Mental health issues, including suicides, continue to be a rising problem and concern for first responders. Other mental health issues include depression, anxiety, addiction, and post-traumatic stress disorder (PTSD). In 2017, there were more first responder suicides than line-of-duty deaths (LODDs) (2018, USA Today). While LODDs consistently receive front-page coverage, first responder mental health issues and suicides do not. With LODDs, we often investigate, ask what went wrong, and ask how we can avoid it in the future. This doesn’t always happen with suicides; firefighter suicides aren’t even always reported. If anything does happen, we’ll discuss what drove the person to it, if we can even fathom why. We will tell others we are here from them. But then we continue with our lives. We aren’t making the changes to stop it from happening. It is common knowledge among the fire service and public safety realm that there is a mental health problem plaguing our responders; however, more, widespread education is needed. Currently, the full scope of the mental health problem within the fire service is unknown.
Organizations like the Firefighter Behavioral Health Alliance and Code Green Campaign are addressing the problem through their programs, which aim to identify if a colleague is suffering, what to do if you are suffering, and ways we can take care of our mental health. Workshops are offered to educate counseling professionals, firefighters, and firefighters’ families; grants are available for fire departments to cover the cost of hosting the class. A self-assessment is offered online for firefighters to establish their suicide ideations. Jeff Dill, founder of the Firefighter Behavioral Health Alliance, states only an estimated 45% of firefighter suicides are reported, in part due to a lack of understanding of mental health (2019). However, this discrepancy in reporting means that groups such as the Firefighter Behavioral Health Alliance are not able to analyze the full nature of the problem if such a significant portion of those affected are not reported and thus not part of the data pool. This does show that more education is imperative as a preventive measure for firefighters to maintain healthy mental health.
According to Dill, one of the first things firefighters need to do is acknowledge that they are human beings first. He calls it a “cultural brainwashing” that leads firefighters to believe that these issues cannot happen to them or to ignore it completely, believing that they can “tough it out” and emphasizes that firefighters are not exempt from struggling nor are they alone. He adds that the data show no discrimination between firefighter and EMS suicides. Dill believes that activities such as sharing your own story, peer support groups, and knowing your surroundings are all ways firefighters can take control of their mental health and adds that all departments should receive education on handling mental health, establish programming of some kind, and create a peer support team or chaplain position. Other treatment options for mental health care include seeking a religious adviser per your beliefs, exercise, medication under the direction of a physician or psychiatrist, talk therapy, meditation, and more. However, it is important and necessary to remember that treatment looks differently from person to person. Consider mental health treatment like an individual puzzle: Everyone has a unique picture to the puzzle, and some require more pieces than others.
One program that Dill offers is called “Internal Size Up,” which aims to teach first responders about stress, anxiety, PTSD, addictions, depression, and anger and addresses suicide and retirement. However, Dill states that an “Internal Size Up” should be performed by all firefighters by asking themselves, “Why am I acting this way?” He feels that firefighters can better identify what negative emotions are attached to and the reasoning through an internal size-up. Dill also recommends listening to others, stating they see you from a different perspective.
The Code Green Campaign is an organization that focuses on mental health advocacy and education geared toward all first responders. “Code Green” is the term they developed to mean calling a medical code on a mental health issue. On the Web site, the Code Green Campaign defines its mission as “Bring awareness to the high rates of mental health issues in first responders and reduce them. Eliminate the stigma that prevents people from admitting these issues and asking for help. Educate first responders on self and peer care and to advocate for systemic change in how mental health issues are addressed by first responder agencies.” The Code Green Campaign provides awareness/educational materials, courses, and resources to educate and eliminate the stigma concerning mental health. To raise awareness, spread knowledge, and show that there are others who can relate, the Code Green Campaign shares firsthand stories from first responders who have struggled with mental health.
Dr. Robin Grant-Hall, a clinical psychologist in Connecticut who worked with police officers after the Sandy Hook shootings, has treated severe abuse victims and those with severe PTSD and specializes in using “eye-movement-desensitization-reprocessing” (EMDR) treatment. She believes that first responders essentially have a different kind of brain–a “super strong” brain, she calls it. The unique characteristics that allow individuals to be successful as first responders allow them to be more resilient, and their brains become more resilient to trauma. However, eventually, the brain essentially overflows like a cup from “cumulative stress overload,” and this is debilitating to the mental health of first responders. She emphasizes that preventive measures and education are necessary for firefighters to better understand mental health issues and how to approach these situations.
