Until Death Do We Part
Suicide Crisis
Co-Authors
Wayne
Zygowicz – BA, EFO, EMT-P
Zygowicz – BA, EFO, EMT-P
Mike
Grill – MS, EFO, EMT-P
Grill – MS, EFO, EMT-P
It was a clear crisp winter day as I stood
in full dress uniform directly in front of Tom’s casket. Hundreds of his
brother firefighters and paramedics from around the state had come to honor this
dedicated public servant who had given much of his life to his fire department
and the community he grew up in. His death was sudden, untimely and difficult
to understand.
in full dress uniform directly in front of Tom’s casket. Hundreds of his
brother firefighters and paramedics from around the state had come to honor this
dedicated public servant who had given much of his life to his fire department
and the community he grew up in. His death was sudden, untimely and difficult
to understand.
The expressions of sorrow, devastation
and loss on the faces of his wife and children would forever be etched in my
mind. Our families had vacationed together since we attended the academy
together 20 years ago. He seemed to have it all; dream job, loving family, nice
house and the respect and admiration of his fellow workers. He loved being a paramedic
for the fire department.
and loss on the faces of his wife and children would forever be etched in my
mind. Our families had vacationed together since we attended the academy
together 20 years ago. He seemed to have it all; dream job, loving family, nice
house and the respect and admiration of his fellow workers. He loved being a paramedic
for the fire department.
As frozen tears ran down my face I
searched for answers. How could I have missed the signs; his pain, suffering
and depression? I never acknowledged his subtle cries for help. I wasn’t there
for my best friend before he took his life by suicide.
searched for answers. How could I have missed the signs; his pain, suffering
and depression? I never acknowledged his subtle cries for help. I wasn’t there
for my best friend before he took his life by suicide.
A Quiet Epidemic
Every year 34,000 people will die by suicide
in the Unites States and another 500,000 will visit emergency rooms from self-inflicted
injuriesEvery 15
minutes another life is lost and the emotional toll on friends and families is overwhelming
and eternal.
in the Unites States and another 500,000 will visit emergency rooms from self-inflicted
injuriesEvery 15
minutes another life is lost and the emotional toll on friends and families is overwhelming
and eternal.
Suicide
is a complex problem that is difficult to understand and often hard to predict.
Mental suffering leading up to death is private and many times inexpressible. The
choice of death is rationalized as the only solution to intolerable
psychological pain. Those suffering often feel a narrowing of choices with
death seen as the only logical answer to escape the pain. Suicide is rarely
spontaneous. It often results from a long-term wearing a way of a person’s ability
to cope.
is a complex problem that is difficult to understand and often hard to predict.
Mental suffering leading up to death is private and many times inexpressible. The
choice of death is rationalized as the only solution to intolerable
psychological pain. Those suffering often feel a narrowing of choices with
death seen as the only logical answer to escape the pain. Suicide is rarely
spontaneous. It often results from a long-term wearing a way of a person’s ability
to cope.
Suicide affects both genders but men are
four times more likely to complete suicide. A previous history of suicide
attempts or a family history of suicide increases the risk. Substance abuse and
alcoholism are factors in 30% of the deaths. Mental health disorders such as
schizophrenia, mood disorders and depression can also increase the risk.
Depression is the leading psychiatric diagnosis associated with people
attempting suicide. Over 60% of all people who die by suicide suffer from major
depression. Treatment for depression is highly effective but many people never
seek help prior to their death.
four times more likely to complete suicide. A previous history of suicide
attempts or a family history of suicide increases the risk. Substance abuse and
alcoholism are factors in 30% of the deaths. Mental health disorders such as
schizophrenia, mood disorders and depression can also increase the risk.
Depression is the leading psychiatric diagnosis associated with people
attempting suicide. Over 60% of all people who die by suicide suffer from major
depression. Treatment for depression is highly effective but many people never
seek help prior to their death.
