How to recognize the warning signs
There are no conclusive numbers regarding how many EMS providers take their own lives, but we do know it happens. When it does, the effects are devastating. Family, friends, co-workers and supervisors ask themselves, “Why didn’t I see it? What could I have done?” Administrators might also wonder, “Who is next?”
According to Dwight Polk, MSW, NREMT-P, an author, senior lecturer, crisis counselor and paramedic track program director at the University of Maryland Baltimore County (UMBC), Department of Emergency Health Services, signs sometimes indicate someone is considering suicide. In his role as a crisis counselor for the Grassroots Crisis Center and two critical incident stress management (CISM) teams in the Baltimore region, he’s learned assessment techniques and prevention strategies that EMS managers can use to help identify and assist those at risk.
Polk notes that EMS providers, like the police and military, are at particular risk for suicide. “The stuff we see on a day-to-day basis affects us–we take it home with us,” he says. Without a healthy release, the emotional response to multiple incidents can build.
Borrowing from a program originally designed by the U.S. Navy and modified by law enforcement, Polk has developed a customized program to help EMS managers recognize warning signs and assist personnel in getting the help they need.
The decision to create such a program came about as the result of “the day that changed my world,” he says. This was the day one of his students at UMBC committed suicide by stepping in front of an oncoming train. “I’m a mental health professional,” Polk says. “I didn’t see [the warning signs].”
Polk began investigating suicide more closely. He learned the following facts:
- Suicide is a permanent solution to a temporary problem;
- Suicide is a conscious act of self-annihilation brought about by multi-dimensional depression
- The number one reason EMS providers commit suicide is relationship issues, such as divorce, break-ups and child custody difficulties.
As a group, public safety responders are particularly susceptible to troubled relationships. “Our life is about control. We’re hard to live with because of our need to control,” he says.
Studying the data on police officers, Polk found that the majority of the 143 police officers who committed suicide in 2009 were between the ages of 35 and 39, with 10—14 years of service. More than 90% of officer suicide cases involve alcohol.1 In surveys, most law enforcement officers say they use alcohol to help process the traumas they see in their job. The problem is that self medicating with alcohol doesn’t allow the mind to process what it has seen. Instead, the trauma simply builds up inside, requiring more alcohol. That’s why, in part, the connection between alcohol and suicide is so strong, Polk says.
Polk describes the typical EMS provider as a Type-A adrenaline junkie. “We are the poster children for ADHD [attention deficit hyperactive disorder],” he says. The requirements of the job create high stress. Not only are providers exposed to re-current traumatic events, but they also develop a “can’t fail” attitude. At home, providers experience high incidences of family and financial stress. Odd work schedules lead to family disruption and poor sleep patterns. Coping mechanisms often include the abusive use of food, caffeine and alcohol.
Profile of a suicide
The most common profile of a suicidal person in EMS is white, male, married and lower in rank, but that is changing. “As we see more and more women get into public service, we will see these numbers change,” Polk says.
A study of police suicides published in 2010 indicates that officers who reported marital problems were 4.8 times more likely to attempt suicide.2 They were 6.7 times more likely to kill themselves if they had been suspended. The presence of both marital problems and a suspension resulted in an approximately 22-fold increase in the likelihood of a suicide attempt. Relationship difficulties were the number-one factor (32%) in all the suicides studied, although Polk cautions that typically, there are a combination of factors that may cause a person to consider ending their own life. A key message for supervisors is to consider a provider’s personal life when considering a suspension.
Another component in suicide risk appears to be retirement. A recent study found that retired law enforcement personnel were 10 times more likely to commit suicide than age-matched peers. Law enforcement personnel who retired because of a disability had the highest suicide rate–2,616 per 100,000 compared to age-matched peers with a rate of 34 per 100,000.3
Stress happens to everyone all the time. However, the nature of EMS creates more stress than most professions, producing the kind of stress that can develop into trauma. In addition to the repeated “routine” horrors, providers are also subject to shame, mistakes, abuses and fears. The cumulative effects of these traumas can mean that only a minor incident is needed to prompt a breakdown or suicide attempt. For every EMS provider suicide, a thousand more providers exist who are still working and suffering from cumulative trauma. Agencies often experience this in terms of increased sick leave, injuries, citizens’ complaints, lawsuits and personnel actions.