Dr. Grant-Hall also believes the framework of the mental health issue is important. She explains that the traumas firefighters witness that cause these mental health issues later more or less replay themselves in the brain, keeping the brain in trauma mode, and that experiencing these traumas causes an internal brain injury. By not acknowledging these traumas, they continue to build up, and the firefighter’s mental health suffers as a result. As part of all of this, the biochemistry of the brain will alter quickly in response to traumatic events to help you, but it causes issues. By not seeking help on one traumatic event and believing that you handled it, the next one could be highly symptomatic. Dr. Grant-Hill agrees that the culture of firefighting can impact why firefighters do not get help, but she has experienced success in framing it as a “brain injury” and explaining the physiological aspects of it. As Dr. Grant-Hall states, firefighters’ brains try to adapt to the numerous traumatic events they witness, knowing that it isn’t normal. By doing so, the brain changes–it is another type of injury. A firefighter generally would not let a physical injury go untreated, knowing that it is impeding the ability to serve. With this and Dr. Grant-Hall’s brain injury framework in mind, firefighters should not question whether to seek treatment for their mental health. Additionally, Dr. Grant-Hill’s experience also shows that prevention and education are vital to firefighters’ maintaining their mental health.
There is one type of a treatment that helps mentally and physically and can be used as preventive treatment and as a resource when you are struggling: meditation or, more specifically, mindfulness meditation. Meditation is estimated to have been practiced for more than 5,000 years and is present in various religions and belief systems such as Buddhism, Hinduism, Taoism, and Confucianism and is also integrated into yoga practices. However, Greek philosophers were known to meditate because of an Indian yogis’ influence, which began as the cultures intersected from Alexander the Great’s military exploits in India. In the past 10 years or so, meditation has become more mainstream, especially as yoga and hot yoga popularity began to rise.
There are seven types of meditation: Mindfulness, Transcendental, Guided, Vipassana Meditation, Loving Kindness, Chakra Meditation, and Yoga Meditation. Benefits of meditation include reducing stress, controlling anxiety, promoting emotional health, enhancing self-awareness, lengthening attention span, improving sleep, reducing blood pressure, increasing compassion (including self-compassion), reducing depression, increasing focus, boosting the immune system, and improving mood. A Harvard study found that participants who meditated for eight weeks grew gray matter where self-awareness and compassion originate, and shrunk areas associated with stress (2010). Research on the benefits is only beginning; as it continues to develop, additional benefits and the full impact of those benefits are discovered.
While transcendental (repeating a mantra) and guided (visualization) meditation can benefit firefighters, mindfulness and yoga have a unique edge toward guiding firefighters. Mindfulness is often taught in yoga as the two intersect; at times, yoga will include a mindful meditation practice. Shannon McQuaide, a California yoga teacher who developed a yoga practice specifically designed to feature movements that are functional to firefighters, states that yoga and mindfulness offer a mind-body integration that act as a pathway for the body to heal. When apply Dr. Grant-Hall’s brain injury framework, this would help firefighters with allowing their mind and body to heal from trauma and stressors of the job.
What is mindfulness? Essentially, mindfulness is being present. Merriam-Webster Dictionary defines mindfulness as “the practice of maintaining a nonjudgmental state of heightened or complete awareness of one’s thoughts, emotions, or experiences on a moment-to-moment basis.” (2019) The University of Berkeley explains that mindfulness is about acceptance and recognizing that there is not a “right” or “wrong” way to think in each moment. Practicing mindfulness is about recognizing your thoughts in that moment rather than referencing the past or contemplating the future. McQuaide emphasizes that mindfulness allows for increased understanding of implicit bias, as you practice being nonjudgmental. In addition to the benefits of meditation, mindfulness can also improve memory; create more cognitive flexibility; improve immune functioning; and enhance morality, intuition, and fear modulation.
