Rescuing our own- “Why don’t those who save others call for help?”

The United States is seeing increasing numbers of first responders suffering from behavioral health despite the increasing of availability of behavioral health resources. Statistical data has shown an increase in first responders suffering from these behavioral health issues such as: anxiety and depression, PTSD, alcohol & substance abuse, and increased risk of suicide. First Responders are exposed to occupational stress at a higher level than many other occupations and we respond differently to potentially traumatic events. Could our responder mind-set and our culture be contributing to the increase in the behavioral health issues?

Consider this: “The American fire service has been rocked in recent years of apparent suicide clusters in large, metro fire departments” (Gist, Taylor, Raak. p.2). “One study that examined North Carolina firefighters found the following: “Compared with professional firefighter line-of-duty deaths (LODDs), suicides occurred more than three times as often” (Salva p.1).

What do we really know about first responders and occupational stress exposure?

As part of the Tampa summit in 2004, the National Fallen Firefighters Foundation (NFFF) identified 16 life safety initiatives in order to improve firefighter health and safety. Fire Life Safety Initiative 13 was born out of the collective research that identified the increasing number of behavioral health issues in the fire service.  The Suicide and Depression Summit held in 2011, which was sponsored by the NFFF, expounded upon FLSI #13 and identified further areas of needed study pertaining to suicide and depression in the ranks of first responders.

To further emphasize the importance of this problem consider the following examples:

Consider the case of Kyle Lenn, a 23 year member of the fire service, and considered one of the most progressive fire chiefs of his time. He was actively involved in the Everyone Goes Home program, active in the Nebraska Fire Chief’s Association, and more. On the morning of January 31rst 2012 his body was found hanging from a bridge from an apparent suicide. His death shocked the fire service community and numerous other deaths like Lenn’s have brought attention to behavioral health problems in the fire service (Wilmoth,).

Or this quote from Clifford F. Carlisle, Mountain Brooke Fire Department-

“Over the years, one of our firefighters, killed his wife and then himself. Another firefighter transferred from a larger department, worked several years, resigned and committed suicide. Others have been involved in a variety of altercations, domestic problems, and stress related episodes and illnesses. One employee who appears to have become a recluse, retired and left the country. His problems followed him overseas” (Shantz, p.1).

In my personal experience, I have lost several friends to suicide and two of those were firefighters. We as first responders experience tragedy, loss, pain, and are with the trauma level hospice worker who compassionately cares for others in their last moments. These experiences are often embedded in our memories and many suffer post-traumatic stress disorder due to this.


Consider the statistical data below concerning first responders/firefighters by an organization who counsels and treats first responders:

  • As much as 37% of the fire service suffers from PTSD.
  • “As a result, some estimates put alcohol abuse in fire departments at upwards of 25 – 30%, approaching two or three times the incidence of alcohol abuse in the general population (7 – 9%).”
  • As much as 30% of firefighters suffer from depression.




Yet, in the face of these overwhelming circumstances there is help for those who save others. The question remains, with behavioral health resources becoming increasingly available, why are first responders not reaching out for help?  In regards to firefighter behavioral health, Fire Life Safety Initiative 13 was developed to provide psychological support and counseling to all firefighters. Due to the suicide clusters, as mentioned in the introduction, this lead to the Suicide and Depression Summit. In Baltimore Maryland 2008, the first FLSI 13 Consensus meeting was held which focused on potentially traumatic events. This consisted of six different research organizations and six different fire service organizations that focused on identifying the resources needed to create behavioral health assistance that would effectively serve firefighters and their families (Gist, Taylor, Raak. P 5.).

The researchers at the Suicide and Depression Summit were the top individuals in the fields of PTSD, Suicide, and Employee Assistance Programs, and Firefighter Health Research. These different organizations were formed into consensus groups that would identify “behavioral health resources, improve upon member assistance programs, and address self-help and peer support” (Gist, Taylor, Raak. p.5). These groups focused on providing programs and support to firefighters/first responders that have been previously been identified into two areas of need:

  • The High Risk Responder: The high risk responder is a first responder who has serves in a disaster role for long durations. As studies have shown that these individuals are at a greater risk (as high as 34%) for developing Post Traumatic Stress Disorders (PTSD). Studies also have shown that there is a “relationship between the duration of traumatic exposure and the development of posttraumatic stress” (Castellano, Plionis p.328). Consider the another perspective of the High Risk Responder: A first responder, firefighter or police officer who serves in very active areas for long shifts, works overtime, and works a second job at another busy job. As public servants, can we see a correlation between serving on the busiest unit, company, or force and the development of post-traumatic stress?
  • Rescuer-Victim Group: The Rescuer-Victim group was identified through studies after Hurricane Katrina. Many of the first responders became victims to the incident themselves. They suffered from three critical incident stress incidents simultaneously: the actual disaster itself, the failure or breakdown of the emergency response organizations, and the personal and ethical crisis that the responders faced during the disaster. These first responders had to choose between obeying their sworn duty and protecting/saving their family. In my experience, this group still exists today without the presence of a disaster event. I believe that the Rescuer-Victim Group occurs when a first responder must choose between dealing with their own personal problem, the failure of support from their organization, and the collateral damage that is thereby caused within their families. This is one reason why many first responders are not seeking help. As they are paralyzed by their problem, know they must do something, but often fail due to the possibility of losing their job, not being aware of the resources available, and the failure of their organizations to adequately train their employees to assist those in crisis.