As the people who respond to others in need, it is especially difficult for EMS personnel to ask for help. Often, suicidal people work hard to make sure no one knows what they intend to do, making spotting someone in trouble even more challenging. However, it appears that completed suicides proceed through a specific thought process; a continuum of stoic behavior that can be observed. “Suicide is very seldom spontaneous,” Polk says. The four phases include:
- Ideation: The thought of suicide as a viable option. “Some people can’t stop thinking about it,” Polk says.
- Gesture: In this phase, the person practices dangerous behavior just to see what it’s like. They may drive too fast or take unnecessary risks, especially on scene.
- Attempt: This is the actual suicide attempt or effort toward suicide. “This is where we can intervene,” Polk says.
- Completion: The person actually completes the suicide, and death occurs.
The warning signs for suicide often start with clinical depression. This could include signs of substance abuse, changes in behavior or changes in sleep patterns. Not getting enough rapid eye movement (REM) sleep for extended periods of time, either due to sleeplessness, prolonged shifts or alcohol abuse, causes serious degradation of mental faculties.
Often those who are contemplating suicide will begin pulling away from interpersonal relationships. They are no longer easygoing. Instead, they become restrained or lose their typical sense of humor. Polk describes it as, “Something just doesn’t seem right.” In the late stages, these people may fear that they can’t trust anyone but themselves. Feeling alone and isolated is a huge warning sign. Losing a sense of trust of one’s self is a sign of imminent danger.
There may be a period of improvement that occurs after a decision to commit suicide is made. For many, the decision is a relief. “They’ve got control back in their life because they made a decision,” Polk says. “The person who is thinking of suicide has worked the numbers. They’ve tried everything they can and see no other choice.”
Other warning signs may include:
- Guilt, shame and self-hatred;
- Fear of losing control;
- Sadness or crying;
- Verbalizing suicidal or hopeless thoughts;
- Giving away personal possessions; and
- Excessive focus on suicide as a subject.
Suicide risk assessment tool
In 1983, researchers developed a clinical assessment tool for medical students to determine suicide risk that goes by the acronym SAD PERSONS.4 The score is calculated from 10 yes/no questions, with one point for each affirmative answer:
S: Male sex;
A: Age 35—39 is the key age range for suicide risk;
P: Previous suicide attempt;
E: Ethanol abuse (alcohol);
R: Rational thinking declines;
S: Social support is lacking;
O: Organized plan exists;
N: No spouse or significantother; and
Anyone with four or fewer “yes” answers is considered a low risk of suicidal behavior. Five to six “yes” answers represents a moderate risk. Anything more than six “yes” answers means the person is at high risk.
As a supervisor, Polk says, you may not be the right person to be asking these questions, especially if you’re being perceived as part of the problem. Have someone both of you trust approach the employee in question. Polk says that for the most part, these people will respond positively to the inquiry. “What it tells people is that you listen and you care,” he says.
What can you do?
If you see a person who exhibits the warning signs for suicide, try to intervene. Don’t wait until tomorrow or next week. First, secure the environment and remember that someone who is capable of being a danger to themselves can also be a danger to others. Be aware of the suicide risk factors and ask specifically about them.
Understand that someone who is feeling suicidal will not trust you initially. Don’t try to push yourself on them. It’s important for them to save face and feel in control. They may display false emotion.
“Most people are ambivalent about dying,” Polk says. Try asking them what’s kept them from killing themselves so far. “That’s your open door,” he says. “It could buy you time to help address their concerns.”
