. Author(s): Janet A. Wilmoth. Published on May 2, 2014.

KYLE IENN WAS ONE OF THE NEW BREED OF FIRE CHIEFS. A 23-year member of the fire service, he led a progressive volunteer fire department in his hometown of Ralston, Nebraska, a suburb of Omaha. He was active on the state and national level with the Nebraska Fire Chiefs Association and the International Association of Fire Chiefs’ Volunteer Combination Officers Section. He served the National Fallen Firefighters Foundation’s “Everyone Goes Home®” program, an initiative to prevent firefighter line-of-duty deaths and injuries. As founder of the Nebraska Serious Injury & Line of Duty Death Response Team, Ienn was first on the scene to help fire departments with the death of a firefighter.

In a 2010 interview for Omaha.com, when asked what kept him motivated, Ienn replied, “Knowing I have helped someone.”

On the morning of January 31, 2012, just days before his 41st birthday, Ienn’s body was found hanging from a bridge in an Omaha park. A fire department vehicle was parked nearby. Omaha police concluded that Ienn committed suicide. He left behind his wife, who worked as an administrative assistant with the fire department, and three teenaged children, two of whom participated in the fire department’s Explorer program.

The suicide of an active, high-profile chief sent a shock wave through the nation’s fire service. Deaths like Ienn’s, along with “suicide clusters” in recent years involving firefighters in metropolitan fire departments around the country, have focused increased attention on behavioral health problems—alcoholism, drug abuse, depression, and post-traumatic stress disorder (PTSD) among them—affecting first responders, primarily firefighters and emergency medical service (EMS) personnel. While empirical data on the problem remains scarce, there are suggestions that behavioral health problems among emergency responders may be widespread; studies have found that as many as 37 percent of firefighters may exhibit symptoms of PTSD. Compounding the problem is a lingering stigma that can make it difficult for emergency responders to acknowledge behavioral issues like depression, whether it’s their own or that of a colleague.

Firefighters hang black bunting

Firefighters hang black bunting at a Connecticut firehouse in memory of a chief who committed suicide. Health experts say the suicides of colleagues can be some of the most difficult events for emergency responders to cope with.
PHOTO: AP/WIDE WORLD

But a host of recent efforts—reports, resources, hotlines, a willingness to simply discuss the issue—is drawing the problem out of the shadows and providing emergency responders with a variety of tools to fight it. The National Fallen Firefighters Foundation (NFFF), for example, is launching a number of initiatives in the coming months, from the creation of behavioral health apps to planning a conference to discuss how to add behavioral health evaluations to annual physicals for emergency responders.

This summer, the International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC) will issue new, broader recommendations on behavioral health, including suicide prevention and awareness, part of the Fire Service Joint Labor Management Wellness-Fitness Initiative launched in 1996. Meanwhile, the NFFF awaits word on funding for a proposed empirical study of firefighter suicide—the first of its kind, and a crucial element for understanding the scope and characteristics of the problem.

Ken Holland, a senior emergency services specialist at NFPA and staff liaison for NFPA 1500, Fire Department Occupational Safety and Health Program, says behavioral health remains a difficult topic for emergency responders for a variety of reasons. “The thinking is, ‘we’re called on to help everyone else—we aren’t the ones who should need the help,’” says Holland, who’s been a first responder for 22 years. “No one wants to admit that they have a concern or an issue. But the cumulative effect of what we see in the fire service day to day, without having a way to offload some of that stuff, is obviously becoming a larger issue.”

'State of the Union'
An influential white paper takes stock of behavioral health problems among emergency responders and offers a plan of action

While a definitive epidemiological study of emergency responder suicide and behavioral health issues has yet to be completed, perhaps the best description of the problem is a paper titled “Suicide Surveillance, Prevention, and Intervention Measures for the U.S. Fire Service,” published in 2011.