While
there are no official statistics on attempted suicides it is generally
estimated for each completed suicide there are 25 attempts. Most individuals
who are suicidal exhibit warning signs. Social isolation, expression of a plan
and access to lethal means or methods are important indicators. Suicide
idea
tion, self reported thoughts of engaging in suicidal behavior, can be a
precursor to an attempt. Dramatic mood changes, withdrawing from society, uncontrollable
anger, recklessness and hopelessness are also signals.
there are no official statistics on attempted suicides it is generally
estimated for each completed suicide there are 25 attempts. Most individuals
who are suicidal exhibit warning signs. Social isolation, expression of a plan
and access to lethal means or methods are important indicators. Suicide
idea
tion, self reported thoughts of engaging in suicidal behavior, can be a
precursor to an attempt. Dramatic mood changes, withdrawing from society, uncontrollable
anger, recklessness and hopelessness are also signals.
Make First Response the Right Response
First
responders interact with suicidal people on a regular basis. Responding time
and again to attempted and completed suicides can be emotionally disturbing and
require dangerous rescues or body recoveries. Responders may carry intrusive
sights, sounds, smells and memories of these violent and often gruesome deaths
with them for their whole career. The grief and sorrow expressed by the surviving
family can “splash over” onto emergency personnel causing critical incident
stress. “Each
one of these suicides leaves a small mark on your soul,” said Monte
Fleming, a Captain with the Littleton Fire Rescue (Colorado). “You just
can’t help but to feel sorry for each of these families knowing the reality
they face.”
responders interact with suicidal people on a regular basis. Responding time
and again to attempted and completed suicides can be emotionally disturbing and
require dangerous rescues or body recoveries. Responders may carry intrusive
sights, sounds, smells and memories of these violent and often gruesome deaths
with them for their whole career. The grief and sorrow expressed by the surviving
family can “splash over” onto emergency personnel causing critical incident
stress. “Each
one of these suicides leaves a small mark on your soul,” said Monte
Fleming, a Captain with the Littleton Fire Rescue (Colorado). “You just
can’t help but to feel sorry for each of these families knowing the reality
they face.”
LFR has been responding to suicides in their
community for many years. Colorado has the 6th highest suicide rate
in the nation. On October 29, 2007 a senior citizen took his life with a hand gun
on the front lawn of Littleton’s Firehouse 13. The elderly man was no stranger
to the crew. Five months earlier he had attempted suicide using carbon monoxide
and Littleton’s crews resuscitated him. He had written a suicide letter and
collected his important personal belongings for whoever would find him (read the
whole story at JEMS.com http://www.jems.com/article/industry-news/too-close-home).
A second incident in Denver involved a 36 year-old woman who jumped to her
death from the back of a moving ambulance during a routine patient transfer. On
a busy interstate highway she removed her cot straps and jumped from the back
door after distracting the attendant. Her family sued the company for damages. Suicide
calls can have profound mental and emotional impact on emergency dispatchers
and first responders.
community for many years. Colorado has the 6th highest suicide rate
in the nation. On October 29, 2007 a senior citizen took his life with a hand gun
on the front lawn of Littleton’s Firehouse 13. The elderly man was no stranger
to the crew. Five months earlier he had attempted suicide using carbon monoxide
and Littleton’s crews resuscitated him. He had written a suicide letter and
collected his important personal belongings for whoever would find him (read the
whole story at JEMS.com http://www.jems.com/article/industry-news/too-close-home).
A second incident in Denver involved a 36 year-old woman who jumped to her
death from the back of a moving ambulance during a routine patient transfer. On
a busy interstate highway she removed her cot straps and jumped from the back
door after distracting the attendant. Her family sued the company for damages. Suicide
calls can have profound mental and emotional impact on emergency dispatchers
and first responders.
