In 2000, I wrote a research paper on the effects of stress and grief on firefighters. My efforts were the result of my personal experiences as a firefighter, EMT-B and mortician witnessing first-hand the emotional trauma these men and women experience in the field. I strongly believe that programs such as Grieving Behind the Badge must be provided to help reduce heart attacks, suicides, substance abuse and divorce in the fire service as well as the emergency medical service and law enforcement communities.
EXECUTIVE SUMMARY
The rapid growth of business and industry in the United States over the last few decades has precipitated a growing concern by government agencies to enact laws and establish guidelines on workplace practices to protect the health and safety of workers. A key issue that has become paramount is the effect of job-related stress on the physical, mental, and emotional health of adults in the workplace.
As the result of the overwhelming concern for firefighters' health and safety, organizations including the International Association of Fire Chiefs and the National Fire Protection Association have recommended safety guidelines and training programs that will reduce injury, death, and long-term emotional stress in the fire service. Although most fire departments have implemented the safety guidelines, many have not provided resources for coping with stress and grief. This may be the result of insufficient budgets, scheduling problems, or lack of interest. However, the rise in the divorce rate and health problems related to stress and grief in the fire service community have made educational programs to cope with these issues necessary and crucial for the emotional health and physical wellness of firefighters.
This paper discusses the current situation of job-related stress in the fire service, the effects of stress and grief on its members, and the additional burdens faced by volunteer firefighters. Furthermore, information will be provided with respect to the Grieving Behind the Badge program offered by the Sweeney Alliance. This educational workshop is the solution to these problems and promotes emotional wellness for all firefighters as well as their families and fire department chaplains.
INTRODUCTION
Today, in the United States, what were once considered safe environments are now battlegrounds. No longer are schools, homes, places of business, or even churches safe from violent acts of aggression. Moreover, our society is witnessing an alarming increase in homicides, rapes, domestic violence, child abuse, and highway injuries and deaths. The aftermath of these traumatic events is having a devastating and adverse reaction on everyone. Nowhere is this more apparent than in the emergency service professions: the men and women who serve their communities as firefighters and pre-hospital caregivers. Their daily experiences with life-threatening and highly stressful events are affecting them physically, mentally, and emotionally. Furthermore, divorce, substance abuse, and heart attack rates in these professions are among the highest in the nation. "In the fire service, heart attacks claim more lives than any other line-of-duty injury" (International Association of Fire Chiefs' Foundation [IAFCF], 1991). Efforts have been made to address some of the critical needs of these community servants. However, there is a lack of opportunities to deal with job-related stress as well as personal trauma and grief for firefighters, their families, and fire department chaplains.
History and Background of the Problem
Many jobs are considered dangerous and stressful by their very nature. Firefighting is one of the most life-threatening and emotionally traumatic occupations. The high levels of stress that firefighters routinely encounter can lead to chemical dependency, physical illness, emotional problems, post-traumatic stress disorder (PTSD), and poor interfamily relationships such as divorce. The lack of public support and compassion by citizens, government agencies, and business officials for the risks these firefighters endure and the occasional negative editorial coverage by the news media adds to their anxiety level.
On average, one hundred firefighters die every year in the line of duty. Of these one hundred deaths more than one third is due to heart attacks either while on duty at the fire scene or shortly thereafter (United States Fire Administration, 1999). Evidence suggests that stress plays a major role in chronic health problems such as cardiovascular disease and psychological disorders (Substance Abuse and Mental Health Services Administration [SAMHSA], 1995). Furthermore, "it is not known for certain, but it is believed that stress may lead to mental illness (including depression), substance abuse, divorce, criminal behavior or suicide” (IAFCF, 1991). Unfortunately, it has not been until recent years that emphasis has been placed on the emotional and mental needs of firefighters. Organizations and agencies such as the International Association of Fire Chiefs and the National Fire Protection Agency have recently made recommendations and implemented standards to address the growing problem of job-related stress along with physical and emotional illness in the fire service.
Firefighters receive little if any training or support to help them cope emotionally with stress. Following a traumatic incident (the death of a child, a mass fatality, or the death of a fellow colleague) some fire departments may implement a critical incident stress debriefing (CISD) or offer the assistance of a department chaplain. However, only a small number of departments offer educational programs on coping with stress. The International Association of Fire Chiefs' Foundation (IAFCF) states that, "with the plethora of recommendations for controlling stress in the fire service, few have been implemented" (1991). This may be due to the lack of initiative or funding. Some department administrators do not believe that help is needed. They believe that traumatic incidents are part of the job and firefighters must learn to cope as best they can with their stress and depression. Retired firefighter, Dr. Harry Carter, writes, "The pressures of life are far greater than they were in the past.… If you mix the problems we all face with our families, our health, and commitments to the community, you can wind up with seemingly insurmountable problems (2000, March 8). Fire departments that want to offer training programs for coping with traumatic events may not have the financial resources to do so. Furthermore, firefighters are frustrated by the federal government’s willingness to fund similar programs for law enforcement officers but seemingly disregard their needs. For example, the National Institute of Justice (NIJ) funds the Corrections and Law Enforcement Family Support program (CLEFS). From 1996-1998, the NIJ awarded twenty-five grants totaling two million dollars. The "grantees are providing stress services to law enforcement and correctional officers and their families…" (NIJ, 1999).
Scope of the Study
The Sweeney Alliance has developed and implemented many educational workshops and community service projects for families and professionals. Because firefighters want help and support in coping with their emotional problems, the Grieving Behind the Badge training program was developed to help them understand and cope with post-traumatic stress issues. This program addresses incidents of job-related stress as well as grief issues encountered in their personal lives; such as, divorce, death of a loved one, or a long-term illness of an aging parent to name a few. Likewise, the Grieving Behind the Badge program is beneficial for the families of firefighters, fire department chaplains and fire academy students.
LITERATURE REVIEW
Definitions
The terms emergency service professional and emergency service worker in this paper mean firefighters (paid and volunteer) along with trained professionals skilled in pre-hospital care to patients (first responders, emergency medical technicians, and paramedics). The terms firefighter, emergency service professional, and emergency service worker are interchangeable. The use of the male gender is in no way meant to overlook or make light of the many contributions women make to these professions. This terminology is being used for simplicity and ease in writing. In addition, the term grief in this paper means the feelings and emotions following any loss that contributes to a person's stress levels.
