The American Institute of Stress https://www.stress.org/how-the-best-handle-s
By Christopher L. McKenna
Few would dispute that being a firefighter or an emergency medical technician (EMT) is a dangerous and a stressful occupation. Despite the risks, 1.13 million men and women served in the fire service in 2014, of which nearly 69 percent served on a voluntary basis.1 Moreover, these individuals responded to approximately 31.6 million calls across the country in 2014, ranging from fires to requests for medical aid, hazardous materials, and false alarms.2 Undoubtedly, many of these situations result in exposure to traumatic or stressful situations. Not surprisingly, those in the fire service have higher rates of depression and suicide.3This raises the question of whether these bold individuals are getting the help they need to combat the, at times, difficult encounters.
For example, a recent study showed that 58 percent of almost 500 participants were more likely to report stigma-related barriers to care as members of the fire service.4 For decades, the fire service has convinced members that they are superheroes and that nothing can get to them. In recent years, however, the spotlight has illuminated the alarming suicide rate in the fire service. Some authors believe that the effects of this stigma cause individuals not to seek mental health care for fear of being labeled as weak or as unfit for duty. (4)
Unfortunately, research on the stigma associated with mental health services among members of the fire service has been overlooked in the existing literature. As such, this article looks at how the stigma affects firefighters in their daily lives and the struggles they face while attempting to seek treatment. Some of the recent firefighter suicide studies point out that one of the reasons the suicide rate might be so high is that firefighters do not seek mental health treatment.5Arguably, firefighters avoid help as a result of the stigma attached to mental health care in the fire service. This stigma labels anyone who seeks mental health treatment as weak and not a real firefighter because they are unable to handle the stresses of the job. The stigma was created by members of the fire service because some truly believe they are superheroes and nothing can hurt them. Yet, not seeking mental health treatment when it is needed can potentially have some drastic effects on a person’s life. On October 15, 2016, Indian River County, Vero Beach, Florida, Fire Rescue Battalion Chief David Dangerfield committed suicide after posting the following to his Facebook page:
“PTSD [post-traumatic stress disorder] for Firefighters is real. If your loved one is experiencing signs, get them help quickly. 27 years of deaths and babies dying in your hands is a memory that you will never get rid of. It haunted me daily until now. My love to my crews. Be safe, take care. I love you all.”6
David’s father, Bruce Dangerfield, confirmed that “[David] was seeing a doctor for a year and a half, about three days a week, to deal with PTSD.”7 The fact that it took Chief Dangerfield more than 25 years to seek mental health treatment is upsetting. Could his death have been avoided if he had felt comfortable seeking treatment sooner? We will never know, but we can work to change this stigma against mental health in hopes of saving someone else’s life.
Recently, as I have discussed this research with friends, people have reacted in one of two ways. Some view this research as a great topic that has the potential to produce very eye-opening results. Others respond by saying, “Why would someone waste so much time and effort to research such a worthless topic?” These perspectives represent the current rift within the fire service pertaining to mental health services. My goal is not to quantify how many members of the fire service ascribe to these two perspectives. The primary objective is to examine the extent to which this stigma is real among a group of fire service personnel and the perceived consequences associated with it.
Members of the fire service (firefighters, EMTs, and paramedics) risk their lives daily for people they have never met. The traumatic sights to which they are exposed would make a normal person cringe. Firefighters/EMTs have to remain calm and focused while treating those seriously injured while trying to suppress what they are seeing. Yet, once an incident is over, the experience begins to set in. Some try to brush it off, saying, “It is just another day in my life.” Some are so affected that it changes their life drastically. For example, some might finally realize that they need to seek help to be able to sleep through the night to avoid reliving the incident. However, when they are treated differently by their peers because they seek help, the problem becomes immensely harder to deal with.
We cannot expect the people who risk their lives for strangers to just shrug off the horrible images they see and go about life as if nothing happened. Mental health requires support, not the division created by this stigma. Left untreated, PTSD can lead to unthinkable consequences. Although not everyone exposed to serious incidents gets PTSD, some do; and those people need support to overcome the worst of it and begin to heal.
The fire service exists to help people in need. Why can’t it help its own members? Yes, the sights that fire service personnel see are horrific, but there needs to be support for those who need help to process these experiences. Departments need to confront this stigma head-on; moreover, they should encourage their members to seek mental health care to divert any potential mental issues later in life. If we do not take care of our firefighters, EMTs, and paramedics when they are in need, who will take care of us when we are in need?