The Suicide and Depression Summit’s efforts developed the following programs to assist firefighters: After Action Review, Psychological First Aid, Screening and Assessment Materials, Behavioral Health Assistance Program standards, Web training in evidence supported intervention for clinicians treating fire service members, and Support for effective peer assistance efforts (Gist, Taylor, Raak. p.8). Many of these programs already existed but were not developed with the fire service specifically in mind due to the complexities of our culture and the need for peer support. Since then the following areas have been developed and are available through the National Fallen Firefighters website under the Everyone Goes Home section. If you are not currently aware of these resources, I strongly suggest after reading this article that you visit their website and begin the journey to learning how to rescue our fellow brothers and sisters.

After Action Review:

After Action Review (AAR) has been practiced by the military for years. Under the Everyone Goes Home program the After Action Review is a training section that evaluates what the first responders just did after every call, every training, or every significant incident. The goal is to take the ‘who’ out of it and to learn why what happened. This is an immediate debriefing involving only the members involved. This can be implemented with ease in any organization regardless of size, staffing, or resources. The leadership can begin discussing calls each day and monitoring their co-workers behavioral health in order to prevent or reduce the increasing rate of behavioral health issues in emergency services today. (


Psychological First Aid (PFA)

PFA is a form of emotional first aid. It has been studied and implemented since 9/11 and Hurricane Katrina. The field application of this model was implemented on 9/11 to the members of the New Jersey Task Force One (NJTF-1). PFA consists of five phases or steps: assessment, stabilization, triage, communication, and follow-up connection. The implementation of PFA was found to be more successful through the use of peer counselors as they “fit the culture of law enforcement emergency personnel and lent credibility and familiarity to the counseling effort” (Castellano, Plionis, p.329).  PFA connects the first responder with “mutual support following high impact calls while enhancing daily performance and citizen satisfaction” (Gist, Taylor, Raak. p.7). It is designed for immediately after the incident which uses evidence based support designed by the US Department of Veterans to prevent the development of post-traumatic stress disorder or PTSD (Brymer M, Jacobs A, Layne C, Pynoos R, Ruzek J, Steinberg A, Vernberg E,Watson P. p.5). As firefighters, the doorway to assist them after an incident is through the assistance of peer counselors. If your organization currently offers training in critical incident stress management (individual and group counseling) I highly recommend that you attend this training in order to better care for those in your fellowship. After all, who sees the first sign of a ‘working fire’ inside of our lives if not our fellow firefighters that work with us 1/3rd of our lives?

A Multi-component CISM model augmented with peer-to-peer counseling:

Many departments employ the use of Critical Incident Stress Management to assist in managing first responder stress to Potentially Traumatic Events otherwise known as PTE’s. This Critical Incident Stress model consists of six components which are acute crisis counseling by peer counselors, an executive leadership program, a multi-disciplinary team, an acute traumatic stress group training, a 24-7 Hot-line for first responders, and a reentry program. Currently there are resources available through the NFFF for CISM training and many departments across the country have certified CISM teams. Does your organization have a CISM team? This is our 911 for our personal May-Day’s.  Does your organization have a Hot-line for those who need to counseling? If this isn’t the case consider the following numbers that can are available for first responders in crisis:

  • The Share the Load Program by The National Volunteer Firefighters Counsel: org/help1-888-731-FIRE FREE (3473)
    This free, confidential help line available 24 hours a day, seven days a week to members of the fire, EMS, and rescue services and their families. Please see their video on the Warning Signs of Firefighter Behavioral Health:
  • Firefighter May-Day: Please visit and click on the Firefighter May-Day page for a list of resources of trained professionals who can assist our fellow brothers and sisters.

The complexities of behavioral health equals further research is needed:

In regards to firefighter behavioral health. First, there is a limited amount of verifiable data available regarding firefighter suicides thus funding should be allocated to provide a better understanding.  Second, as the Suicide and Depression Summit recruited the top experts in the field the fire service should recruit the experts in the military who are already performing similar studies and programs pertaining to suicide. Those who encourage action in this field should be instructed to present their findings based on observable and verifiable data; not based on assumptions and personal experience.

The contributing factors for suicide in the fire service should be researched further focusing on elements of thwarted belongingness and personal contribution as they may contribute to higher risk of suicides (Gist, Taylor, & Raak p.22). Screening and intervention approaches should be created and designed specifically for the fire service. Such programs have been developed such as the TSQ-Trauma Screening Questionnaire as part of the FLSI #13 initiative. This is a tool that allows the supervisor to quickly determine whether or not an employee needs further care or assistance. It is valuable due to its simplicity and its similarity in how firefighters ‘size-up’ problems.

