalizing that. I think if you want to start mitigating the effects of bullying or hazing, then those of you that are actually employees here — you guys have to start being open with it. So, myself and Molly and Kelly and Myrrhanda, we know that we support mental health and I think all of you guys do if you’re here. But if we go in, we’re not in the trenches, so it’s easy for us to say that. I think it takes other people going, “Yeah, I did it and it was helpful.” And someone goes, “Okay, I’ll try it too.” Being vulnerable. Yeah. 

And I don’t even know if it’s — I think vulnerability does exist for some people. I’m finding more and more people are starting to feel really energized after they go to treatment. Like, I don’t know if it’s just my place — I’m sure it’s not — I think people are just, like, so happy to start getting some of this junk out and actually seeing results for it that they’re like, “Oh, cool.” It’s kinda like when you go to the gym and you finally start to lose five pounds, you’re like, “Yeah, this worked.” So, I think I’m finding a lot of firefighters are actually going into their departments, and they might not initially say that they went, but when they hear someone else talk about it and they’re like, No, I went, it was great. I got it done. It was super effective.” Or they said, “No, it helps me with this. You should try it.” That goes a long way. 

So, this question is similar. This is how it starts: When attempting to address one’s mental health, that can bring a sense of isolation because that person may feel like, “I can’t talk about this without other firefighters.” Would your advice be to not talk about it, and once you kind of get a stronger basis and treatment, to then start kind of doing what we just said, as far as telling people what’s worked and what hasn’t? Or do you have other advice as far as maybe warding off some isolation that could come with asking for help? 

I think it’s different for everybody. Like, everybody needs to do their process. I have some people that are very open with treatment and they, actually, it helps them to say that they’re in it and it helps them to talk about their process. I have other people that they don’t want anybody to know. And a lot of times, it’s not even for that perceived social judgment as much as it’s more of their own judgment of themselves and their working through stuff. My first thing to tell them is, “Look, man, your secrets are yours and they are privileged, and not everybody gets the privilege of knowing everything about you. So, you work through this.” And I think as long as that connection with the therapist is there, then that’s going to help them feel connected. And, of course, encouragement to clinicians too. If the department has a good peer support team or maybe encouraging the client to reach out to like a support group if they don’t have a peer support team, they don’t want to use their own department. Reaching out to like someone through the IAFF or some sort of support group via Facebook so that they can be anonymous, but it helps normalize things too.

So, similar question. What about for members of the LGBTQ population? Do you feel like you have any specific advice or know of any specific resources out there for members of that population? 

Off the top of my head, I would not. I’m not even going to pretend to be able to name-drop any organization. For me, it would just be, like, let’s not assume to know everything about every group of people. Those unique nuances that LGBT firefighters experience — that’s going to be unique. And so I, at least for me as a clinician, all of you guys can maybe adopt this strategy. I go in knowing I don’t know it all, right? I might be standing in front of someone that I know enough to be able to work with them, but I’m not scared to ask them, “Can you tell me about this? Because I want to know what that is for you.” Just for all intents and purposes, not every LGBT firefighter is exactly the same too, so I don’t necessarily have an additional resource for you. As much as I would just tell everyone to know, like, everyone’s process is idiosyncratic. Everyone’s process is unique, and so we have to be open to learning about that individual. 

So, what is your advice? I’ve got a couple of more questions. What is your advice if department management isn’t behind mental health and they’re more focused on physical fitness for their members? Do you have any ideas or tips on how to advocate a little bit more for mental health services? 

I just got this great suggestion from one of my departments about talking to the union. Really, kind of going to your union body and advocating on the behalf of you and your people on why this is needed. Now, if anything — if your admin is not supportive of mental health, then it does fall to you to build the resources. And who knows — maybe you could be your own resource pool of information and be kind of vocal about, like, “Look guys, here’s this resource. Here’s all of this.” And you kind of do the research or get assistance with IAFF to put resources out there. But I did recently just get this suggestion about just going straight to the union and starting to advocate for employee benefits. 

A couple more questions. If anyone else has any other questions, definitely send them in. So, what are your thoughts around involuntary commitments versus strongly encouraging someone to go get an assessment at an inpatient facility, or just going directly to an outpatient clinician like yourself? What do you think the best kind of course of action is? 

It depends on what you’re looking at. Someone was caught most recently in an attempt, maybe even making a suicidal gesture. It depends. It depends what — so, at least in my capacity, a lot of my departments call us directly, even though we’re outpatient. Why? Because we’re 24/7. So, they actually have that ability to access this progressive sort of chain of treatment. Which admittedly, I always like outpatient better because at some point, the person has to get there. And for those of us that are familiar, inpatient facilities are not always restorative. They’re not always healing for a person in distress. They do what they’re supposed to — they keep someone safe and potentially give someone medication that has been untreated for a while and needs to be. Definitely, facilities are there and use them, but they’re not always the most healing. They can be rather disrupting for someone. 

So, if you do find that someone was engaged in a gesture, how far that gesture goes, that would differentiate between strongly encouraging them to go and maybe accompanying them to a facility, or, “Can we get you into an appointment?” ‘Cause the other question is how quickly can you get that appointment? I think that’s where you have to use discretion of how at-risk is this person as well, considering the risk factors and the warning signs that we’ve just talked about. So, definitely utilizing your resources, maybe asking questions of those resources that you know of and planning ahead. I think that’s really kind of the piece there — not finding yourself in a moment of crisis and then being reactive. Kind of putting these things in ahead of time — that’s important, right? I will tell you, involuntary is always not the most ideal. Someone making choices for themselves is always going to carry the most efficacy. 