STIGMA EVIDENT IN MILITARY AS WELL
Suicide in the fire service is growing at an alarming rate.8 It was only in 2010 that Captain (Ret.) Jeff Dill decided to undertake the task of tracking firefighter suicides in the United States.9 According to the Firefighter Behavioral Health Alliance Web site, the number of firefighter suicides in the United States was 81 in 2012; 70 in 2013; 112 in 2014; 132 in 2015; and 111 in 2016, the last figures reported. We should not look at firefighter suicides in the United States only. Dill began to look at international firefighter suicides in 2013. The fact is that the fire service has a growing rate of suicide for two main reasons: a cultural stigma against mental health care and untreated mental health disorders.10
In trying to understand why firefighter suicide is on the rise, a recent report found that 58 percent of 483 firefighters in the study “reported stigma-related barriers to care.” (4) In the same study of those 483 firefighters, [t]he most frequently cited stigma-related barriers were concerns about being treated differently by peers (44%, N=210), appearing weak (42%, N=205), having a harmed reputation (41%, N=198), being thought less of by others (37%, N=178), embarrassment (30%, N=147), and being blamed (26%, N=126). (4)
This study shows that fear of fire service members to seek mental health services is a factor in the high suicide rate. The stigma against mental health is not limited to the fire service. This stigma has for years lived in the ranks of the United States military. In a study conducted on soldiers returning from Iraq, those who had scored positively for mental health problems (in an interview required of all soldiers prior to returning home) were twice as likely to report fear of stigmatization and concern about barriers to obtaining mental health treatment.11
The authors of this same report found it crucial to understand what the meaning of a stigma is and to define the two types of stigma faced by returning military personnel. Stigma is defined as “a negative and erroneous attitude about a person; it is a prejudice or negative stereotype.” (11) There are two types of stigma: public stigma and self-stigma. “Public stigma is the reaction of the general public toward people with mental illness; self-stigma is the internalization of how the general public portrays people with mental illness and the belief in that portrayal.” Although these types of stigma are distantly different, they are composed of stereotypes and discrimination. (11) The stigma attached to mental health treatment may damage a person’s self-esteem and hinder treatment needed.12
In the military, it is harder for soldiers to report potential mental health problems than medical problems. (11) Soldiers deployed to Afghanistan and Iraq reported feeling that if they asked for mental health services, they would feel embarrassed and appear as weak. (12) In a study that compared active duty military to National Guard soldiers, it was found that “active duty soldiers consistently reported higher perceptions of stigma than National Guard soldiers at three and 12 months postdeployment ... active duty respondents endorsed stigma twice as often as their National Guard counterparts.”13
The need for mental health treatment in both the military and the fire service starts with the exposure to a traumatic event. In the military, 90 percent of soldiers returning from war have been exposed to a traumatic event. (11) There is no way to measure how many fire service personnel are exposed to a traumatic event during their time in the fire service, but one can speculate it is nearly every member of the fire service. If soldiers or firefighters internalize the stigma behaviors of those around them, they are likely to develop a self-stigma. (11)
“The development of a self-stigma has been hypothesized to lower one’s self-esteem, which, in turn, could inhibit one’s ambition to seek mental health care.” (11) On some occasions, individuals may view themselves as responsible for their disorder because they feel they should have control over their mind or they may feel responsible for experiencing symptoms of PTSD. (11) A better understanding of these stigmas will help individuals to see why soldiers and firefighters would choose to avoid seeking mental health treatment. This stigma against mental health is affecting professions in which people serve others; the fire service and the military are just two examples.
Members of the fire service and the military have voiced concerns about their reputation and being embarrassed. (4) Both express a need to decrease this stigma to increase treatment for their members. (11, 4) In his article, “The Stigma of Mental Health Problems in the Military,” Thomas W. Britt refers to a three-method program aimed at reducing the stigma attached to mental illness. The first strategy is protesting, an attempt to suppress the stigmatizing attitudes and behaviors. This would serve to inform society that it should not hold negative stereotypes or prejudices against mental illness. The second strategy is educating society on mental disorders. This is meant to provide realistic descriptions of problems, including the cause of the problems and how different problems can be addressed through a variety of treatments. The third strategy is to promote contact with individuals who have a mental illness. This is aimed at showing others that having a mental illness does not turn one into a bad person. This was the option that most successfully reduced the stigma. (11)
The fire service has also found a successful method for reducing this stigma. A study found that a two-day training program on mental health awareness and promoting the use of counselors was helpful to management in departments and even changed many chiefs’ attitudes toward mental health programs.14 In addition, the National Fallen Firefighters Foundation (NFFF) started a program called “Everyone Goes Home,” which is focused on “16 Life Safety Initiatives” designed to give the fire service a blueprint for making changes.15 The 13th initiative advocates psychological support for firefighters and their families.
CHALLENGES TO TREATING FIREFIGHTERS
Mental health providers face challenges when treating firefighters. The main problem is the stigma against seeking help, which often causes fire service members to distrust the mental health professionals. To prepare for this distrust, “it is imperative that clinicians who wish to work in this area have an in-depth knowledge of firefighter culture.” (10) Funding is another challenge for department and health professionals who want to work with first responders. “Large departments often have greater funding to provide a multitude of resources, which leaves a substantial gap of resources for a majority of the fire service, which operates on volunteers.” (10) Volunteer departments are unable to afford a number of resources large departments provide their members. As a result, volunteer departments are often overlooked. Most departments that do not have a program already established should have mental health professionals assist them in establishing policies and procedures to address suicide and mental health. (10)
HOUSTON FIRE DEPARTMENT PROGRAM
The Houston (TX) Fire Department (HFD) has implemented a successful Suicide Prevention Program. The impetus for the program was three active duty suicides and four retiree suicides that occurred between 2001 and 2007. The department’s administration worked with Baylor College of Medicine and the HFD Physiological Services to create a peer-based suicide prevention program.