The paper, a result of a conference that brought together representatives of the psychological, medical, public health, and fire service communities, was coauthored by Dr. Richard Gist, principal assistant to the director of the Kansas City (Missouri) Fire Department and a faculty member in the Department of Preventive Medicine at Kansas City University of Medicine and Biosciences; Vickie Taylor, a licensed clinical social worker from the Prince William County (Virginia) Community Services Board; and Scott Raak, an EMT-P from Kansas City, Missouri. The paper summarized what they had learned about emergency responder suicide and identified the experts and their work and how it translated to the fire service. Taylor describes it as “a kind of ‘state of the union,’ as in what do we know, where are we, and where do we go from here.”

Read more about the paper, including a list of recommendations.

Information gap
It can be easy to interpret news of another firefighter suicide as evidence that the problem is on the rise. But some researchers, including Kim Van Orden, an assistant professor of psychiatry at the University of Rochester Medical Center, aren’t convinced that behavioral health issues are actually increasing among emergency responders, arguing instead that the growing awareness around the issue is finally shedding light on long-buried problems. “We’re just becoming aware of a problem that’s been there all along,” she says.

Part of the problem with addressing behavioral health issues among emergency responders is the difficulty in quantifying it. Psychological risk is an undeniable part of the job; emergency responders may die by suicide at about the same rate as the general population, the NFFF says, but they are exposed to suicide attempts and completed suicides at a significantly higher rate than most other occupations. As anecdotal evidence of related behavioral health problems mounts, though, empirical data remains scarce. “Surveillance is a problem—the U.S. does a really crummy job of that in general,” says Van Orden. “Our data on any one particular occupation in the U.S. is very poor.”

No recognized national agency collects statistics on firefighter and EMS suicides; death certificates do not universally include occupational data, making it difficult to track information or construct trends, and information on many retired firefighters does not specify an occupation at the time of death. Sixty-nine percent of the U.S. fire service is volunteer, and their fire service affiliation is unlikely to be mentioned on death certificates.

The most widely recognized source for this information is Jeff Dill, a captain with the Palatine (Illinois) Fire Protection District and a licensed counselor specializing in firefighter behavioral health issues. Dill gathers information from suicide reports on ffbha.org, the website for the Firefighter Behavioral Health Alliance (FFBHA), a non-profit organization he founded in 2011. Dill says 360 confirmed firefighter suicides occurred between 2000 and 2013, with more of those deaths occurring in recent years; 57 occurred each year in 2012 and 2013 out of a national population of 1.1 million career and volunteer firefighters.

But the information Dill receives is sent voluntarily, and represents only a fraction of the nation’s more than 30,000 fire departments. Dill is reluctant to estimate the actual number of emergency responder suicides, but he believes his data offers a window into the scope of the behavioral health problem among emergency responders. “Imagine if we had 80 or 90 percent reporting,” he says. “The numbers would be much greater.”

According to Dill’s data, more than 70 percent of firefighter suicides are white males, the dominant demographic among U.S. firefighters. Firearms are the leading method of completed suicides, followed by hanging. The age range with the highest frequency of suicide is 41–50, followed by 31–40; 18–30 and 51–60 are tied. The majority are active-duty personnel, as opposed to retired.

To address the need for empirical data, the NFFF has applied to the Assistance to Firefighters Grant Program, administered by the Federal Emergency Management Agency, for funding to support research on firefighter suicides, ideation, and attempts. The work would evaluate claims that “the job” is causing more firefighters to take their own lives, and that their rate of suicide is higher than the rest of society, information that could help the fire service and health professionals properly guide preventative efforts.

“No quick fix here”
What is known is that that the nature of the job has changed dramatically in recent decades. While the number of fire calls has declined, in part due to improved fire prevention methods, fire departments have taken on many new responsibilities: rescues, vehicle extrications, hazardous materials incidents, and a tripling in the number of medical aid calls over the past 25 years, according to NFPA data. Responders routinely encounter incidents that include severe injuries and death—including suicides. “Our people are the ones who take people down [from hanging], and they see suicide firsthand when they clean up the gunshot wounds,” says Elizabeth Crowe, coordinator of human relations for the Chicago Fire Department. Emergency responders also face the risk of exposure to cancer-causing chemicals, the trauma of mass-casualty incidents, and, recently, of becoming the targets of active shooters. The risks faced by emergency responders are more varied than they’ve ever been.