Most EMS providers have little or no training in suicide crisis
intervention. Few standardize training programs or response guidelines address what
to do or say to someone attempting suicide or how to support the surviving family
of those completing suicide. In 2001 the US Department of Health and Human
Service released the National Strategy
for Suicide Prevention, Goals and Objectives (NSSP). This document was a
milestone in suicide awareness, prevention and education. Part of the strategy was to implement training for key
“gatekeepers” of society; teachers, clergy, nursing home staff, primary health
care providers, mental health care professionals, police officers and emergency
medical personnel. These people have daily face-to-face contact with large
numbers of the community and should be trained to identify at-risk suicidal
behavior. NSSP recommended suicide awareness training be incorporated into
basic educational and training curriculums. Communication specialists should
be well trained to interact with suicidal callers. All suicidal situations are
volatile and every threat should be taken seriously. The dispatcher should determine
the exact location of the caller if unknown. Every effort should be made to build
a rapport with the caller. The dispatcher should gather as much information as
possible and talk specifics; does the caller have the means, method and a plan
to take their life. The conversation should focus on the reality and finality
of the caller’s potential decision while bringing positive reinforcement into
the discussion.
Responding to threats and attempted
suicides should be handled cautiously by first responders allowing law enforcement
to stabilize the scene first. Introduce yourself and state the reason for your
presence while observing the person’s body language and hand position. Take charge
of the situation and avoid physical confrontations by not violating the
individual’s personal space. Establish a rapport by using good listening
skills. Show compassion and understanding and don’t be judgmental. Always show
empathy and respect for the person and their situation no matter how bad it
appears. Assess lethality by questioning the person directly about a suicide
plan, means and method of injury. Look for a suicide letter or indications that
the person has made final arrangements. Everyone who threatens suicide should
be transported for physical and psychological evaluation. During transport
evaluate for evidence of injury, previous suicide attempts and signs of depression
or substance abuse. Before leaving the scene responders should encourage the
family to remove all lethal means from the home, especially firearms and
medication, prior to the person’s hospital discharge.
suicides should be handled cautiously by first responders allowing law enforcement
to stabilize the scene first. Introduce yourself and state the reason for your
presence while observing the person’s body language and hand position. Take charge
of the situation and avoid physical confrontations by not violating the
individual’s personal space. Establish a rapport by using good listening
skills. Show compassion and understanding and don’t be judgmental. Always show
empathy and respect for the person and their situation no matter how bad it
appears. Assess lethality by questioning the person directly about a suicide
plan, means and method of injury. Look for a suicide letter or indications that
the person has made final arrangements. Everyone who threatens suicide should
be transported for physical and psychological evaluation. During transport
evaluate for evidence of injury, previous suicide attempts and signs of depression
or substance abuse. Before leaving the scene responders should encourage the
family to remove all lethal means from the home, especially firearms and
medication, prior to the person’s hospital discharge.
All completed suicides should be
considered a crime scene and immediate access restricted from family and pets.
The body and surrounding environment should not be disturbed unless it’s
necessary to declare death. Confirm the identity of the deceased and note the
position and manner of death. Medical control should be consulted as local
protocol requires. A detailed patient care report should include time of death given
by medical control, environment conditions, body position, location of weapons,
type of injuries, presence of a suicide letter and any information that will
aid in the investigation. Efforts to support the surviving family should be a
priority. Realize the impact your words and actions can have on them and ensure
that they are not further traumatized. Introduce yourself and assign a crew
member to assist the family as needed. Validate the family’s personal loss and
support their immediate needs. Help survivors mobilize their own support network;
family, friends and clergy. Prepare survivors for what will occur when law
enforcement investigators and the coroner arrive. Leave a business card so the
family can contact you later if necessary and a suicide resource brochure with
important telephone numbers and web sites for later reference (see suicide
brochure at JEMS.com).
considered a crime scene and immediate access restricted from family and pets.