The team consisted of nine active duty firefighters who received basic training on suicide and mental health. The program was well received and the team members received additional training and functioned as an internal unit working alongside the staff psychologist and other team members. Since the program was implemented in 2007, there have been no suicides within the department. (10) Peer-based and other in-house programs are essential in tackling the stigma toward mental health. (10)
“The stigma associated with mental illness, and especially suicide, is one reason people are reluctant, even as gatekeepers, to get involved or intervene.”16 The suicide rate in the fire service is climbing at an alarming rate, and the stigma is contributing to the climb. Members of the fire service are not invincible when it comes to experiencing PTSD symptoms. If the fire service does not come together to destroy this stigma, the fire service will slowly destroy itself. This research is meant to be that starting place for the fire service. In raising awareness of this issue, my objective is to start that discussion about the stigma and what we can do to create a friendly environment toward mental health in the fire service. Becoming proactive to attack this stigma is the only way to save future lives that may be lost to suicide.
Social theory plays an enormous role in the struggle with mental health stigma. A theory that can help explain this issue is “labeling theory,” which was created in the early 1960s.17 A simple definition of the labeling theory is that “societal reaction in the form of labeling or official typing, and consequent stigmatization, leads to an altered identity in the actor, necessitating a reconstitution of self.” (17) In other words, this theory explains how the self-identity and behavior of individuals can be determined or influenced by the way others describe them. The theory is based on the concept that people accept as their personal identity a label given to them by others—others see them as weak, and they come to look on themselves as weak.
Being labeled in the fire service creates barriers between the individuals and their fellow firefighters. So often people think of the fire service as a tightly knit family that is always there for each another. That is not always true. When people finally build up the courage to admit they need help and ask for it, sometimes that family leaves them. With the stigma that exists in the fire service, when someone asks for help, he runs the risk of being labeled as weak or unfit for the job by members who were once considered “family.” The person asking for help loses a great deal of support through this process.
Labeling someone unfit or weak because of a request for mental health care after witnessing what first responders see daily creates an environment in which self-care is viewed as insignificant. No one should be labeled because they need to process what they have seen, nor should they have to contend with any push-back from their peers.
STUDY: CONSEQUENCES OF MENTAL HEALTH STIGMA
The primary objective of this project was to assess the existence and perceived consequences of the mental health stigma in the fire service. The method used was firsthand accounts obtained through interviews. The project was approved by the Mount St. Mary’s University Institutional Review Board in October 2016.
PARTICIPANTS AND PROCEDURES
Volunteers were recruited through flyers posted at the National Fire Academy and fire stations around the greater Washington, D.C., area. The participants volunteered for the project and chose the place of the interview, which was conducted in a semi-structured format. The individuals were asked a set of questions; if additional questions presented themselves during the interview, they were asked as well. The study focused on eight members of the fire service (N=8), unfortunately falling short of the original goal of 15 participants.
The participants came from a variety of backgrounds in the fire service. For this study, the term “fire service” includes career, volunteer, and “hybrid” (both career and volunteer) firefighters. (5) Participants consisted of five volunteers, two career firefighters, and one hybrid firefighter; seven were male and one was female. The percentage of male to females in this study was slightly lower than the national percentage of the fire service. As of 2014, the fire service (both career and volunteer) was comprised of 1.051 million males and 82,550 females.18 Flyers for this project were posted from mid-October 2016 through the end of January 2017. A second “posting” of the flyer was done around the end of November in hopes of attracting more interest. Interviews were electronically recorded and then stored on an encrypted hard drive. The audio files were transcribed to enable further analysis.
Content analysis (the “systematic analysis of the symbolic content of communications in which the content is reduced to a set of coded variables or categories”19) was used to examine and study the interviews. Within my research, I analyzed the transcripts of the interviews and coded them into categories based on what I considered the most important information to include in the final report. The unit of analysis used was the sentence level. The manifest (the obvious meaning of the words) and latent content (the underlying meaning of the interaction that may not be specifically stated but can be derived from the context) were evaluated.
When the interviews were completed, the transcripts were first examined to identify commonalities and then to code the relevant information and categorize it. Categories were comprised of data that were similar. Three categories established were (1) the type of service for the individuals (career, volunteer, or hybrid); (2) the type of mental health services available; and (3) the presence of the “Superhero Effect” (to be discussed later). Random names were assigned to the transcripts of the interview so they could be referenced in the report while protecting their identity.
A few themes played a key role in the final determination of the effects of the mental health stigma. Four main themes came up in all of the interviews: the type of service, the type of mental health services available, the Superhero Effect, and the use of alcohol to escape from the pain.