Stress in the Workplace
The concern for the health and safety of Americans has prompted the federal government to implement programs and set standards to reduce injury and death in the workplace. For example, the Occupational Safety and Health Act (OSHA) has addressed the issue of hazardous materials by regulating the proper clothing and protective eyewear that must be worn by persons who come in contact with or who must handle these dangerous agents. Safety devices on machinery, proper ventilation of highly toxic gases and fumes, and strict rules for handling blood-borne pathogens further enhances the safety and health of today’s workers.
Job-related stress is another priority in today's workplace environment. Job-related stress is not only a serious concern of workers, but it can affect health organizations as well. The short- and long-term aftermath of stress on the job can eventually increase workers' compensation costs, medical and mental health premiums, and death benefit payments. According to the American Psychology Association (APA, 1997), "… stress costs American industry more than $300 billion annually" as the result of absenteeism and reduced productivity. On average, forty-three percent of adults in the United States suffer adverse health effects from stress following corporate downsizing, company layoffs and mergers, and bankruptcies. Additional stress can be brought on by "computer surveillance of production, fewer health and retirement benefits, and the feeling they [workers] have to work longer and harder just to maintain their current economic status" (Miller, L. & Smith, A., 1997). However, these examples pale in comparison to the stress incurred following a traumatic event that threatens the safety and emotional well being of employees. "Traumatic stress encompasses exposures to events or the witnessing of events that are extreme and/or life threatening" (Volpe, 1996). These extreme or life threatening events include deliberately caused man-made disasters (homicides, arson, etc.) and accidental disasters, such as motor vehicle accidents, fires, and explosions. It is important to note that "homicide is now the second most common cause of death in the U.S. workplace" (VandenBos, G. & Bulatao, E., 1996). Examples of other traumatic disasters include September 11, 2001, the Oklahoma City bombing, train derailments, airline crashes, and school shootings.
Following any type of stressful situation most adults will experience some degree of emotional instability. They may feel nervous and apprehensive. They may experience guilt, anxiety, depression, and sleep disturbances or they may be unable to concentrate for long periods of time on simple tasks. However, for adults who suffer from traumatic or chronic (long-term) stress, the long-range effects may include high-blood pressure and an increased susceptibility to heart disease, diabetes, and cancer. Furthermore, the Substance Abuse and Mental Health Services Administration (SAMHSA, 1995) states that chronic stress may cause "psychological problems including depression, withdrawal, apathy, and relationship problems in general." In addition, this type of stress can lead to an “increase use of alcohol, tobacco, and other drugs.” If left untreated, chronic or long-term stress can lead to post-traumatic stress disorder (PTSD). PTSD is a condition that manifests itself through flashbacks (mental or visual re-experiencing of a trauma), nightmares, a sudden and painful onslaught of emotions, or avoidance phenomena, which affects the person’s ability to relate well with others (American Psychiatric Association, 1997). Moreover, the Occupational Safety and Health Administration has declared, “stress a hazard of the workplace" (APA, 1997).
Companies and government agencies continue to address the safety and health of employees as well as their emotional needs. Moreover, business owners and human resource managers are taking a holistic approach to employee wellness. These business leaders realize they must provide not only a safe working environment, but also a workplace that offers positive mental and emotional re-enforcement; much more than the proverbial "pat on the back." In the past, stress, grief, and violence in the workplace were topics that few company executives viewed as potential problems. However, these issues have initiated the implementation of support programs and training seminars. Classes on time and anger management, conflict resolution, and self-defense tactics as well as coping with stress and grief have been effective in promoting a healthier and safer work environment. These programs have helped associates and their families cope with an array of emotional issues thus promoting a healthier outlook on their job and their personal life.
Stress in the Fire Service
With the advancement of fire prevention technology, such as flame-retardant building materials, smoke detectors, and sprinkler systems, fire departments are responding to fewer and fewer fire calls than ever before. However, for the more than one million firefighters in the United States, firefighting is still considered a very hazardous and highly stressful occupation. Firefighters are at greater risk of injury and death than most other professions as the result of flames and intense heat, “poisonous, flammable, or explosive gases and chemicals, or radioactive or other hazardous materials” (Bureau of Labor Statistics, 1999). Clark & Zak (1999) state that firefighters “are more likely than other workers to die violently—from gunshots, vehicle accidents, and fire-related incidents. Their risk of suffering a fatal incident is three times greater than for all workers.” Likewise, firefighters risk the chance of injury and death with every emergency call that they respond to. Patients under the influence of narcotics or alcohol, family members of the victim, or bystanders may threaten them with knives, guns, or physical assault. "Firefighters often become the object of a victim's anger" or they may be "blamed for not doing enough" (IAFCF, 1991). Because of this, many fire departments have issued bulletproof vests to protect the lives of their members.
Fire departments respond to more and more non-fire emergency calls. For example, "In 1997, there were over 10 million emergency medical calls made to fire departments in the United States" (Clarke & Zak, 1999). Because of this, firefighters are usually the first on the scene of accidents, suicides, and acts of violence (assault and battery, rapes, bombings, school shootings, etc.). Emergency service workers respond to floods, earthquakes, and airline crashes where the death toll and property destruction is overwhelming. They care for victims of domestic violence and child abuse. Firefighters extricate mangled bodies from motorized vehicles following an accident and provide medical assistance to homeless patients on the streets of inner cities. At times, they must physically restrain patients who are combative due to mind-altering drugs or head injuries. Likewise, they comfort parents and family members when a child or loved one has died. All too often they must cope with grief following the death of a fellow firefighter in the line of duty. As a result of these examples and many more, "firefighters frequently experience trauma, death, and sorrow" (NFPA, 1997).
Firefighters routinely struggle with the trauma of witnessing tragedy and death. The frequent contact with patients who die has a profound effect on the emotional well being of emergency service professionals (Floren, 1984, p.43). "Disaster and emergency workers are affected by traumatic events irrespective of rank or years of experience" (SAMHSA, 1995). For example, many emergency service professionals are still coping with emotional trauma as the result of their rescue and recovery efforts following the events of September 11, 2001 and the Oklahoma City bombing in 1995 because "a disaster with [only a few or] no survivors can be especially frustrating to deal with" (Laughlin, 1980, p.25). "Research indicates that the critical time for a delayed trauma to surface is between three to five years after the initial tragedy" (Owen, 1999). A large number of rescue and recovery workers were experiencing stress and emotional trauma years after the Oklahoma City bombing and the events of September 11. Owen writes that "divorces were three times higher than normal in the Oklahoma Fire Department" and numerous suicides occurred on the Oklahoma Police Department. Owen further states that, "family violence and addiction--including substance abuse and gambling--has increased among workers connected with the bombing rescue."