The body and surrounding environment should not be disturbed unless it’s
necessary to declare death. Confirm the identity of the deceased and note the
position and manner of death. Medical control should be consulted as local
protocol requires. A detailed patient care report should include time of death given
by medical control, environment conditions, body position, location of weapons,
type of injuries, presence of a suicide letter and any information that will
aid in the investigation. Efforts to support the surviving family should be a
priority. Realize the impact your words and actions can have on them and ensure
that they are not further traumatized. Introduce yourself and assign a crew
member to assist the family as needed. Validate the family’s personal loss and
support their immediate needs. Help survivors mobilize their own support network;
family, friends and clergy. Prepare survivors for what will occur when law
enforcement investigators and the coroner arrive. Leave a business card so the
family can contact you later if necessary and a suicide resource brochure with
important telephone numbers and web sites for later reference (see suicide
brochure at JEMS.com).
&n
bsp;
bsp;
In The Line of Duty
The impact of suicide on society is
substantial. It’s estimated that each suicide intimately affects a minimum of
six people who may suffer subsequent mental health problems, guilt, pain and
personal agony. Sometimes those people are the emergency responders. The impact
of emergency work on responders is difficult to measure since most don’t
usually talk about their feelings and aren’t the type of people to voluntarily
seek help. Stress is
expected in a profession where death, disfigurement, long shifts, sleepless
nights, poor nutrition, dangerous working conditions, and self-guilt, e.g., “Did I do everything possible to help this
patient?” are constant companions.
substantial. It’s estimated that each suicide intimately affects a minimum of
six people who may suffer subsequent mental health problems, guilt, pain and
personal agony. Sometimes those people are the emergency responders. The impact
of emergency work on responders is difficult to measure since most don’t
usually talk about their feelings and aren’t the type of people to voluntarily
seek help. Stress is
expected in a profession where death, disfigurement, long shifts, sleepless
nights, poor nutrition, dangerous working conditions, and self-guilt, e.g., “Did I do everything possible to help this
patient?” are constant companions.
It’s no surprise that mental health
issues emerge as a critical factor in performance, retention, and quality of
life for emergency responders yet consistent occupational mental health
statistics within the fire/EMS service remain elusive. What is not obscure is that
suicide completion among fire and EMS providers could be more prevalent than
previously thought. For example, in 2009 the Chicago Fire Department had an
above average number of suicide attempts and completions. Since December of
2009, the Phoenix Fire Department alone has experienced four suicide
completions. Are these departments a microcosm of a larger, more widespread problem
nationwide?
issues emerge as a critical factor in performance, retention, and quality of
life for emergency responders yet consistent occupational mental health
statistics within the fire/EMS service remain elusive. What is not obscure is that
suicide completion among fire and EMS providers could be more prevalent than
previously thought. For example, in 2009 the Chicago Fire Department had an
above average number of suicide attempts and completions. Since December of
2009, the Phoenix Fire Department alone has experienced four suicide
completions. Are these departments a microcosm of a larger, more widespread problem
nationwide?
The number and availability of
mental health programs for fire and EMS providers are limited and restricted by
a culture of machismo which implies
that it is a sign of weakness to seek help for mental health issues.
Additionally, the popular mental health model of Critical Incident Stress
Debriefing (CISD), developed by Dr. Jeffrey Mitchell in the 1980’s, is
considered by a number of researchers to be controversial.
mental health programs for fire and EMS providers are limited and restricted by
a culture of machismo which implies
that it is a sign of weakness to seek help for mental health issues.
Additionally, the popular mental health model of Critical Incident Stress
Debriefing (CISD), developed by Dr. Jeffrey Mitchell in the 1980’s, is
considered by a number of researchers to be controversial.
Resiliency Education: A Holistic Approach to Stress Management
Fire and EMS providers exposed to
traumatic events can develop stress-induced thoughts, dreams and behaviors
which may lead to PTSD. CISD – once thought to minimize these problems has
shown controversial results. A new approach, substantiated by research data, has
been having a positive impact in behavioral health intervention for people
experiencing the effects of traumatic situations. This new methodology focuses
on a holistic, preventative process capable of being taught in a non-clinical
academic setting.
traumatic events can develop stress-induced thoughts, dreams and behaviors
which may lead to PTSD. CISD – once thought to minimize these problems has
shown controversial results. A new approach, substantiated by research data, has
been having a positive impact in behavioral health intervention for people
experiencing the effects of traumatic situations. This new methodology focuses
on a holistic, preventative process capable of being taught in a non-clinical
academic setting.