McQuaide, founder of FireFlexYoga and a contributor to Fire Life on www.fireengineering.com, has worked with hundreds of California firefighters on yoga and mindfulness meditation for five years now. FireFlexYoga is meant to be a very practical yoga practice, with functional movement and stress assessment uniquely designed for firefighters and tracked with qualitative and quantitative data. While McQuaide sees yoga and mindfulness as a mind-body integration for healing, especially PTSD, she also sees yoga as a preventive measure, physically and mentally. Yoga helps as it improves flexibility, increases muscle strength and tone, improves cardiovascular and circulatory health, leads to weight reduction, protects from injury, and improves athletic performance. This is beneficial, as many firefighter injuries tend to be sprains and strains and yoga helps prevent those. Additionally, by practicing meditation, you are conditioning the mind.
Mindfulness and meditation are often misinterpreted or misunderstood. Some believe that mindfulness is a complicated production or that their minds are far too busy to quiet. This is not necessarily the case. Mindfulness can be as simple as focusing your attention to the sensation of your breath–feeling the air flow in and out or recognizing how it makes the rest of your body feel. Focusing on the sensation breath can help you understand the impact it has on the rest of the body and its impact on the emotions we feel, especially ones with greater intensity. This takes a conscious effort of control. This measured breathing can also help restore calm and has a physical impact on the body. Andrew Rae of The New York Times quotes Dr. Richard Brown (an associate clinical professor of psychiatry at Columbia University and co-author of “The Healing Power of the Breath”) that “consciously changing the way you breathe appears to send a signal to the brain to adjust the parasympathetic branch of the nervous system, which can slow heart rate and digestion and promote feelings of calm as well as the sympathetic system, which controls the release of stress hormones like cortisol.” (Breathe. Exhale. Repeat: The Benefits of Controlled Breathing, 2016) This response by the parasympathetic response is reacting to the idea that everything is well within the body, allowing the individual to become calmer. Deep breathing (also called diaphragmatic breathing) is a key component of yoga, which goes back to the idea of meditation and yoga intersecting.
An article entitled “The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults” Xiao Mal, et. al (Frontiers in Psychology, 2017) summarized their study on the benefits of deep breathing to better understand its mental benefits. They found that those who received the deep breathing eight-week training showed a decrease in negative effect as compared to their baseline, increased sustained attention, and significantly lowered levels of cortisol. The conclusion was that deep breathing can have a healthy impact in healthy individuals on both cognitive states and reduce negative and physiological states. (2017) However, they also call for more research on this to improve the depth of understanding concerning the physical and mental impact of deep breathing.
There are different types of meditations for different goals, and there are different types of mindfulness meditations depending on your goal. Fortunately, there are numerous resources available to learn meditation, including books and mobile applications. Popular apps include “Headspace,” “Calm,” and “10% Happier.” The Apple Watch features a “Breathe” app that provides the user with a minute, guided breathing exercise to, essentially, take a breather from the day. Many of the apps require a subscription for the full service but also include a variety of free guided meditations, videos, tips, and more. There is also an abundance of information and articles available on the Internet about practicing mindfulness and meditation. These resources essentially teach you how to meditate. Dan Harris, a journalist for the ABC News Corporation, wrote two books on meditation, 10% Happier and 10% Happier: Meditation for Fidgety Skeptics, and developed the 10% Happier app. His journey through meditation began after suffering a panic attack during a live “Good Morning, America” segment. Harris was a meditation skeptic himself initially but now remains a dedicated participant who practices daily meditations. He amusingly refers to meditation as “woo-woo,” noting his own skepticism toward the practice initially. However, Harris explains that it is a simple practice with scientific evidence to have positive benefits on the mind and body. Through meditation, Harris was able to “rein in” the “incessant and insatiable” voice in his head.