They probably feel overwhelmed. Ask them what made it so bad today. Validate what they are saying and listen carefully. Be patient and understanding. Do not judge. Focus on the main problem. Build trust. “It doesn’t have to be big trust,” Polk says. “The most important thing is to get some help now.”
Among public service personnel, employees often resist using employee assistance programs (EAP) due to a concern that they may be fired or that the counselor will not understand the particular rigors of their job. Polk says that one of the best support systems is each other. “In fire, police and EMS, there’s that brotherhood–we trust each other. Buddy care works,” Polk says. “There needs to be a general awareness by everyone that we need to watch out for and take care of each other.”
Polk is also a big proponent of spousal education programs.”We bring this stuff home with us,” he says. Spousal education and support programs help
educate non-public service spouses about what life’s like for their loved ones. It can explain why their husbands or wives change over time and give them some guidance about when to be concerned. If a spouse comes home from a hard day and just wants to sleep, that’s okay. If a spouse comes home every day and wants to be left alone, that is a warning sign.
“Never be afraid to reach out for help,” Polk says. “Start with your department chaplain or CISM team.”
A group of active and retired law enforcement officers has developed an Emotional Self-Care Training program, available on the website Badge of Life (www.badgeoflife.com). They note that thousands of dollars are spent each year on vehicle maintenance, but little thought is given the emotional health of personnel. Rather than using therapy only as a reaction to an event, they maintain that it should be applied proactively and often. The most critical component of any mental health program is that it remains voluntary and confidential. Badge of Life stresses that any department that tries to “mandate” such a program will fail.
They also stress the following steps for self-care:
- Look at the past year;
- See how you’re doing;
- See what you did well–and what you could do better;
- Identify your strengths and apply them to the next year;
- Be prepared for stress and trauma before they happen (and know what to do, right away, if they do); and
- Have a therapist already there, if you need them.
More research is necessary to determine the effectiveness of various types of prevention and intervention programs. The police group recommends a few common sense steps that can be taken to prevent both loss of life and secondary trauma. These steps are applicable to EMS as well.
- Conduct psychological pre-employment screening of all applicants;
- Provide education to personnel and their family members regarding depression, suicide, stress management and available employee assistance or counseling resources;
- Conduct middle-management education on depression, signs and symptoms of suicide and appropriate policy and procedures should an employee be identified as possibly suicidal;
- Make resources, including chaplains, peer support, 24-hour hotlines and mental health personnel available to department personnel and their family members;
- Track individuals who meet specific at-risk criteria either because of life events (e.g., divorce, for example) or because the individual shows significant signs and symptoms of distress (i.e., sudden drop in performance, increase in complaints, anger and negativity);
- Debrief after high-stress incidents; and
- Provide retirement transition seminars and assistance to prepare individuals for the emotional and social changes that will occur.
Suicide is no longer the great mystery it once was; many of the myths have been debunked. Researchers have identified basic components of suicide that can help others to act proactively. These informed interventions save lives. The reality is that someone who is contemplating suicide is in extreme pain and suffering, the source of which is complex and most likely involves a variety of factors.
In the end, mental wellness programs aren’t just about preventing suicides. They are about emotional survival.
- O’Hara AF, Violanti J. Police suicide–A comprehensive study of 2008 national data. J Emerg Mental Health. 2009;11(1):17—23.
- Janik, J, Kravitz HM. Linking work and domestic problems with police suicide. Suicide and Life-Threatening Behavior. 1994;24(3):267—274.
- Gaska CW. The rate of suicide, potential for suicide, and recommendation for prevention among retired police officers. Doctoral Dissertation. Detroit, Michigan: Wayne State University, 1980.
- Patterson WM, Dohn HH, Bird J, et al. Evaluation of suicidal patients: The SAD PERSONS scale. Psychosomatics. 1983;24(4):343—345,348—349. doi:10.1016/S0033-3182(83)73213-5