Firefighter Wellness.pdf

 RECONNECTING: WHAT IT MEANS TO BE EMOTIONALLY WELL A few years ago, I received a call from a fire chief who was concerned about one of his firefighters, Pete. The chief had always considered Pete to be one of his best fire­ fighters, but there had recently been some worrisome cha...

 RECONNECTING: WHAT IT MEANS TO BE EMOTIONALLY WELL A few years ago, I received a call from a fire chief who was concerned about one of his firefighters, Pete. The chief had always considered Pete to be one of his best fire­ fighters, but there had recently been some worrisome changes in Pete's behavior. Pete's productivity had dropped, and he had become angry and snappy. The chief did not call me in an effort to punish Pete; Pete was not in trouble. The chief was concerned, how­ ever, that Pete was heading for trouble if he continued down the same path. The chief wanted to help Pete, so he sent him to talk to me. Disconnected first responders can be found in every county and in every department. Because of the shift-oriented lifestyle of a first responder, stress and trauma on the job, emergency calls that never seem to end, and the lack of time for self, many first respond­ ers walk around angry, disappointed, bored, frustrated, and simply burned-out. Because first responders are typically hard-working, uncomplaining people, the average friend or civilian might not notice the incongruity in behavior. But every once in a while, a lack of balance will show up as an emotional or physical health crisis, the collapse of a rela­ tionship, a snafu on the job, or another life debacle. That is when they often seek profes­ sional help. For Pete, there was a dramatic drop in productivity paired with a surprising rise in cynicism. Pete was an excellent firefighter who was highly active in a number of extra assignments. He had always been a high achiever, but for the first time, he started feel­ ing resentful of how hard he was working compared to those around him. On top of being a firefighter, he held a part-time job, and he spent his free time flipping houses, doing all the work himself. So Pete decided to do a complete one-eighty. In one of our first counseling sessions, he explained to me that he had decided to drop to the level at which he perceived every­ one else was working. As Pete explained, 'Tm just going to work like everyone else does. I have been giving 200%, but now I will only give 100%." Since everyone around him was accustomed to seeing his 200% effort, however, his reduced performance was quite noticeable. For a long time, Pete had been spreading himself too thin. He pushed his needs aside to focus on achievement, as many first responders do. He became resentful and isolated under the endless list of demands weighing on him. He felt disconnected from the person he wanted to be because of the person he currently was. 1. 2 First Responder Emotional Wellness Pete needed to reconnect. He needed to find himself again and get back to what was most important to him. In our work together, Pete began to realize that he needed to slow down. He began taking things off his plate. He resigned from his part-time job and started doing more things that he loved to do. He started working out more, spending more time with his wife, and traveling. He became increasingly comfortable with "doing nothing." In his quest to reconnect, he began asking himself, "What, really, is my motivation for high achievement?" For many first responders, achievement is driven by childhood abuse or neglect, but for Pete, bullying from his childhood peers motivated his actions as an adult. In more than 20 years of listening to people, I have discovered that many first responders have been bullied by peers in the past, and it can whisper a subtle lie into the heart of a vulnerable child: "You're not good enough. You need to prove yourself." These bullied kids often grow up to be highly busy adults who have more than proven that they are sufficient. Many first responders believe that the more they achieve, the more loveable they are. This seemed to be true for Pete, who was working hard to achieve so that he felt worthy. Although his parents had been wonderful and supportive, his peers had been vicious. Pete was charismatic, funny, good-looking, and smart. Never in your wildest dreams would you think he had a history of being bullied, but bullying was the driver. As a child, Pete had wanted desperately to belong and to feel good enough, and so he filled his adult sched­ ule with opportunities to prove he was capable and worthy of respect. Achievement is like a drug, and when you slow down, you can feel odd or antsy. So next, I told him to expect discomfort with doing nothing. His job was just to sit with that uncomfortable feeling for a while. I am happy to say that after six months of therapy and slowing down, Pete is doing well. Maybe you are reading this because you feel disconnected. In your first responder career, you feel a bit lost, bored, frustrated, unhappy, or burned-out. Where do you even begin? A useful place to start is to understand what it looks like to be "connected," so you can begin to envision what your life may look like if you reconnected. What Is Connected? A connected person is an emotionally well person. Emotional wellness is dealing with difficulties in a healthy, intentional way, so you can think about things clearly; live a life free from secrets, burdens, and shame; and be ready to continue living, taking on new dreams, and bouncing back in the face of adversity. Connected does not mean stuff­ ing down the painful memories you have experienced. It does not mean you keep your struggles hidden from your spouse, friends, family, or coworkers. Connected is the opposite of "Suck it up, Buttercup." Connected involves balanced thinking, authentic conversations, being present and in the moment, and being flexible and adaptable throughout life's changes.  