With those risks comes emotional stress. Firefighters have historically been reluctant to talk about those stresses, in part out of fear that they could be stigmatized as weak or vulnerable. While they may consider talking to peers about these kinds of problems, many emergency responders maintain an almost perverse aversion to therapists or other “outside” professionals who, some responders believe, understand neither the work nor the stresses they face.

While some observers like Van Orden see signs that the stigma is declining, anecdotal accounts suggest it remains pervasive in the macho, male-dominated culture of the American fire service. Emergency responders pride themselves on being a tightly knit brotherhood that works together in dangerous environments, relying on each other for survival. Individuals with that kind of bias for action may be unwilling or unable to step out of their comfort zone and ask ‘What’s going on with you?’ when a colleague withdraws or fails to respond to questions or concerns.

“The prevailing ethos is ‘break the windows, kick in the door, and run in with a hose line,’” says Dr. Richard Gist, principal assistant to the director of the Kansas City (Missouri) Fire Department and a faculty member in the Department of Preventive Medicine at Kansas City University of Medicine and Biosciences. “Firefighters may be looking for a quick fix [to behavioral problems], but there is no quick fix here.” Unfamiliar with how to address the problem, sufferers of PTSD or depression can self-medicate with alcohol or drugs, compounding the problem and speeding the downward spiral.

Despite, or because of, the difficulties of the job, emergency responders can sometimes focus on little else. “People make firefighting their everything in life, with the signs on their cars and collections of fire memorabilia,” says Crowe. The strong sense of belonging and the camaraderie needed to take risks can work in reverse when a firefighter retires or leaves the fire service and no longer has that connectedness. Firefighter suicides often involve the loss of a job, particularly for medical conditions beyond a person’s control, such as heart or stress-related illness or work injuries. Males over the age of 55 are a particularly high suicide risk when faced with retirement or sudden job loss.

But behavioral health advocates hope the efforts to promote awareness around the issue will make it more acceptable, if not actually easier, for emergency responders to acknowledge that a problem exists—and that they have a lot of company, both among other responders as well as the general public. One in four U.S. adults experience a mental illness in any given year, according to the Centers for Disease Control, and half of all U.S. adults experience a mental illness at some point in their lives.

Even semantics has a role to play; the term “behavioral health” is intended to erase some of the stigma of “mental health” or “mental illness,” while encompassing a broader range of psychological behavior including emotions, temperament, and motivation. “Emergency responder exhaustion syndrome” has been proposed as a more occupation-specific term for the psychological rigors faced by firefighters and EMS personnel.

Addressing the problem
The focus on the behavioral health of emergency responders increased after September 11, 2001. Responders had watched helplessly as desperate people, trapped by flames in the burning World Trade Center towers, jumped to their deaths. They had worked among the rubble piles at Ground Zero in a grim search for human remains, all the while coping with the loss of hundreds of their own. The Federal Emergency Management Agency (FEMA) sought behavioral health assistance for responders, and the NFFF answered FEMA’s call by providing peer support to firefighters and their families. As a result, the foundation developed prevention programs for PTSD through interventions that rely heavily on peer support.

In 2004, the NFFF invited 200 leaders from 43 fire organizations to a line-of-duty death prevention summit in Tampa, Florida. A result of the meeting was a document titled “16 Firefighter Life Safety Initiatives” (lifesafetyinitiatives.com) designed to reduce the number of annual firefighter deaths. Among the initiatives was number 13, “Psychological Support,” which stated “Firefighters and their families must have access to counseling and psychological support.”