Research has shown that “forty-three percent of all adults suffer adverse health effects from stress” (Miller, L., 1997); however, it is the men and women in the emergency service professions that are at a greater risk of suffering long-term stress that can lead to PTSD. The “rate for diagnosable PTSD among firefighters was 16.5 percent compared to a one percent to three percent rate for the general population—about one percent higher than PTSD rates of Vietnam veterans” (DeAngelis, 1995, p.36). The International Association of Fire Chiefs’ Foundation (1991) has stated that
In addition to the life-threatening and job-related stress they encounter in their professional lives, firefighters must also cope with an array of personal and family issues as well. "The dangers of the job create anxiety in the firefighter's family" (Martin, 1991, p.2). These factors may include, but are not limited to, a troubling child in the home, the death of a loved one, “aging or invalid family members, terminal illness, divorce, and the daily demands of raising a family” (SAMHSA, 1995). "Some firefighters take their problems home to their [spouses] and families or seek outside employment (moonlighting) to compensate for the stress and frustration of the firefighting job" (IAFCF, 1991). Many of these emergency service workers feel that their families and friends do not understand the magnitude of their duties nor the emotional strain they must endure on a daily basis. The International Association of Fire Chiefs’ Foundation (1991) states that firefighters "want to protect loved ones from what happened [on the job]." Also, a firefighter's spouse must cope with the constant stress, sacrifice, and frustration of "living with the worry of having their husbands [or wives] constantly walking into the jaws of danger" (Burns, 1998). Most firefighters are very reluctant to discuss the death, carnage, and human suffering they witness on the job with their family and friends. Moreover, emergency service professionals struggle with thoughts of inadequacy as a spouse, parent, or social friend. They may suffer from restless sleep or nightmares, alcohol and drug addiction problems, and thoughts of suicide as the result of their constant exposure to life-threatening situations and the multitude of mentally and emotionally challenging emergency calls. "Despite the nightmares, the guilt for not doing enough, the questions of their own sanity, the trauma stays inside" (Owen, 1999). All of these examples, and many more, contribute to the growing concern by government agencies and members of the fire service community as a whole for the health, safety, and emotional wellness of firefighters today.
Stress Among Volunteers in the Fire Service
Volunteer firefighters comprise approximately eighty-four percent of all firefighters in the United States and "save localities across the country an estimated $36.8 billion per year" (National Association of State Foresters, 1993). Most do not receive monetary compensation for their efforts. Most volunteer firefighters have full-time jobs in addition to their duties and responsibilities at the fire department. However, these firefighters are exposed to the same dangers, experience the same job-related stress, and must cope with grief just as their comrades in career (paid) departments. They fight fires, save lives, and protect property. Many are trained as first responders, emergency medical technicians, or paramedics. Some receive additional training in specialized areas, such as vehicle extrication, high-angle rescue, hazardous materials, and water rescue. Volunteer firefighters respond to major disasters, motor vehicle accidents, domestic violence and child abuse calls, and school shootings. They are placed in life-threatening situations and many of them are victims of violence. Sadly, one hundred firefighters die in the line of duty each year. The majority of these firefighters are volunteers (National Fire Protection Association, 1999).
Although some volunteer departments are in large cities most are in small, rural communities. Therefore, these "emergency workers frequently know the victims and/or their families thus compounding their levels of stress and emotional trauma" (SAMHSA, 1995). Furthermore, many rural departments may only respond to ten or fifteen calls per year. These firefighters "may not be as regularly exposed to certain types of incidents and may not be as emotionally desensitized (SAMHSA, 1995). Because of this, many volunteer firefighters in rural areas with few calls may find it just as difficult to cope with stress and grief as firefighters who respond to many calls in larger cities.
Most volunteer departments must rely on fundraising or donations to replace unsafe clothing (turnout [bunker] gear), repair older vehicles, and purchase or replace mandated safety equipment such as self-contained breathing apparatus and personal protective alarm systems. This is due in part to the expensive costs and very low budgets for operating a volunteer fire department. In some cases, volunteer firefighters must purchase their own safety equipment. In addition, the diversity of their emergency calls has required specialized training classes. For the most part, these classes are paid by the volunteer firefighter themselves rather than by their department. Therefore, "Volunteering in the fire and EMS service… is one of the most demanding volunteer activities today" (Bush, Schaenman, & Thiel, 1999).
Since 1983, the number of volunteer firefighters has declined steadily. Because of this, volunteer fire departments "are having to do more with less" (Bush, Schaenman, & Thiel, 1999). This decline is due to an increase in time demands at the fire department (greater number of emergency calls), an increase in training hours to comply with national standards, fund raising activities, and responsibilities of family and home. In some states, volunteer firefighters and emergency medical personnel must meet the training requirements established by the National Fire Protection Association. Although important, these training requirements add to the number of hours that firefighters must be away from their families and non-fire service responsibilities. Many businesses may allow volunteer firefighters to respond to emergency calls during work hours; however, they may not pay them for the hours they are away from the job. This may contribute to additional financial burdens. As a result of these issues, "Stress is a major problem in volunteer fire departments and it's a big reason for attrition" (Streng, 1985, p.24).
Current Methods to Reduce Stress in the Fire Service
Due to the overwhelming concern for the firefighters' safety and health, government agencies and fire service organizations have established standard operating procedures and strict guidelines that can reduce injury, death, and long-term emotional trauma. Flame and heat retardant protective clothing (turnout gear), self-contained breathing apparatus, and personal alarm safety systems have helped to deter the life-threatening aspects of firefighting. Fire service administrators have been encouraged to install “gentler wake-up systems for firefighters that replace clanging bells with dim lights, speakers, and a tone” (DeAngelis, 1995, p.36). Furthermore, DeAngelis writes that “equipping firefighters with radios so they can hear what’s going on in an emergency” can also save lives. The National Fire Protection Association (NFPA), an international codes and standards organization, has made recommendations and has established guidelines to further reduce the risk to firefighters’ health and wellness. Three of these recommendations include the Members Assistance Program (MAP), the Critical Incident Stress program, and the Chaplaincy program (1997).