Chapter 1 Reconnecting: What It Means to Be Emotionally Well 3 Connected is a confident ability to face hard days on the job with resiliency in the face of a tough call. Studies from Benedek and others and the National Institutes of Health (NIH) have noted that connected people are able to handle life's stresses in healthy ways and are also able to adapt to change.' When a first responder is connected and self-aware, it pours out into everyday life, job performance, relationships, thoughts, physical health, and sense of well-being. According to experts at NIH, there are three signs of connected people: 1. They have more positive emotions and fewer negative emotions. 2. They are resilient amidst stress and change. 3. They can keep perspective and appreciate the good things in life.2 Emotional wellness can be defined as "the ability to be aware of and accept our feel­ ings, rather than deny them, have an optimistic approach to life and enjoy life despite its occasional disappointments and frustrations."3 Does this sound like where you are at right now? If not, remember Pete. Pete knew he was out of balance. When he turned his attention toward becoming well again, he was surprised by how good life could be. When Pete reconnected with himself and slowed down his schedule, he found life to be so much more abundant, peaceful, and full of real connection with others than he had experienced in the past. He learned that achieve­ ment does not earn love. Reconnected people can see such truths emerge in their lives. It is not that people who are connected with themselves do not have stress, loss, or problems in their lives; it is that they have learned how to manage stress, to process and grieve losses, and to resolve problems and conflicts in their lives in healthy ways. They choose to heal, resolve pain, and thrive. They choose to pay attention to their needs, so they can take care of them and become well for the long run. If you are reading this book, it is likely that you are ready to do that, too. So get out your pen, and let us pinpoint some areas where you would like to grow. As you read "Actions of Balanced People," place a check mark next to the action that you want to grow in your life. Actions of Balanced People Get enough sleep, ideally seven to nine hours a night. Reduce stress by being with friends and family. Exercise in a manner that is balanced, not excessive. Spend time on self-care, including healthy eating, taking breaks, and spending time outdoors. Deal with losses in a healthy way, including talking to trusted people and getting support. Surround themselves with community, including friends, church, sports, and other social networks. 4 First Responder Emotional Wellness Make new friends and keep long-term friends. Think through decisions based on personal values and are comfortable with taking wise advice. Seek help when needed and work independently when needed. Enjoy reciprocal relationships. Sometimes you will be on the giving end of the friendship, and sometimes you will be on the receiving end. Try new things confidently. Are comfortable with being challenged by personal growth. Know that they are responsible for their actions. Emotional wellness is about bringing yourself into balance. When one area is out of balance emotionally, it can affect other seemingly unrelated areas of life. That is why this book is set up to discuss the wide variety of issues first responders face. Many first responders discover that they are wrestling with something that seems disconnected from their most obvious issue-such as trauma, for example-when, in fact, seemingly unrelated struggles are often entwined. Feeling disconnected or out of balance is the direct result of a mind that is trying to come back to homeostasis. I suggest viewing your emotional wellness as a web of support. The most "connected" first responders have a broad web of individuals and habits that sustain and help them recover in the midst of a busy, stressful career. Those who do not have a widespread web of support may find themselves barely coping when they encounter trauma, physical exhaustion, and emotional turmoil. The Firefighter Support Web If I could design a web of support around you to help you become balanced and healthy, here is what it would look like (fig. 1-1). As you begin to work toward becoming a more emotionally well, connected first responder, one of your primary tasks will be to build a robust social support web for yourself, focusing your energy on the actions of balanced people which you circled above. Looking at Ourselves from Seven Dimensions of Wellness In 1976, Dr. Bill Hettler developed a list, "Six Dimensions of Wellness," which I like to use as a mirror for my clients to analyze their wellness. 4 A seventh dimension, environmen­ tal wellness, is often added with this list.  