Suicides declined in the U.S. from 2018 to 2019, and fell again from 2019 to 2020. Regrettably, there is no indication that suicides among emergency responders dropped. EMTs and paramedics have a suicide rate higher than the U.S. population as a whole and higher than many other occupational groups as well. These suicides have a devastating and debilitating impact on those left to cope with such losses.
Suicide aftermath
Several years ago, we heard from an EMT who said that a paramedic she worked with had died by suicide two months earlier. The caller said everybody at the station was still struggling to come to terms with this loss, but getting nowhere.
Some were angry that “he did something like that,” others felt betrayed that he did not turn to them; most blamed themselves for missing his pain or blamed him for hiding it. All were confused. None could understand how this could happen to a guy who had helped so many and who would have been helped by anyone had he just asked.
Over the years, there had been several suicides in the county EMS community, but this was the first one at that station. At a debriefing, no one said anything and their body language suggested that they did not want to be there. Later efforts to talk about it ended in arguments or everybody walking away. “What should we do? We’re just trying to bury it but it won’t stay down.” She referred to the climate at her station as “toxic.”
This scenario may be all too familiar to anyone who has lost a colleague to suicide “on the job.” Suicide prevention has received more attention in EMS over the past decade or so, but little attention has been given to dealing with the aftermath of a suicide.
The nature of suicide loss
Exposure to a suicide is itself a serious risk factor for suicide and EMS does not need another suicide risk factor. Critical Incident Stress Management (CISM) techniques help abate the trauma and mental health effects of these experiences. However, they may not be enough when someone who you rode with or worked with closely is lost to suicide.
Suicide loss is a severe emotional trauma. A number of factors may bring it about. Suicides produce shock and disbelief; unanswerable questions about the deceased’s intent; and strong feelings of anger, betrayal, abandonment, shame and guilt. All may be present after an emergency responder’s suicide.
The unanticipated nature of most suicides may lead to an obsessive search for the “why” by survivors. This search may go on privately for some staff long after it stops being a matter of discussion at the station. Notes, text messages, or e-mails, even if left, may be of little help.
Response to a suicide in an EMS agency
EMS members’ response to a suicide is culturally conditioned. EMS culture is comprised of the values, attitudes and behaviors shared across the field. Some common EMS cultural elements include:
- Quick-fix orientation. Stabilizing a problem rather than solving it
- Us vs. them mentality. Having each other’s backs, being someone others can count on
- Projecting Strength. Feeling bullet-proof, able to handle anything, not appearing weak
- Disparaging vulnerability. Seeing emotionality as inadequacy
A culture valuing strength, toughness, self-reliance and control creates an environment antagonistic to mourning, even after a suicide. Being blindsided by a suicide only shuts things down even more.
Grief style also affects response to a suicide. Many emergency responders have an instrumental style of grieving. They are less likely to express emotions outwardly and rely on a cognitive, problem-solving approach. Instrumental grievers use distraction to cope and press for quick closure by repressing loss and trying to work through it.
This contrasts with the intuitive style of grieving that relies more on expressing, sharing, exploring and processing feelings. This style is less common in EMS.
How long one is affected by suicide loss depends on how close one feels to the person they lost. Some EMS suicide loss survivors experience a short-term bereavement, which passes within several weeks. Those with stronger ties to the deceased may experience a longer, more intense bereavement of one year or even much longer. Grieving in EMS settings is usually hidden as quickly as possible, but it lingers unacknowledged for long periods.
Though EMS personnel are at high risk of suicide, most agencies do not have resources in place to deal with the aftermath of staff suicides. This is postvention and it must be part of every agency’s suicide prevention program, though these are uncommon as well. Postvention can enable those distressed by suicide loss to come to terms with loss in what has traditionally been a grief-unfriendly setting.
Obstacles to recovery from suicide loss
The inhospitality of the EMS culture to grief does not prevent feeling loss, but it makes grieving difficult. Grieving is social in nature and requires the support of others. This is especially true of the grief that follows a suicide. In EMS, mutual support may be tentative or nonexistent, due to the toxic, “man up,” culture present in some organizations.