Member Assistance Program
MAP is a "generic term used to describe the various methods found in the workplace for the control of alcohol and drug abuse, stress and personal problems that adversely affect job performance" (IAFCF, 1991). Fire departments that provide Member Assistance Programs refer firefighters to various agencies that provide counseling and treatment centers. Health promotion programs also provide a variety of activities for the firefighter and his family. Programs, such as "career advisement, family orientation and education programs on… weight control, healthy heart, … smoking cessation and pre-retirement planning" are also available through the MAP program (IAFCF, 1991).
Critical Incident Stress Program
A vital and intrinsic aspect of emotional help for firefighters is Critical Incident Stress Debriefing (CISD). "Critical incident stress is a normal reaction experienced by normal people following an event that is abnormal" (NFPA, 1997). CISD is a "reactive form of treatment either on the scene of a disaster or within a short period of time after the disaster by means of a debriefing" (IAFCF, 1991). The "main goal [of CISD] is to lessen the long-term psychological impact of the event and to accelerate the recovery process" in the emergency service worker (Clark, 1991). Clark also states that CISD is "used solely to regenerate the normal support process." A CISD is implemented following "mass casualties… fatalities involving children, fatalities or injuries involving fire department members, and any other situation that affect the psychological… well-being" of an individual (NFPA, 1997). However, CISD does not afford the emergency service professionals preventative training or long-range, follow-up support and education. Therefore, the firefighter may experience recurring, adverse side effects as the result of continuous emotional trauma. These side effects can include, but are not limited to, anxiety, insomnia, gastro-intestinal problems, and an increased risk of heart attacks and severe depression.
Chaplaincy Program
Many fire departments request the assistance of chaplains following a line of duty death of one of their firefighters. "Chaplaincy programs are beneficial in helping fire department members deal with the stress of their work" (IAFCF, 1991). In addition, chaplains provide emotional and spiritual help for firefighters and their families as well as CISD members. Firefighters who do not initially "relate well to outsiders will often turn to and accept the help of a chaplain who practices strict confidentiality when dealing with personal problems" (IAFCF, 1997).
CONCLUSION
Traumatic events, including mass casualties, injury or death of children, life-threatening situations, or a line of duty death have a profound impact on the mental and physical health of firefighters. Without coping skills, emergency service professionals can experience unhealthy side effects, such as stress, high blood pressure, and depression, as well as disabling illness including heart attacks, substance abuse, and post-traumatic stress disorder (PTSD). Personal life issues such as divorce, long-term illness, or death of a family member, etc. can have a negative effect on them as well. Although research has shown that there are some resources available for firefighters and their families to cope with stress, there is a need to have a training program that will provide information on grief, suicide and addiction prevention, and promoting emotional wellness for everyone as well.
The International Association of Fire Chiefs' Foundation (1991) states, "continuing education and training within fire departments are favored by many as tools for alleviating stress." Furthermore, "Specific training in dealing with death, crisis and suicide are needed, and orientation programs may help recruits better prepare for the physical and psychological rigors of their new profession." SAMHSA (1995) has made the following recommendations:
Floren (1984, p.43) suggests that there is a "strong need to provide a more humanistic approach in the training of emergency [service] personnel." Also, "we need to learn more about death and dying, the stages of grief, what to expect from a suddenly bereaved family and how we may most helpfully interact with family members." Furthermore, emergency service workers must be able to talk about the pressures involved in traumatic situations, to understand what others have experienced in similar situations, and know that they are not alone in their feelings. Floren continues,
Finally, the National Institute of Mental Health states that "The use of both prevention and treatment strategies can potentially decrease or eliminate negative effects of stress" (1990).
The Grieving Behind the Badge training program addresses stress and grief and promotes emotional wellness for everyone. Unlike critical incident stress debriefing the Grieving Behind the Badge program does not focus on a single incident but rather the frequent professional traumas as well as personal life stressors these men and women experience. Throughout the training everyone is encouraged to openly share their anxieties in a safe environment. Interactive dialogue provides opportunities to discuss issues that cause nightmares, family discontent, substance abuse, and thoughts of suicide. The students learn coping skills for job-related stress issues as well as personal life traumas. These men and women realize they are not alone in their thoughts and feelings. Family members can discuss their needs as well as their fears and frustrations. Fire department chaplains receive information to help them provide emotional support to firefighters and their families. Additional programs on coping with grief can be offered to families and departments who have experienced a line of duty or non-duty related death of a firefighter. Recruits receive valuable information and coping skills that can prevent long-term stress and grief. As a result of the Grieving Behind the Badge program, emergency service professionals, their families, and chaplains have a better understanding of stress and grief and the effects they have on their lives. Moreover, everyone can gain the knowledge necessary to resolve many of their professional and personal problems because of the information and resources that are provided.
If fire departments and organizations want to reduce the number of lives that are lost from physical illness, substance abuse, and suicide in the fire service then they must provide firefighters with help and coping skills. Training them to deal with trauma, stress, and grief is no less important then training them to be safe on the fire ground. No longer can job-related stress in the fire service be ignored. It is the duty and responsibility of every fire service officer to provide for and enhance the emotional wellness of his or her department. Without the support and dedication of everyone stress and grief will continue to take a toll on firefighters and their families.
The emotional wellness of firefighters is at risk. Stress and grief are problems that are not easily detected or easily resolved. Severe depression, heart attacks, and the high rates of divorce, addiction, and suicide in the fire service prove this. There has been a call to action and The Sweeney Alliance has answered that call. The Sweeney Alliance is the solution to these problems. The Grieving Behind the Badge training program is proven to address these problems and to help resolve them for the men and women in the fire service. Grieving Behind the Badge should be made available to all emergency service professionals, their families, recruits, and fire department chaplains.
Copyright 2003 Peggy Sweeney. All rights reserved.
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Bush, R., Schaenman, P., & Thiel, K. (1998). Recruitment and retention in the volunteer fire service: Problems and solutions. Wasgington, D.C.: National Volunteer Fire Council and United States Fire Administration.
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EXECUTIVE SUMMARY
The rapid growth of business and industry in the United States over the last few decades has precipitated a growing concern by government agencies to enact laws and establish guidelines on workplace practices to protect the health and safety of workers. A key issue that has become paramount is the effect of job-related stress on the physical, mental, and emotional health of adults in the workplace.