These programs should be preventative and intervention based while grounded in empirical data. Cognitive Behavioral Therapy, suicide ideation program training, and behavioral health care training should be readily available and inexpensive to the fire service, its leaders, and the necessary heath care providers. Sadly, most firefighters aren’t aware of these programs and neither are their leaders. Peer support programs should consist in training members in addressing suicide. Each organization should follow a strategic plan of action similar to the National Strategy for Suicide Prevention which explains a more comprehensive approach to suicide prevention through education, screening and better medical care, and more available resources for the individual after they have been discharged to help re-acclimate them back into their daily life.  The materials for these trainings should be easily accessible along with a suicide hotline listed. The materials should be developed in cooperation with IAFF, IAFC, NVFC, and USFA. These organizations all are have significant influence on the fire service and through this partnership it would ensure a more successful implementation. All of these recommendations will be made possible only by allocating funds for their research and implementation.

Many firefighters and first responders do not readily seek help for their behavioral health problems due to a lack of knowledge of the resources currently available. As mentioned above, there are currently numerous resources available to first responders and firefighters such as the FLSI #13 resources which are based on the following programs: After Action Review, Psychological First Aid, Screening and Assessment Materials, Behavioral Health Assistance Program standards, and free web based training. Many departments currently employ the multi-disciplinary CISM approach which offers employees defusing’s, debriefings, and follow-up if needed after potentially traumatic events. The belief that firefighters don’t readily seek help isn’t based upon opinion; it is based on the numerous interviews with first responders, counselors, fire chiefs, and personal observations and interviews with those in my sphere of influence. The continual trend of not being aware of these resources lead to the writing of this article.


 We have identified the problem, now what?

We are constantly training to stay ready for the next challenge we may face. Let us ask ourselves, how well are we trained in saving our brothers and sisters from their own personal may-day? As a member of the emergency service world, let us ask us ourselves the following questions:

  • Does your organization currently offer any services for its members for behavioral health concerns such as: alcohol, substance abuse, depression, PTSD, counseling, and stress management?
  • What services do they currently offer?
  • Are you familiar with Fire Life Safety Initiative #13
  • Are you familiar with CISM-Critical Incident Stress Management
  • If you or someone you knew needed help in any of these areas would you know how to receive assistance?

How well were you able to answer the questions above? On average, most first responders are not aware of the resources their organization provides and are not aware of how to help someone or themselves in the event of a personal crisis. This identifies the need for training. As leaders, we should be just as well-trained in taking care of our people as we are proficient at providing services for our customers. There are internal customers and external customers. We need to take care of our own so they may thrive and provide even better service to our citizens. The incentive to the organizations for offering this training is reduced employee behavioral health issues which results in reduced medical expenses, longer careers due to better management of these behavioral health issues, and reduced cost to the employer by maintaining their workforce rather than firing/losing employees due to these issues. If we are to truly be accountable for the profession that we serve we should be well-trained at rescuing our own. The greatest save we may ever make could be the person next to us. Let us take up the challenge and not let our brothers and sisters lives burn down around them. Begin the rescue of our brothers and sisters today by beginning a personal commitment to learn more, become trained in these areas, and teach others to do the same.

May their cries for help go unanswered no more….

Andy J. Starnes

Bringing Back Brotherhood Ministries



Works Cited:

Antonellis Jr. Paul J., Thompson. Denise A. A Firefighter’s Silent Killer: Suicide. Fire Engineering University. Penn well Publishing. (Pg.1)

Brymer M, Jacobs A, Layne C, Pynoos R, Ruzek J, Steinberg A, Vernberg E, & Watson P. Psychological First Aid. Field Operations Guide Second Edition. National Child Traumatic Stress Network. (p.5). retrieved from:

Castellano, Cherie. Plionis, Elizabeth. (2006) Comparative Analysis of Three Crisis Intervention Models Applied to Law Enforcement First Responders During 9/11 and Hurricane Katrina. Oxford Journals. Retrieved from:

Ford, Travis. (2006). Building Support for Firefighter Life Safety Initiatives in Higher Education. Executive Leadership. Retrieved from:

Gagliano, Anne. (2009). What Every Firefighter’s Spouse Should Know. Fire Engineering. Retrieved from:

Gist, Taylor, & Raak, (2011).Suicide Surveillance, Prevention, and Intervention Measures for the US Fire Service. Findings and Recommendations for the Suicide and Depression Summit. Retrieved from:

Manning, William A. (2007). Fire Life Safety Initiatives. Everyone Goes Home Summit White Paper. Retrieved from:

Nock, Matthew K. Joiner, Thomas. Berman, Alan L. (2011) Issues of Depression and Suicide in the Fire Service. Retrieved from:

Salvia, JS. (2008). “Suicide among North Carolina professional firefighters: 1984-1999.” Dissertation Abstracts International, 69.

Shantz, Mark. (2002) Effects of Work Related Stress on the Firefighter/Paramedic. EASTERN MICHIGAN UNIVERSITY SCHOOL OF FIRE STAFF AND COMMAND. Retrieved from:,%20Fitness,%20Wellness/Effect%20of%20Work%20Related%20Stress%20on%20the%20Firefighter%20Paramedic.pdf

Wilmoth, Janet. Trouble in Mind. NFPA Journal. May 2014. Retrieved from:


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