Chapter 1 Reconnecting: What It Means to Be Emotionally Well 5 RELATIONSHIPS Spouse Family Brotherhood Trusted Friends Department Leadership Peer Supporter(s) Counselor/ Mental RESOURCES Health Community First Responder Church/Reli ion SELF­ Training AWARENESS leadership Department FIREFIGHTER Meditation Walking Meditation Emotional Wellness Training SUPPORT WEB Writing Counseling Chaplains Prayer Peer Support SELF-CARE Yoga Addiction Treatment Setting Boundaries Programs Connection with Trusted Relationships Exercise Nutrition Rest Connecting with Nature Figure 1-1. Circle the items on this firefighter support web that you know are lacking in your own social support web. People are much more than physical beings, which means that their wellness is much broader than just physical health. A person's quality of life is largely affected by how well he or she is in seven specific areas of life: physical, emotional, intellectual, social, spiritual, environmental, and occupational. These areas of life are often called the "Seven Dimensions ofWellness."5 Let me explain each of them. 1. Physical Wellness Physical wellness means getting adequate sleep, physical activity, hydration, and nutrition. It means caring for your body and eliminating harmful habits like smoking, drug use, and excessive alcohol consumption. Physical wellness can be judged by how well you feel, how many injuries you have, and the results from your physical exam at the doctor's office. I You can build physical wellness through daily exercise, good sleep habits, wearing protective equipment, recognizing illness and seeking help when needed, eating a vari­ ety of nutritious foods, consuming appropriate portions for your body, stopping smok­ ing, and drinking alcohol in moderation or abstaining from alcohol use altogether. Based on this description, what grade would you give yourself in the dimension of "physical wellness"? ___ 2. Emotional Wellness Emotional wellness is heavily influenced by the other six dimensions of wellness. Emotional wellness means processing experiences around you, growing from experiences, and allowing yourself to feel the feelings associated with them. This starts with identifying your feeling. Then by addressing it properly, you can help yourself become emotionally 6 First Responder Emotional Wellness well and balanced. Choosing a positive outlook and choosing resiliency both contribute strongly to emotional wellness. You can build emotional wellness by identifying your thoughts and feelings, com­ municating these thoughts and feelings with others, choosing to look at things optimis­ tically, practicing reconnecting with yourself, seeking support when needed, talking about pain with safe people, and accepting and forgiving yourself. Based on this description, what grade would you give yourself in the dimension of "emotional wellness"? --- 3. Intellectual Wellness Intellectual wellness means doing things that are creative and stimulating. Your mind is meant to be challenged, inspired, and illuminated. If you are intellectually well, you are open to possibilities and use your mind to expand your knowledge and continue to improve your skills. This involves staying up-to-date on the industry's latest best prac­ tices, choosing activities that stimulate the mind, and reading a variety of literature. You can build intellectual wellness by attending courses and workshops, learning new languages, earning new certifications, reading, subscribing to interesting podcasts, choosing mentally stimulating hobbies, and learning to appreciate the arts. Based on this description, what grade would you give yourself in the dimension of "intellectual wellness"? --- 4. Social Wellness Social wellness means communicating in healthy ways, connecting intimately within safe relationships, creating a support network of friends and family members, and inter­ acting with your global community positively. This means respecting others and your­ self. It means building a sense of belonging in your family and community. Often a person will still consider a longtime friend "close," even though communication with that friend is infrequent. Yes, that individual is a part of your social support network. Building new friendships and continuing to connect with old friendships, however, will be critical for social wellness across your whole lifespan. 6 You can build social wellness by investing time in healthy relationships, getting involved in community events and friendships, and communicating thoughts, emotions, and ideas with those around you. Choosing to reach out and spend time with old and new friends is like putting nails in the studs of a new house. The more nails you add, the stronger the house becomes. People who are socially well are hard to knock down in a storm. Based on this description, what grade would you give yourself in the dimension of "social wellness"? --- 5. Spiritual Wellness Spiritual wellness means assessing your values and priorities and choosing faith, hope, and commitment to a belief system. Those who are spiritually healthy are willing to seek meaning and purpose, to question and appreciate the things that cannot be  Chapter 1 Reconnecting: What It Means to Be Emotionally Well 7 understood, and to look outside the physical world for answers to their existential ques­ tions. Spiritual health is about harmony with others and connection with a higher power or forces outside life on this earth. To build spiritual wellness, you can spend time reading spiritual books, meditate, pray, and ask questions that go beyond daily thinking. You can seek guidance from a chaplain, spiritual counselor, or pastor. You can choose to be fully present, to ask ques­ tions, to grow through life's challenges, and to explore your spiritual core. Based on this description, what grade would you give yourself in the dimension of "spiritual wellness"? ___ 6. Environmental Wellness Environmental wellness means connecting with nature and the world around you. Nature benefits the other six dimensions of wellness. According to Colin Capaldi, Carleton University, and others, numerous studies have shown