As the result of the overwhelming concern for firefighters' health and safety, organizations including the International Association of Fire Chiefs and the National Fire Protection Association have recommended safety guidelines and training programs that will reduce injury, death, and long-term emotional stress in the fire service. Although most fire departments have implemented the safety guidelines, many have not provided resources for coping with stress and grief. This may be the result of insufficient budgets, scheduling problems, or lack of interest. However, the rise in the divorce rate and health problems related to stress and grief in the fire service community have made educational programs to cope with these issues necessary and crucial for the emotional health and physical wellness of firefighters.
This paper discusses the current situation of job-related stress in the fire service, the effects of stress and grief on its members, and the additional burdens faced by volunteer firefighters. Furthermore, information will be provided with respect to the Grieving Behind the Badge program offered by the Sweeney Alliance. This educational workshop is the solution to these problems and promotes emotional wellness for all firefighters as well as their families and fire department chaplains.
INTRODUCTION
Today, in the United States, what were once considered safe environments are now battlegrounds. No longer are schools, homes, places of business, or even churches safe from violent acts of aggression. Moreover, our society is witnessing an alarming increase in homicides, rapes, domestic violence, child abuse, and highway injuries and deaths. The aftermath of these traumatic events is having a devastating and adverse reaction on everyone. Nowhere is this more apparent than in the emergency service professions: the men and women who serve their communities as firefighters and pre-hospital caregivers. Their daily experiences with life-threatening and highly stressful events are affecting them physically, mentally, and emotionally. Furthermore, divorce, substance abuse, and heart attack rates in these professions are among the highest in the nation. "In the fire service, heart attacks claim more lives than any other line-of-duty injury" (International Association of Fire Chiefs' Foundation [IAFCF], 1991). Efforts have been made to address some of the critical needs of these community servants. However, there is a lack of opportunities to deal with job-related stress as well as personal trauma and grief for firefighters, their families, and fire department chaplains.
History and Background of the Problem
Many jobs are considered dangerous and stressful by their very nature. Firefighting is one of the most life-threatening and emotionally traumatic occupations. The high levels of stress that firefighters routinely encounter can lead to chemical dependency, physical illness, emotional problems, post-traumatic stress disorder (PTSD), and poor interfamily relationships such as divorce. The lack of public support and compassion by citizens, government agencies, and business officials for the risks these firefighters endure and the occasional negative editorial coverage by the news media adds to their anxiety level.
On average, one hundred firefighters die every year in the line of duty. Of these one hundred deaths more than one third is due to heart attacks either while on duty at the fire scene or shortly thereafter (United States Fire Administration, 1999). Evidence suggests that stress plays a major role in chronic health problems such as cardiovascular disease and psychological disorders (Substance Abuse and Mental Health Services Administration [SAMHSA], 1995). Furthermore, "it is not known for certain, but it is believed that stress may lead to mental illness (including depression), substance abuse, divorce, criminal behavior or suicide” (IAFCF, 1991). Unfortunately, it has not been until recent years that emphasis has been placed on the emotional and mental needs of firefighters. Organizations and agencies such as the International Association of Fire Chiefs and the National Fire Protection Agency have recently made recommendations and implemented standards to address the growing problem of job-related stress along with physical and emotional illness in the fire service.
Firefighters receive little if any training or support to help them cope emotionally with stress. Following a traumatic incident (the death of a child, a mass fatality, or the death of a fellow colleague) some fire departments may implement a critical incident stress debriefing (CISD) or offer the assistance of a department chaplain. However, only a small number of departments offer educational programs on coping with stress. The International Association of Fire Chiefs' Foundation (IAFCF) states that, "with the plethora of recommendations for controlling stress in the fire service, few have been implemented" (1991). This may be due to the lack of initiative or funding. Some department administrators do not believe that help is needed. They believe that traumatic incidents are part of the job and firefighters must learn to cope as best they can with their stress and depression. Retired firefighter, Dr. Harry Carter, writes, "The pressures of life are far greater than they were in the past.… If you mix the problems we all face with our families, our health, and commitments to the community, you can wind up with seemingly insurmountable problems (2000, March 8). Fire departments that want to offer training programs for coping with traumatic events may not have the financial resources to do so. Furthermore, firefighters are frustrated by the federal government’s willingness to fund similar programs for law enforcement officers but seemingly disregard their needs. For example, the National Institute of Justice (NIJ) funds the Corrections and Law Enforcement Family Support program (CLEFS). From 1996-1998, the NIJ awarded twenty-five grants totaling two million dollars. The "grantees are providing stress services to law enforcement and correctional officers and their families…" (NIJ, 1999).
Scope of the Study
The Sweeney Alliance has developed and implemented many educational workshops and community service projects for families and professionals. Because firefighters want help and support in coping with their emotional problems, the Grieving Behind the Badge training program was developed to help them understand and cope with post-traumatic stress issues. This program addresses incidents of job-related stress as well as grief issues encountered in their personal lives; such as, divorce, death of a loved one, or a long-term illness of an aging parent to name a few. Likewise, the Grieving Behind the Badge program is beneficial for the families of firefighters, fire department chaplains and fire academy students.
LITERATURE REVIEW
Definitions
The terms emergency service professional and emergency service worker in this paper mean firefighters (paid and volunteer) along with trained professionals skilled in pre-hospital care to patients (first responders, emergency medical technicians, and paramedics). The terms firefighter, emergency service professional, and emergency service worker are interchangeable. The use of the male gender is in no way meant to overlook or make light of the many contributions women make to these professions. This terminology is being used for simplicity and ease in writing. In addition, the term grief in this paper means the feelings and emotions following any loss that contributes to a person's stress levels.
Stress in the Workplace
The concern for the health and safety of Americans has prompted the federal government to implement programs and set standards to reduce injury and death in the workplace. For example, the Occupational Safety and Health Act (OSHA) has addressed the issue of hazardous materials by regulating the proper clothing and protective eyewear that must be worn by persons who come in contact with or who must handle these dangerous agents. Safety devices on machinery, proper ventilation of highly toxic gases and fumes, and strict rules for handling blood-borne pathogens further enhances the safety and health of today’s workers.