Just as activity and awareness around behavioral health were increasing, a disturbing phenomenon rippled through the fire service. In 2008, the Chicago Fire Department announced it had experienced seven suicides (both active and retired personnel) within 18 months, and similar patterns, known as “suicide clusters,” were discovered in Phoenix, Philadelphia, and in other large metropolitan fire departments around the country. Departments and firefighter unions launched a variety of programs to address behavioral health, but no in-depth epidemiological studies were made to determine why such patterns occurred, or of the conditions that existed that could lead to such behavior.

Behavioral health experts say the fire service can learn something from law enforcement when it comes to educating personnel about suicide. For starters, experts say, police nationwide keep much better numbers on behavioral health problems; according to the National Surveillance of Police Suicides (NSOPS), a comprehensive study conducted by the Badge of Life Police Mental Health Foundation, police suicides dropped from 141 in 2008 to 126 in 2012, based on an estimated population of 900,000 sworn law enforcement officers in the U.S. According to its authors, NSOPS tentatively attributes the drop “to the increased number of departments adopting peer support programs and the increased willingness of officers, many of them younger, to seek professional assistance”—not only when they have a problem, but also through preventive measures such as annual mental health checkups. Similar efforts are underway for emergency responders through the FFBHA workshops and the NFFF programs.

Some observers have speculated that the new attention being paid to emergency responder suicide and behavioral health problems might be due in part to former active-service military personnel entering the emergency responder ranks and bringing PTSD and other behavioral problems with them. While there is no data that specifically tracks this link, programs like the Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment and the Gatekeeper Program instituted by the Air Force address a range of behavioral health issues for veterans and active-duty military personnel. Last year, the “Stress First Aid” training developed by the U.S. Navy was adapted and introduced to the fire service.

Action steps
In February, Tom McGowan, a public fire protection staff liaison for NFPA, posted an entry on the association’s “Today’s Responder” blog . McGowan is a retired member of a small fire department in Massachusetts, and the entry was about the suicide of a former firefighting colleague—a 25-year member of the department—who had recently retired. McGowan lamented the unknowable nature of why the man had taken his own life, and presented a range of responses from fellow firefighters, from sadness to anger.

He also issued a call to action. “This is not a eulogy,” he wrote. “This blog is to make all of us in the fire service and in public safety aware of the stresses of the job or home life or a combination and to say something, out loud, early! Don’t hold it in, don’t be a hero.” While the post received only a handful of comments on a related Facebook page, it had more than 2,500 views in the two days after it appeared—exponentially more than the site’s posts typically receive.

“Maybe people were looking for some sort of assistance or help or direction,” McGowan says of the volume of views. “If I can help prevent one other person from committing suicide, or at least get them to seek help or intervention, then the blog served a purpose.”

Last year, NFPA incorporated firefighter behavioral health issues into its national standards. According to NFPA’s Ken Holland, two chapters in the 2013 edition of NFPA 1500 were re-titled—they’re now “Behavioral Health and Wellness Programs” and “Occupational Exposure to Atypically Stressful Events”—to broaden the perspective of firefighter health and to allow for a more comprehensive application of behavioral health programs. The latest edition of NFPA 1500, Holland says, “takes in the whole continuum of behavioral health and wellness of fire department members as opposed to one particular snap-shot.”

Help is Here
Online behavioral health resources for emergency responders

suicidepreventionlifeline.org    1-800-273-TALK (8255)
Launched in 2005 by the U.S. Substance Abuse and Mental Health Services Administration and the Mental Health Association of New York City, the National Suicide Prevention Lifeline provides free and confidential 24/7 support to people in suicidal crisis or emotional distress.

nfpa.org/1500
The document information page for NFPA 1500, Fire Department Occupational Safety and Health Program, includes chapters titled “Behavioral Health and Wellness Programs” and “Occupational Exposure to Atypically Stressful Events.”

ffhba.org
This site includes information on the Firefighter Behavioral Health Alliance and on training workshops, a suicide questionnaire, and how to report firefighter and emergency medical service suicides. 

flsi13.everyonegoeshome.com/
The website for the National Fallen Firefighters Foundation “Everyone Goes Home” program offers resources for officer training, peer-support, and behavioral health issues in the fire and EMS services.