What about any information or research that you might be aware of, as far as increasing mental health awareness problems around behavioral health issues and suicide to a toxic administration? We kind of already answered this, but do you think, again, that’s just kind of advocating, reaching out to different resources, encouraging or asking them to kind of help you in that advocacy? 

Yeah, I would. I think my answer will still be the same — that your union is going to be your biggest support there. I know I’ve worked really closely with the union. When I come on with a new city and if I’ve started with admin, one of my first places I always go after I’ve gotten on is I schedule a meeting with a union president or one of the board members. Something just so that they can start. I’m sure that question comes from a personal place, but certainly, I would say using your union to help advocate and maybe doing some of the legwork and the research yourself too. 

What about any recommendations? I had a little technical difficulty there — silent dark — but what about any recommendations for improving resiliency in firefighters? 

Training is always great, but good trainings — ones that people can connect to things like this. Building resiliency too. Making sure that you’re building resiliency in terms of all broad scopes of your life. Physical health is important, and making sure that they do have access to resources in their personal life, making sure that mental health resources are accessible and encouraged. I think all of those things. When I think resiliency and building it, you got to look at your mental health, your physical health, your emotional health. You’ve got to look at everything, and it’s not just in the department — it’s at home too. So, that one’s kind of a loaded answer. I think using some cognitive strategies — I have people that will come into treatment just because they’re starting to get a little jaded and funky, and they just want to learn how to look at things a little happier in life. And not that everything has a silver lining, but it’s, like, “I just don’t want to be so grumpy all the time, so how do I figure that out?” Learning some mental strategies to reframe life so it doesn’t suck so much. 

I’ve got one last question. So, do you think organizational leadership, good or bad, contributes to mental health problems or increased suicide within the department for their members? 

I would tell you guys that I can’t support this with research — it’s just experience — a good administrative organization and wonderful leadership always is so beneficial for mental health. I can’t say that the bad ones directly correlate to poor mental wellness; I don’t have the research to support that or say that definitively. I think we can all think about it from a practical sense — how that would really complicate someone that’s already in a state of distress if they’re going into work and they don’t feel supported or defended by leadership or they don’t have the resources that they need. Administration doesn’t support them. Advocate — that’s the word I was looking for. So, I would say good leadership always just carries so much weight with the people. 

Awesome. Well, that’s all that we have as far as questions go. Do you have any final thoughts or anything that you want to wrap up with? 

No, thank you, guys. I’m sorry I ran over, and thank you so much for entertaining this two-plus hours and indulging me in the learning curve of the webinar universe. 

Molly:
Well, thank you so much for being on with us. I think that was a very informative presentation and we’re just really grateful to have you. Thank you, Dr. Benson. Thank you to all of our attendees. I know we have almost 150 people still here, so clearly they enjoyed the information that was shared and no doubt will utilize it to improve their own agencies. So, thank you all for leading the charge. I know some people are up against a lot of factors, some of which we talked about today, and really, we just appreciate you championing behavioral health. If there are any questions, one of my lovely colleagues — I think Myrrhanda — will drop our emails in the chat. Should you need to follow up on anything that you might’ve heard or seen today, we’d love to help you with that. If there are any questions that come to you after the presentation, please send them our way and we’ll make sure that either Dr. Benson gets them or that we’re able to answer them ourselves. We hope to see you all in October. October 8th, Molly will be presenting “Building Cultural Competency for Clinicians.”

So, that’s a really great introductory training if you know of anyone or might be a clinician yourself looking for more cultural information about how you can best set yourself up to support firefighters and fire service members who may be seeking your assistance as Dr. Benson talked about today. Then October 15th, we’ll be revisiting addiction in the fire service. So, focus on substance use disorders of several different kinds — what that looks like for fire service members and treatment options that are available. 

And we did highlight a little bit about inpatient treatment centers, and there are a spectrum. I’ll give my shameless plug that the IAFF Center of Excellence is an entirely voluntary facility that was designed with firefighters in mind. So, while that’s not necessarily the case for most inpatient centers just based on the level of acuity of their clients, we’ve been able to have a facility that is not a lockdown facility — that is a lot more approachable for fire service members. And it’s something to consider if you do have a colleague, family member, friend, who might be in need of assistance. So, we are so appreciative for everything that you’ve done for us today, Dr. Benson. We’re so appreciative of all of those who’ve been engaged. Thank you so much. Have an amazing afternoon or rest of your day, depending on what time zone you’re in. We hope to see you in the future. Thanks so much, guys.

Thank you for joining us. Please visit our website IAFFrecoverycenter.com for future training opportunities and recorded webinars. Thank you for all you do.

Webinars:

• Behavioral Health Among Fire Fighters and Paramedics
• Work Life Balance in the Fire Service

Articles:

• Knowing the Warning Signs of Suicide Can Help Save a Life
• Fire Fighter Suicide: Know the Signs
• Speaking Out About Fire Fighter Suicides
• Losing a Brother or Sister to Suicide
• 5 Tips for Achieving Work-Life Balance