Job-related stress is another priority in today's workplace environment. Job-related stress is not only a serious concern of workers, but it can affect health organizations as well. The short- and long-term aftermath of stress on the job can eventually increase workers' compensation costs, medical and mental health premiums, and death benefit payments. According to the American Psychology Association (APA, 1997), "… stress costs American industry more than $300 billion annually" as the result of absenteeism and reduced productivity. On average, forty-three percent of adults in the United States suffer adverse health effects from stress following corporate downsizing, company layoffs and mergers, and bankruptcies. Additional stress can be brought on by "computer surveillance of production, fewer health and retirement benefits, and the feeling they [workers] have to work longer and harder just to maintain their current economic status" (Miller, L. & Smith, A., 1997). However, these examples pale in comparison to the stress incurred following a traumatic event that threatens the safety and emotional well being of employees. "Traumatic stress encompasses exposures to events or the witnessing of events that are extreme and/or life threatening" (Volpe, 1996). These extreme or life threatening events include deliberately caused man-made disasters (homicides, arson, etc.) and accidental disasters, such as motor vehicle accidents, fires, and explosions. It is important to note that "homicide is now the second most common cause of death in the U.S. workplace" (VandenBos, G. & Bulatao, E., 1996). Examples of other traumatic disasters include September 11, 2001, the Oklahoma City bombing, train derailments, airline crashes, and school shootings.
Following any type of stressful situation most adults will experience some degree of emotional instability. They may feel nervous and apprehensive. They may experience guilt, anxiety, depression, and sleep disturbances or they may be unable to concentrate for long periods of time on simple tasks. However, for adults who suffer from traumatic or chronic (long-term) stress, the long-range effects may include high-blood pressure and an increased susceptibility to heart disease, diabetes, and cancer. Furthermore, the Substance Abuse and Mental Health Services Administration (SAMHSA, 1995) states that chronic stress may cause "psychological problems including depression, withdrawal, apathy, and relationship problems in general." In addition, this type of stress can lead to an “increase use of alcohol, tobacco, and other drugs.” If left untreated, chronic or long-term stress can lead to post-traumatic stress disorder (PTSD). PTSD is a condition that manifests itself through flashbacks (mental or visual re-experiencing of a trauma), nightmares, a sudden and painful onslaught of emotions, or avoidance phenomena, which affects the person’s ability to relate well with others (American Psychiatric Association, 1997). Moreover, the Occupational Safety and Health Administration has declared, “stress a hazard of the workplace" (APA, 1997).
Companies and government agencies continue to address the safety and health of employees as well as their emotional needs. Moreover, business owners and human resource managers are taking a holistic approach to employee wellness. These business leaders realize they must provide not only a safe working environment, but also a workplace that offers positive mental and emotional re-enforcement; much more than the proverbial "pat on the back." In the past, stress, grief, and violence in the workplace were topics that few company executives viewed as potential problems. However, these issues have initiated the implementation of support programs and training seminars. Classes on time and anger management, conflict resolution, and self-defense tactics as well as coping with stress and grief have been effective in promoting a healthier and safer work environment. These programs have helped associates and their families cope with an array of emotional issues thus promoting a healthier outlook on their job and their personal life.
Stress in the Fire Service
With the advancement of fire prevention technology, such as flame-retardant building materials, smoke detectors, and sprinkler systems, fire departments are responding to fewer and fewer fire calls than ever before. However, for the more than one million firefighters in the United States, firefighting is still considered a very hazardous and highly stressful occupation. Firefighters are at greater risk of injury and death than most other professions as the result of flames and intense heat, “poisonous, flammable, or explosive gases and chemicals, or radioactive or other hazardous materials” (Bureau of Labor Statistics, 1999). Clark & Zak (1999) state that firefighters “are more likely than other workers to die violently—from gunshots, vehicle accidents, and fire-related incidents. Their risk of suffering a fatal incident is three times greater than for all workers.” Likewise, firefighters risk the chance of injury and death with every emergency call that they respond to. Patients under the influence of narcotics or alcohol, family members of the victim, or bystanders may threaten them with knives, guns, or physical assault. "Firefighters often become the object of a victim's anger" or they may be "blamed for not doing enough" (IAFCF, 1991). Because of this, many fire departments have issued bulletproof vests to protect the lives of their members.
Fire departments respond to more and more non-fire emergency calls. For example, "In 1997, there were over 10 million emergency medical calls made to fire departments in the United States" (Clarke & Zak, 1999). Because of this, firefighters are usually the first on the scene of accidents, suicides, and acts of violence (assault and battery, rapes, bombings, school shootings, etc.). Emergency service workers respond to floods, earthquakes, and airline crashes where the death toll and property destruction is overwhelming. They care for victims of domestic violence and child abuse. Firefighters extricate mangled bodies from motorized vehicles following an accident and provide medical assistance to homeless patients on the streets of inner cities. At times, they must physically restrain patients who are combative due to mind-altering drugs or head injuries. Likewise, they comfort parents and family members when a child or loved one has died. All too often they must cope with grief following the death of a fellow firefighter in the line of duty. As a result of these examples and many more, "firefighters frequently experience trauma, death, and sorrow" (NFPA, 1997).
Firefighters routinely struggle with the trauma of witnessing tragedy and death. The frequent contact with patients who die has a profound effect on the emotional well being of emergency service professionals (Floren, 1984, p.43). "Disaster and emergency workers are affected by traumatic events irrespective of rank or years of experience" (SAMHSA, 1995). For example, many emergency service professionals are still coping with emotional trauma as the result of their rescue and recovery efforts following the events of September 11, 2001 and the Oklahoma City bombing in 1995 because "a disaster with [only a few or] no survivors can be especially frustrating to deal with" (Laughlin, 1980, p.25). "Research indicates that the critical time for a delayed trauma to surface is between three to five years after the initial tragedy" (Owen, 1999). A large number of rescue and recovery workers were experiencing stress and emotional trauma years after the Oklahoma City bombing and the events of September 11. Owen writes that "divorces were three times higher than normal in the Oklahoma Fire Department" and numerous suicides occurred on the Oklahoma Police Department. Owen further states that, "family violence and addiction--including substance abuse and gambling--has increased among workers connected with the bombing rescue."