nvfc.org/help
The National Volunteers Fire Council website offers reports, online training, and other resources for first responders.

impact-uw.org
IMPACT is an evidence-based depression care program developed at the University of Washington, including tools, manuals, and videos on depression treatment.

csff.org
Counseling Services for Firefighters includes resources for training senior officers and clinicians for working with first responders.

firehero.org/resources/families/survivors
The website of the Fire Service Survivor Network includes resources for families and coworkers of firefighters killed in the line of duty.

nvfc.org/help  1-888-731-FIRE (3473)
This free, confidential helpline available 24 hours a day, seven days a week to members of the fire, EMS, and rescue services and their families.

brattlebororetreat.org/usp
The Uniformed Service Program includes specialized trauma and addiction treatment for law enforcement, fire, military (active and veterans), EMS, and corrections personnel.

badgeoflife.com
A website run by the Badge of Life Police Mental Health Foundation and devoted to the psychological health of police officers nationwide.

Discussions are also underway to include additional material on behavioral health for emergency responders in NFPA 1582, Comprehensive Occupational Medical Program for Fire Departments. “Tying behavioral health into the annual fire service physical would provide another opportunity to detect these kinds of problems and to address them,” Holland says.

During the revision process for the 2013 edition of NFPA 1500, Chapter 12, “Occupational Exposure to Atypical Events,” the topic of critical incident stress debriefing, or CISD, generated controversy. For more than 20 years, the peer-based CISD has been used to reduce psychological stress for emergency responders; following a critical incident such as a violent event or a coworker’s death, responders could talk to teams of trained fire service members. CISD was considered effective when it was introduced, but recent research indicates other methods, including the use of outside behavioral health professionals, may be more effective with first responders after such incidents.

The committee for NFPA 1500 acted on a public proposal, submitted by Gist, which removed CISD from Chapter 12 and made only minor mention of it in the chapter annex. Committee members believed, based on the research and data they had before them, as well from their own experiences, that a different approach was needed to address fire department members and how the occupation could impact them. The CISD could be too intense for some responders, they said, arguing that a lower-key, more open-ended approach such as the “after-action review” would work better for more people.

The proposal drew sharp criticism from supporters of the CISD approach, but the committee was not swayed. The revised text in Chapter 12 focuses on the use of professional services when addressing exposure to atypical stressful events and moves away from the debriefing model as a requirement or desirable intervention.

The NFFF, meanwhile, is busy on a number of fronts. In addition to planning a conference on behavioral health screening, the organization is preparing an industry-wide outreach campaign based on the acronym “ACT”—Ask, Care, Take, a variation of the U.S. Army’s “ACE” program, for Ask, Care, Escort—emphasizing the need to take action to assist emergency responders in need of help. This summer, it plans to launch the first PocketPeer web/app program, funded by an AFG grant, that combines web training in motivational interviewing—essentially, how to get a person in need to act on a referral—with information on recognizing suicidality and resources to link that person with effective sources of professional care. NFFF has applied for another AFG grant for a second PocketPeer web/app program to address stigma issues and promote help-seeking among responders.)

Later this year, NFFF plans to contribute additional information regarding suicide and intervention to the “Helping Heroes” site, helping-heroes.org, created to provide behavioral health professionals working with firefighters with resources to learn the best evidence-based treatment techniques for conditions affecting the fire service. 

Efforts by the NFFF, NFPA, and many others suggest a new openness to addressing behavioral health issues, and that troubled emergency responders need not suffer silently or in isolation. Even so, and despite the wealth of new resources at their disposal, some incidents can be especially difficult for emergency responders to handle—like the suicide of one of their own. After the death of Kyle Ienn, the up-and-coming Nebraska fire chief, a CISD team arrived to assist members of the hard-hit department. Joe Eischeid, the assistant chief at the time of Ienn’s death, makes it clear how tough it can be to recover from emotional wounds. “Two years later,” he says, “we still have members who are struggling.”