The concept – termed resiliency – is defined as the ability to bounce back from adverse events
and cope with stressors in a healthy manner. Research literature clearly substantiates that resilient people are
far less likely to experience the effects of PTSD. In fact, not only are resilient people more
capable of dealing with stress; they actually thrive and grow as a result of stressful experiences.
and cope with stressors in a healthy manner. Research literature clearly substantiates that resilient people are
far less likely to experience the effects of PTSD. In fact, not only are resilient people more
capable of dealing with stress; they actually thrive and grow as a result of stressful experiences.
A resiliency curriculum – known as
the Supportive Education for Returning Veterans – or SERV – has been developed
by Dr. Michael Marks, Lead Psychologist for the outpatient PTSD clinic at the
Veteran’s Administration Hospital in Tucson, Arizona and Dr. Phil Callahan, a
professor at the University of Arizona (and a nationally registered paramedic).
The SERV curriculum has received national recognition by the Veteran’s
Administration as an evidence- based program that works, producing profound
results within the military veteran population. Upon completion of the SERV
program, for example, veterans’ were less likely to develop post-traumatic
stress disorder (PTSD), demonstrated improved dietary and physical fitness
habits, strengthened their social support system and were more likely to remain
enrolled in higher education. In fact, students successfully completing SERV
resiliency education as a pre-requisite to enrollment in college-level courses
were 15
times more likely to remain enrolled in college compared to students
who did not enroll in a resiliency training program.
the Supportive Education for Returning Veterans – or SERV – has been developed
by Dr. Michael Marks, Lead Psychologist for the outpatient PTSD clinic at the
Veteran’s Administration Hospital in Tucson, Arizona and Dr. Phil Callahan, a
professor at the University of Arizona (and a nationally registered paramedic).
The SERV curriculum has received national recognition by the Veteran’s
Administration as an evidence- based program that works, producing profound
results within the military veteran population. Upon completion of the SERV
program, for example, veterans’ were less likely to develop post-traumatic
stress disorder (PTSD), demonstrated improved dietary and physical fitness
habits, strengthened their social support system and were more likely to remain
enrolled in higher education. In fact, students successfully completing SERV
resiliency education as a pre-requisite to enrollment in college-level courses
were 15
times more likely to remain enrolled in college compared to students
who did not enroll in a resiliency training program.
The resiliency curriculum consists
of teaching responders to identify, measure, and subsequently improve their
ability to cope with home and work stress. Initially, each responder
establishes a baseline of their current ability to cope with both personal and
professional stress. Next, the responder is taught how to improve both their physiological and psychological resiliency skills.
of teaching responders to identify, measure, and subsequently improve their
ability to cope with home and work stress. Initially, each responder
establishes a baseline of their current ability to cope with both personal and
professional stress. Next, the responder is taught how to improve both their physiological and psychological resiliency skills.
Physiological resiliency includes:
·
Proper nutrition, including establishing a
nutritional baseline and the importance of a balanced diet based on an
individual’s basal metabolic rate.
Proper nutrition, including establishing a
nutritional baseline and the importance of a balanced diet based on an
individual’s basal metabolic rate.
·
Importance of physical exercise using the FITT
principle: frequency, intensity, time spent, and type of exercise.
Importance of physical exercise using the FITT
principle: frequency, intensity, time spent, and type of exercise.
·
Good sleep hygiene with an emphasis on how to
use cognitive behavioral approaches to eliminate or minimize nightmares.
Good sleep hygiene with an emphasis on how to
use cognitive behavioral approaches to eliminate or minimize nightmares.
Psychological resiliency teaches
responders to:
responders to:
Relax using proper breathing techniques and
progressive muscle relaxation.
·
Change self-defeating thought patterns into
positive and more realistic thinking.