Research has shown that “forty-three percent of all adults suffer adverse health effects from stress” (Miller, L., 1997); however, it is the men and women in the emergency service professions that are at a greater risk of suffering long-term stress that can lead to PTSD. The “rate for diagnosable PTSD among firefighters was 16.5 percent compared to a one percent to three percent rate for the general population—about one percent higher than PTSD rates of Vietnam veterans” (DeAngelis, 1995, p.36). The International Association of Fire Chiefs’ Foundation (1991) has stated that
Stress is one of the most serious occupational hazards in the fire service, affecting health, job performance, career decision-making, morale, and family life. Emotional problems, as well as problems with alcohol and drugs, are becoming increasingly evident. High rates of attrition, divorce, occupational disease, and injury continue… [and] suicide is a real and tragic alternative for some.”
In addition to the life-threatening and job-related stress they encounter in their professional lives, firefighters must also cope with an array of personal and family issues as well. "The dangers of the job create anxiety in the firefighter's family" (Martin, 1991, p.2). These factors may include, but are not limited to, a troubling child in the home, the death of a loved one, “aging or invalid family members, terminal illness, divorce, and the daily demands of raising a family” (SAMHSA, 1995). "Some firefighters take their problems home to their [spouses] and families or seek outside employment (moonlighting) to compensate for the stress and frustration of the firefighting job" (IAFCF, 1991). Many of these emergency service workers feel that their families and friends do not understand the magnitude of their duties nor the emotional strain they must endure on a daily basis. The International Association of Fire Chiefs’ Foundation (1991) states that firefighters "want to protect loved ones from what happened [on the job]." Also, a firefighter's spouse must cope with the constant stress, sacrifice, and frustration of "living with the worry of having their husbands [or wives] constantly walking into the jaws of danger" (Burns, 1998). Most firefighters are very reluctant to discuss the death, carnage, and human suffering they witness on the job with their family and friends. Moreover, emergency service professionals struggle with thoughts of inadequacy as a spouse, parent, or social friend. They may suffer from restless sleep or nightmares, alcohol and drug addiction problems, and thoughts of suicide as the result of their constant exposure to life-threatening situations and the multitude of mentally and emotionally challenging emergency calls. "Despite the nightmares, the guilt for not doing enough, the questions of their own sanity, the trauma stays inside" (Owen, 1999). All of these examples, and many more, contribute to the growing concern by government agencies and members of the fire service community as a whole for the health, safety, and emotional wellness of firefighters today.
Stress Among Volunteers in the Fire Service
Volunteer firefighters comprise approximately eighty-four percent of all firefighters in the United States and "save localities across the country an estimated $36.8 billion per year" (National Association of State Foresters, 1993). Most do not receive monetary compensation for their efforts. Most volunteer firefighters have full-time jobs in addition to their duties and responsibilities at the fire department. However, these firefighters are exposed to the same dangers, experience the same job-related stress, and must cope with grief just as their comrades in career (paid) departments. They fight fires, save lives, and protect property. Many are trained as first responders, emergency medical technicians, or paramedics. Some receive additional training in specialized areas, such as vehicle extrication, high-angle rescue, hazardous materials, and water rescue. Volunteer firefighters respond to major disasters, motor vehicle accidents, domestic violence and child abuse calls, and school shootings. They are placed in life-threatening situations and many of them are victims of violence. Sadly, one hundred firefighters die in the line of duty each year. The majority of these firefighters are volunteers (National Fire Protection Association, 1999).
Although some volunteer departments are in large cities most are in small, rural communities. Therefore, these "emergency workers frequently know the victims and/or their families thus compounding their levels of stress and emotional trauma" (SAMHSA, 1995). Furthermore, many rural departments may only respond to ten or fifteen calls per year. These firefighters "may not be as regularly exposed to certain types of incidents and may not be as emotionally desensitized (SAMHSA, 1995). Because of this, many volunteer firefighters in rural areas with few calls may find it just as difficult to cope with stress and grief as firefighters who respond to many calls in larger cities.
Most volunteer departments must rely on fundraising or donations to replace unsafe clothing (turnout [bunker] gear), repair older vehicles, and purchase or replace mandated safety equipment such as self-contained breathing apparatus and personal protective alarm systems. This is due in part to the expensive costs and very low budgets for operating a volunteer fire department. In some cases, volunteer firefighters must purchase their own safety equipment. In addition, the diversity of their emergency calls has required specialized training classes. For the most part, these classes are paid by the volunteer firefighter themselves rather than by their department. Therefore, "Volunteering in the fire and EMS service… is one of the most demanding volunteer activities today" (Bush, Schaenman, & Thiel, 1999).
Since 1983, the number of volunteer firefighters has declined steadily. Because of this, volunteer fire departments "are having to do more with less" (Bush, Schaenman, & Thiel, 1999). This decline is due to an increase in time demands at the fire department (greater number of emergency calls), an increase in training hours to comply with national standards, fund raising activities, and responsibilities of family and home. In some states, volunteer firefighters and emergency medical personnel must meet the training requirements established by the National Fire Protection Association. Although important, these training requirements add to the number of hours that firefighters must be away from their families and non-fire service responsibilities. Many businesses may allow volunteer firefighters to respond to emergency calls during work hours; however, they may not pay them for the hours they are away from the job. This may contribute to additional financial burdens. As a result of these issues, "Stress is a major problem in volunteer fire departments and it's a big reason for attrition" (Streng, 1985, p.24).
Current Methods to Reduce Stress in the Fire Service
Due to the overwhelming concern for the firefighters' safety and health, government agencies and fire service organizations have established standard operating procedures and strict guidelines that can reduce injury, death, and long-term emotional trauma. Flame and heat retardant protective clothing (turnout gear), self-contained breathing apparatus, and personal alarm safety systems have helped to deter the life-threatening aspects of firefighting. Fire service administrators have been encouraged to install “gentler wake-up systems for firefighters that replace clanging bells with dim lights, speakers, and a tone” (DeAngelis, 1995, p.36). Furthermore, DeAngelis writes that “equipping firefighters with radios so they can hear what’s going on in an emergency” can also save lives. The National Fire Protection Association (NFPA), an international codes and standards organization, has made recommendations and has established guidelines to further reduce the risk to firefighters’ health and wellness. Three of these recommendations include the Members Assistance Program (MAP), the Critical Incident Stress program, and the Chaplaincy program (1997).