Emergency responders are susceptible to disenfranchised grief. This occurs when grief is not recognized, expressed or even tolerated. Suicide loss in EMS may be met with indifference, inappropriate comments or criticism. Ignoring workplace grief does not alleviate it. Unacknowledged grief creates stress and, at worst, may produce complicated grief reactions and depression.
EMS professionals may attempt to detach themselves from the bereavement in the station. Rather than going away, the emotional reactions can build up inside over time and may become increasingly difficult to handle. Individuals may turn to alcohol or drugs to self-medicate emotional pain. They may isolate or withdraw from others because of an inability to handle emotions or emotionally relate to others.
Suicide Postvention first aid
In the first hours and days after a suicide, those in proximity to the victim may need:
- To see how their feelings are normal. Those bereaved by suicide may think they are suffering a psychiatric crisis
- To get support. Suicide loss is best endured with help – a good source of help is contact with others who had a similar experience
- To have time to deal with their loss. A three-day funeral leave will not suffice – suicide loss does not conform to the “get over it” approach to grieving
Postvention meets these needs. It should be available after every suicide.
Postvention involves support with the grieving process and assisting those who may be vulnerable to anxiety and depressive disorders, suicidal ideation, self-medicating and other harmful outcomes. As noted above, every EMS agency should have a suicide prevention plan that includes a postvention policy. Accepting postvention is voluntary but its availability is not optional.
EMS leaders can take these steps soon after a staff suicide:
- Establish rapport with agency survivors. Extend an offer of help and caring by “being there.” This can be done individually or at group meetings.
- Initiate grief normalization. Affected staff must be able to discuss their feelings and concerns. They must learn that their emotional turmoil is normal after a suicide.
- Share information on community services. Provide contact information for local grief support resources. Ask county crisis services or suicide prevention groups for help.
- Maintain suicide loss resources. These are available from the American Foundation for Suicide Prevention and the Suicide Prevention Resource Center.
Professional-led or peer-led suicide loss support groups can reduce marginalization, provide mutual aid and share insights. CISM is a form of postvention that fits EMS culture, but suicide loss does not respect culture. A looser, less structured support group can help as well. An effective suicide loss group will come with a box of tissues and make participants not afraid to use them.
Helping personnel recover from suicide loss
Postvention offsets the possible onset of suicidality related to a peer’s suicide. Suicide loss may amplify others’ suicide risk factors and promote suicidal ideation. In terms of EMS culture, postvention is how you try to “fix” suicide loss. It is problem-solving, not grief therapy.
Postvention reduces trauma in individuals already carrying many severe stressors. EMS leaders can use the steps outlined above and draw on the emerging literature for managers on coping with suicide in the workplace to fashion a strategy to help their personnel recover from suicide loss.
When EMTs and paramedics learn to handle suicide loss in their ranks, they will do a better job supporting those they encounter on the scene of a suicide in the community.
Read more
What’s your department’s suicide prevention plan?
Here are five ways EMS is leading the way and doing more to prevent death by suicide
Learn more about suicide postvention
Learn more about combatting suicide loss and suicide ideation with these postvention resources:
- Bauter, E. “Suicide in EMS: Same as it ever was” The Overrun
- Grill, M & Zygowicz, W. (2011) Suicides Affect Patients & EMS Providers, JEMS
- Gulliver S., Pennington M., Leto F, et al. (2016) “In the wake of suicide: Developing guidelines for suicide postvention in fire service” Death Studies. 40(2):121-128
- Short, M. (2020) “Promoting Suicide Safety for EMS Providers”. Washington, DC: American Ambulance Association
- “Support for Community Helpers Who Have Experienced a Suicide Loss “Compiled by Suicide Prevention Coalition of Jefferson, Clear Creek and Gilpin Counties (Colorado)