Change self-defeating thought patterns into
positive and more realistic thinking.
·
Empathetic communication and the power of
perspective.
Empathetic communication and the power of
perspective.
The importance of establishing – and maintaining
– a strong social support system.
(See 13 tools of Resiliency at JEMS.com).
A significant difference between CISD
and resiliency education focuses on when
responders are expos
ed to each. The CISD
process takes place after the fact with the bad event being the trigger. Resiliency
education, on the other hand, occurs at the beginning
of a provider’s career, an inoculation if you will, to the horrific events
all responders eventually are exposed to. Regular reinforcement of resiliency
concepts then occurs after the initial training, such as the beginning of a
physical fitness program or the daily practice of relaxation techniques. Both
Dr. Marks and Callahan believe the results seen thus far with veterans can
transfer into the world of fire and EMS, assisting providers to minimize the
effects of stress and its cumulative effects.
and resiliency education focuses on when
responders are expos
ed to each. The CISD
process takes place after the fact with the bad event being the trigger. Resiliency
education, on the other hand, occurs at the beginning
of a provider’s career, an inoculation if you will, to the horrific events
all responders eventually are exposed to. Regular reinforcement of resiliency
concepts then occurs after the initial training, such as the beginning of a
physical fitness program or the daily practice of relaxation techniques. Both
Dr. Marks and Callahan believe the results seen thus far with veterans can
transfer into the world of fire and EMS, assisting providers to minimize the
effects of stress and its cumulative effects.
Currently,
an advisory group consisting of leaders within the fire service, EMS, and
academia has been formed to determine if resiliency education can produce
measurable improvements in the reduction of stress, PTSD, and rates of suicides
within the fire/EMS profession. Pilot testing of the curriculum for the
fire/EMS service will occur later this year in at least four sites nationwide.
The resulting data will be compared to those of military veterans. If
favorable, resiliency education will be expanded to organizations looking for a
proven methodology to assist emergency personnel experiencing issues related to
mental health.
an advisory group consisting of leaders within the fire service, EMS, and
academia has been formed to determine if resiliency education can produce
measurable improvements in the reduction of stress, PTSD, and rates of suicides
within the fire/EMS profession. Pilot testing of the curriculum for the
fire/EMS service will occur later this year in at least four sites nationwide.
The resulting data will be compared to those of military veterans. If
favorable, resiliency education will be expanded to organizations looking for a
proven methodology to assist emergency personnel experiencing issues related to
mental health.
Taking Care of
Our Own
Our Own
Suicide is treatable and
preventable and as gatekeepers of society its part of our fundamental mission
to save these lives especially when some of them are our own. The first step
starts with collecting accurate data on work related stress, suicide attempts
and completions to help identify trends within our industry. Getting good data
will be difficult to acquire until we reduce the sigma surrounding help-seeking
behavior and encourage our fellow responders to come forward and get the help
they may need. Development of a comprehensive suicide prevention strategy,
improving access to mental health counseling and developing a responder support
network is paramount to saving our brothers and sisters.
preventable and as gatekeepers of society its part of our fundamental mission
to save these lives especially when some of them are our own. The first step
starts with collecting accurate data on work related stress, suicide attempts
and completions to help identify trends within our industry. Getting good data
will be difficult to acquire until we reduce the sigma surrounding help-seeking
behavior and encourage our fellow responders to come forward and get the help
they may need. Development of a comprehensive suicide prevention strategy,
improving access to mental health counseling and developing a responder support
network is paramount to saving our brothers and sisters.
Teamwork is foundational of
Fire/EMS. What affects one individual will likely have some impact on others
and ultimately affect the team’s performance. Identification of mental health risk
factors and promoting individual health and well-being through education is
critical to the success and evolution of our profession.
Fire/EMS. What affects one individual will likely have some impact on others
and ultimately affect the team’s performance. Identification of mental health risk
factors and promoting individual health and well-being through education is
critical to the success and evolution of our profession.
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