Doing more harm than good
I saw a phrase used in a news story about the death of a firefighter and contacted Dena Ali who has written and presented information about firefighter suicides, to ask her if the phrase “post-traumatic stress injury” was the new term to use instead of “suicide.” In recent years, on the news side of firefighting, various organizations often promoted certain phrases to be used instead of “suicide, “killed themselves,” and “took their own life.”
Here is her response. – Bill
By Dena Ali
9 August 2021
We honor those who we have lost to suicide by understanding and combating their cause of death. According to leading suicide researcher and educator, Thomas Joiner, “People can be brought back from a suicidal crisis, but to bring them back, they have to be detected, then understood. Like any dangerous and lethal thing, that causes human suffering, suicide needs to be understood, so as to manage and allay its fearsomeness – survivors deserve this understanding and compassion.”
Fire service news publications have been circulating a story about the death of a firefighter in the Pacific Northwest. One of the articles reports, “The medical examiner has not released an official cause of death, though the fire district has indicated it was due to trauma associated with PTSI.”
“Tina Curran, public information officer for the fire district, told The Gateway that the death was not being considered a suicide. Rather, she said, it was a “by-product” of the job stresses of being a first responder.” 
This is pernicious on so many levels. First and foremost, according to leading researchers and the action Alliance for Suicide Prevention, suicide is never the result of a single cause. Rather, it’s the result of a complex interplay of many factors, to which are varied from person to person. Attributing to a single cause is not only wrong, but also harmful. There are underlying factors that can be so deep-seated, that even the individual can’t appreciate their significance.
For example, somebody with an Adverse Childhood Experience (ACE) score of 6, is at a 5000% increased likelihood of suicide attempt. According to Van Der Kolk, the “more isolated and unprotected a person feels, the more death will feel like the only escape.”
We cannot and should not make assumptions based on profession alone. While we know that certain professions have higher rates of suicide, we also know that it’s not the profession that leads to suicide, but rather individual factors associated with individuals who enter their respective professions. For example, we often attribute military and first responder careers with suicide and blindly attribute the suicide to “the traumatic calls.” However, military findings have discovered no relationship between combat and suicide. According to war journalist Sebastian Junger, there are several underlying factors that members bring to the military and additional factors created by military association.
Dr. Craig Bryan explains, “we train our warriors to use controlled violence and aggression to suppress strong emotional reactions in the face of adversity, to tolerate physical and emotional pain, and to overcome the fear of injury and death.” These factors are all associated with increased risk for suicide. Dr. Brene Brown takes it one step further by explaining that “in organizations when we lead, teach, or preach from a gospel of Viking or Victim, we crush faith, innovation, and adaptability to change. Take away the guns, in fact, and we find outcomes similar to those for soldiers and police in corporate America. The American Bar Association reports that suicides among lawyers are close to four times greater than the rate of the general population.”
For the previously mentioned populations, strength, resilience, courage, and personal sacrifice in the face of adversity is valued. Yet, the stigma associated with illness, suicide, and a desire to die by suicide is seen as weakness. Furthermore, a sample in which white men are over-represented will have more deaths by suicide than a representative sample simply because white men are more likely to die by suicide.
Therefore, the association between being a firefighter and suicide is not causal, but instead due to a host of other variables to which they are both linked, and which explains their association. This means, we cannot generalize causal factors based on occupation, we must consider individual factors.
Here is an analogy, breast cancer mortality is .3 per 100,000 for men and 20.5 for women. 91% of registered nurses are women. Would it be fair to say nurses are at increased risk of breast cancer because they’re nurses? Or should we focus on the other risk factors that increase rates of breast cancer such as genetics, obesity, sedentary lifestyle, heavy drinking and use of birth control. Whenever there is a casual connection, you can almost spell out the steps. To claim that being a firefighter causes suicide is not only factually untrue, but also pernicious. According to Joiner, “it leads people to misunderstand the true facts and circumstances of their loved one’s deaths, and to thus prolong their mourning.”
Moreover, there is no such thing as PTSI. While you will find PTSD in the diagnostic and statistical manual (DSM), you will not find PTSI. I understand the reasons people explain for using this term. They claim that PTSD is too harsh of a diagnosis since disorder blames the individual, and Injury is less stigmatizing.We must understand that PTSD is real, however, so is PTS. Post-Traumatic Stress is universal, and it’s normal, and all of the symptoms associated are healthy and adaptive. Most people exposed to trauma display PTSS (Post Traumatic Stress Symptoms). And with good sleep, a good social network, good coping skills, most people will not develop PTSD.
Furthermore, 80% of people who do develop PTSD will recover! PTSD IS NOT A LIFE SENTENCE. However, we must understand that it is real and there are things we can do to prevent it’s manifestation. For example, we know isolated and alienated people are at greater risk for both suicide and PTSD. Moreover, so are people who are unable to disclose their true sources of pain, and people who are unable to receive post traumatic support.
Finally, by blindly attributing suicide to trauma, PTSD, PTS, or PTSI, we are causing more damage to those who are struggling in silence from other stressors. We are conveying the message that PTSD/I is an honorable and unpreventable cause of suicide. Through this messaging, we are further silencing those suffering from depression, anxiety, substance use disorder, bullying, and the many other common mental health issues. Suicide is neither honorable or dishonorable. It is quite simply a profound human tragedy with no current effective algorithm for prediction. This does not mean it’s not preventable. It is. However, it’s prevented only through true understanding; and as Dr. Bryan says, we must move beyond warning signs and mental health to address engineering controls outside of the individual. These include improved sleep, elimination of bullying, means restriction, more rest, safe and secure organizations, financial security, and the use of crisis resources stored in the limbic system (mindfulness).
Think about the reduction in traffic fatalities despite more cars on the road and distracted drivers. This reduction was a result of engineering controls and environmental behavior. Environmental controls are the future of suicide prevention.
1. “Gig Harbor Fire says ‘post-traumatic stress injury’ led to death of firefighter” Chase Hutchinson, The News Tribune, 9 August 2021
Dena Ali is a captain with the Raleigh, NC Fire Department. She is a founding member of the Carolina Brotherhood and founder and director of North Carolina Peer Support. Dena has a master’s degree in public administration from the University of North Carolina at Pembroke; her research focused on firefighter suicide. She has an undergraduate degree from North Carolina State University. Dena teaches about suicide prevention at at many fire service events.
Photograph courtesy of Dena Ali.