Mindfulness and meditation do not need to be long, drawn-out events either. Harris explains that just starting will help get you on the right track. He also admits that he realizes it how difficult it is to develop healthy habits, which is part of the reason he wrote his second book, 10% Happier: Meditation for Fidgety Skeptics, to provide individuals with more of a how-to guide toward meditation. On the 10% Happier Web site, Harris recommends starting with five minutes a day as you build up a daily practice and then working up to 25 or 30 minutes a day. Additionally, people often wonder if they are meditating “correctly.” For beginners, Harris states that you should aim to simply focus on “the experience of breathing” and to begin again when you realize you have gotten distracted, such as by intruding thoughts. Undoubtedly, outside and intrusive thoughts will invade your practice, and mindfulness encourages you to acknowledge these thoughts as they are in the moment and then let them go. Mindfulness focuses on being in the present, so the proper response is to recognize the thought is there but not to dwell on it or make it go further. In a similar vein, mindfulness includes acknowledging judgmental or negative thoughts but, again, not to focus on them. This is especially significant to firefighters, as it will help improve understanding of certain emotions they are feeling after an incident or experience and recognize that what they are feeling is normal. Mindfulness can promote a greater acceptance of emotions.
Dill acknowledges that some firefighters may be hesitant to try meditation and mindfulness because of its cultural connotation and how it is portrayed in the media. As well, he recognizes that it is difficult to do and that firefighters may be impatient with the practice. However, Dill recommends trying it and giving 100% as to learn the calm within yourself. Additionally, Dill cites “grounding” as another method that can support firefighters through treatment and as they are learning meditation. Grounding is a mindfulness practice that connects to the five senses (touch, taste, sight, smell, and sound) to connect you to the present. The sense you are using is meant to distract you from what is causing you distress, such as a flashback. Like mindfulness, grounding can be done anywhere and requires only what you need to stimulate your senses. Dr. Grant-Hill also states that first responders tend to not get help until they are already in distress and that getting help can make a difference as a preventive measure.
Dill and McQuaide both believe that progressive, forward-thinking departments will invest in mental health programming and education as a means of prevention and treatment. McQuaide commented that mindfulness and yoga programs can prevent injury and distress, potentially resulting in fewer on-the-job injuries and saving fire departments in costs concerning injuries and providing firefighters with the possibility of improved physical and mental health in their retirement years. Dr. Grant-Hall also believes that preventive treatment will be valuable in the long run to firefighters aiming to maintain good mental health. Maintaining positive mental health will begin to manifest itself in other aspects of life outside the fire station, adding to the benefits. Just as negative mental health can be a cycle, positive mental health can too.
Mindfulness is just one way that firefighters can begin to take control of their mental health. The benefits of mindfulness meditation are plentiful, and when it goes hand-in-hand with yoga, firefighters can gain even more. These practices can help firefighters prevent their mental health from deteriorating and allow them to have a resource in their toolbox before they are struggling. Preventive measures are just as important as treatment in response to a specific incident or trigger. By taking preventive measures, you are providing yourself with a stronger baseline. Additionally, it helps prepare them for when they do struggle and provides them with a tool to get through the tough times.
Without a doubt, we can do better when it comes to our mental health. One way for firefighters to eliminate the stigma toward treating mental health is to lead the way. Take initiative and take control of your mental health. It is important for firefighters to recognize that they need to take control of their mental health just as they would their physical health and that mental health is just as important. By sharing their stories about mental health, others may be inspired to open up or seek help as well. Education can also help firefighters understand that their feelings are normal, and that getting help is the right thing to do.
It also is necessary to look at the big picture when it comes to mental health. As a brotherhood, we need to stand together and support one another through these struggles. It is more than saying you will be there for someone. Taking initiative, reaching out when you think someone is struggling, and promoting education are all ways to help support your fellow firefighters. This is what makes prevention, education, and treatment toward firefighter mental health so important. Don’t worry about how it looks if you start meditating or doing yoga to improve and maintain your mental health. Recognize that you are doing what is best for you. There is not an excuse to not taking care of your mental health. We need to grow beyond the stigma, and all it might take is one of us to start taking noticeable steps in maintaining our mental health. Any one of us can make a difference–not just in ourselves but in helping others.
The National Suicide Prevention Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week. It is committed to improving crisis services and advancing suicide prevention by empowering individuals, advancing professional best practices, and building awareness. If you are having suicidal thoughts, call 1-800-273-8255.
Victoria Mikulan, MPA, has a BA in English Studies from Robert Morris University and a masters of public administration from Penn State. She is a firefighter 1/EMT-B.