Member Assistance Program
MAP is a "generic term used to describe the various methods found in the workplace for the control of alcohol and drug abuse, stress and personal problems that adversely affect job performance" (IAFCF, 1991). Fire departments that provide Member Assistance Programs refer firefighters to various agencies that provide counseling and treatment centers. Health promotion programs also provide a variety of activities for the firefighter and his family. Programs, such as "career advisement, family orientation and education programs on… weight control, healthy heart, … smoking cessation and pre-retirement planning" are also available through the MAP program (IAFCF, 1991).
Critical Incident Stress Program
A vital and intrinsic aspect of emotional help for firefighters is Critical Incident Stress Debriefing (CISD). "Critical incident stress is a normal reaction experienced by normal people following an event that is abnormal" (NFPA, 1997). CISD is a "reactive form of treatment either on the scene of a disaster or within a short period of time after the disaster by means of a debriefing" (IAFCF, 1991). The "main goal [of CISD] is to lessen the long-term psychological impact of the event and to accelerate the recovery process" in the emergency service worker (Clark, 1991). Clark also states that CISD is "used solely to regenerate the normal support process." A CISD is implemented following "mass casualties… fatalities involving children, fatalities or injuries involving fire department members, and any other situation that affect the psychological… well-being" of an individual (NFPA, 1997). However, CISD does not afford the emergency service professionals preventative training or long-range, follow-up support and education. Therefore, the firefighter may experience recurring, adverse side effects as the result of continuous emotional trauma. These side effects can include, but are not limited to, anxiety, insomnia, gastro-intestinal problems, and an increased risk of heart attacks and severe depression.
Chaplaincy Program
Many fire departments request the assistance of chaplains following a line of duty death of one of their firefighters. "Chaplaincy programs are beneficial in helping fire department members deal with the stress of their work" (IAFCF, 1991). In addition, chaplains provide emotional and spiritual help for firefighters and their families as well as CISD members. Firefighters who do not initially "relate well to outsiders will often turn to and accept the help of a chaplain who practices strict confidentiality when dealing with personal problems" (IAFCF, 1997).
CONCLUSION
Traumatic events, including mass casualties, injury or death of children, life-threatening situations, or a line of duty death have a profound impact on the mental and physical health of firefighters. Without coping skills, emergency service professionals can experience unhealthy side effects, such as stress, high blood pressure, and depression, as well as disabling illness including heart attacks, substance abuse, and post-traumatic stress disorder (PTSD). Personal life issues such as divorce, long-term illness, or death of a family member, etc. can have a negative effect on them as well. Although research has shown that there are some resources available for firefighters and their families to cope with stress, there is a need to have a training program that will provide information on grief, suicide and addiction prevention, and promoting emotional wellness for everyone as well.
The International Association of Fire Chiefs' Foundation (1991) states, "continuing education and training within fire departments are favored by many as tools for alleviating stress." Furthermore, "Specific training in dealing with death, crisis and suicide are needed, and orientation programs may help recruits better prepare for the physical and psychological rigors of their new profession." SAMHSA (1995) has made the following recommendations:
1. "information about normal reactions [to stress and grief], education about ways to handle them, and early attention to symptoms can speed recovery and prevent long-term problems.
2. "The use of prevention and treatment strategies can potentially decrease or eliminate negative effects of stress such as decline in job performance, burnout, high turnover rate, health problems, and family problems for workers.
3. "Such training should be an integral and ongoing part of regular training programs. Protecting emotional safety is just as important as protecting physical safety."
Floren (1984, p.43) suggests that there is a "strong need to provide a more humanistic approach in the training of emergency [service] personnel." Also, "we need to learn more about death and dying, the stages of grief, what to expect from a suddenly bereaved family and how we may most helpfully interact with family members." Furthermore, emergency service workers must be able to talk about the pressures involved in traumatic situations, to understand what others have experienced in similar situations, and know that they are not alone in their feelings. Floren continues,
Our training should emphasize the need for supportiveness and free expression of feelings… in stressful situations to help prevent serious problems. We need to be prepared for the internal conflicts that may surround a patient's death and know how our self-image may seem threatened by that event.
Finally, the National Institute of Mental Health states that "The use of both prevention and treatment strategies can potentially decrease or eliminate negative effects of stress" (1990).
The Grieving Behind the Badge training program addresses stress and grief and promotes emotional wellness for everyone. Unlike critical incident stress debriefing the Grieving Behind the Badge program does not focus on a single incident but rather the frequent professional traumas as well as personal life stressors these men and women experience. Throughout the training everyone is encouraged to openly share their anxieties in a safe environment. Interactive dialogue provides opportunities to discuss issues that cause nightmares, family discontent, substance abuse, and thoughts of suicide. The students learn coping skills for job-related stress issues as well as personal life traumas. These men and women realize they are not alone in their thoughts and feelings. Family members can discuss their needs as well as their fears and frustrations. Fire department chaplains receive information to help them provide emotional support to firefighters and their families. Additional programs on coping with grief can be offered to families and departments who have experienced a line of duty or non-duty related death of a firefighter. Recruits receive valuable information and coping skills that can prevent long-term stress and grief. As a result of the Grieving Behind the Badge program, emergency service professionals, their families, and chaplains have a better understanding of stress and grief and the effects they have on their lives. Moreover, everyone can gain the knowledge necessary to resolve many of their professional and personal problems because of the information and resources that are provided.
If fire departments and organizations want to reduce the number of lives that are lost from physical illness, substance abuse, and suicide in the fire service then they must provide firefighters with help and coping skills. Training them to deal with trauma, stress, and grief is no less important then training them to be safe on the fire ground. No longer can job-related stress in the fire service be ignored. It is the duty and responsibility of every fire service officer to provide for and enhance the emotional wellness of his or her department. Without the support and dedication of everyone stress and grief will continue to take a toll on firefighters and their families.
The emotional wellness of firefighters is at risk. Stress and grief are problems that are not easily detected or easily resolved. Severe depression, heart attacks, and the high rates of divorce, addiction, and suicide in the fire service prove this. There has been a call to action and The Sweeney Alliance has answered that call. The Sweeney Alliance is the solution to these problems. The Grieving Behind the Badge training program is proven to address these problems and to help resolve them for the men and women in the fire service. Grieving Behind the Badge should be made available to all emergency service professionals, their families, recruits, and fire department chaplains.
Copyright 2003 Peggy Sweeney. All rights reserved.
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1 comments:
Firefighters are real heroes here in Orange County, Southern California . . . the stories we heard about the risks they take to protect our lives and property are humbling, to say the least!
BRAVO for the firefighters!!!
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