that nature contact-brief or intermittent expo­ sure to plants, pictures of nature, paintings, or nature on television-and nature connectedness-longer-term interaction with the outdoors and natural surroundings­ promote positive mental health. Capaldi and others also note that exposure to nature improves mental clarity and focus, physiologically reduces stress in the body, and creates a domino effect into other areas of life, influencing more creativity, generosity, connect­ edness, and resilience.7 Nature touches almost every type of wellness struggle. It alleviates anxiety, depression, loneliness, fatigue, stress, and even physical illnesses. A person can build environmental wellness through personal contact with nature. Visiting beautiful places releases dopamine in the brain that creates happiness, joy, and a desire to pursue goals. Going on walks outside, having a picnic, hiking local trails, camping at a nearby campsite, exploring national parks, going fishing or hunting, lying in the grass with your children, watching videos about outdoor locations, and even put­ ting potted plants in your home or workspace will help balance all your dimensions of wellness. The natural oils released from trees send signals to the brain, reestablishing wellness. Perhaps one reason so many people struggle with emotional wellness these days is because we are surrounded by concrete. We spend less than 10% of each day outside. 8 Being near the water is also rejuvenating for the brain. 9 Another way to build your environmental wellness is to spend time near a body of water-an ocean, bay, river, or lake. In a society that is overstimulated and constantly involved in social networking, it is easy for our minds and emotions to become overloaded. Nature is a welcomed break, beckoning you to move and breathe freely. Connecting with nature is a key piece to your wellness puzzle. Based on this description, what grade would you give yourself in the dimension of "environmental wellness"? 7. Occupational Wellness Occupational wellness means bringing the best of yourself, your skills, your passions, and your gifts to the table in the way you spend your time. Those who use their unique 8 First Responder Emotional Wellness skills at work, at home, and in personal hobbies will feel more accomplished and fulfilled than those who are working outside of their skill sets.They will feel motivated and will be able to maintain a positive attitude about work.People who are occupationally well are satisfied with, though challenged by, their jobs. You can become occupationally well by creating a vision for your future in the fire service, identifying personal skills, being intentional about sharing those with the brotherhood, dreaming about a retirement occupation, and being open to change and using other pieces of your unique skill set. Based on this description, what grade would you give yourself in the dimension of "occupational wellness"? ___ *** If you are a first responder, it is likely that at least one of these areas feels disconnected from the rest of your life.When one area of our lives is not well, it puts strain on the rest of our lives.When we are put of balance, we are less resilient to the trials, challenges, or hardships of life.Instead of staying well, we fall into a cycle of physical, emotional, and social problems, compensating for those with unhealthy behaviors and eventually expe­ riencing unwellness and functional decline (fig.1-2). Remember, people are holistic.You have so many layers and parts, and each of those plays into the bigger picture of how you are doing. So, really...how are you doing? Are you ready to learn about how to face some of the disconnected areas in your life? I hope so. There is so much life and joy for those who reconnect. RECOVERY & RESILIENCE DISCONNECTED / SELF·CARE Setting Boundaries Connection with Trusted Relationships PHYSICAL, EMOTIONAL. Exercise & SOCIAL OUTCOMES Nutrition Counseling Anxiety Rest Depression Journaling , Trauma/PTSO insomnia Hypertension COMPENSATORY Digestive Problems BEHAVIORS Cancer Marital Problems Substance Abuse/ Addiction Relationship Issues Suicidal Ideation DECLINE Workaholism Controlling Behaviors !=igure 1-2. Emotional wellness trajectories  RESCUER'S DEPRESSION M y father was a correctional officer for more than 20 years at Stateville Correctional Center, one of the toughest maximum-security prisons in Illinois. In the 1970s and 1980s, there were numerous gang riots at Stateville, and they had frequent lockdowns. My dad was an excellent shot, so they assigned him to the towers as a sharpshooter. To this day, I can only imagine the things he saw, heard, and did at Stateville. Like most first responders, he sheltered me from his pain by avoiding mention of it. I grew up entirely unaware of any sadness in him, only aware of his temper (see fig. 2-1). Until my dad died in 2017, I did not understand the depth of trauma and depression that shrouded his career and life. He hid it well. In fact, he stayed so busy that no one could get a clear glimpse of any emotion in him-that is, except anger. Like my dad, many first responders struggle with depression. They conceal it from the world around them and often conceal it from themselves. Masters of compartmen­ talizing, they keep work and emotions separate. Emotions get pushed to the back burner, while tasks, projects, and work remain in the fore. This is why a first responder can out­ wardly seem perfectly okay while actually walking around each day carrying a mill­ stone of depression that threatens to grind him to a halt if he loses momentum long enough to catch his breath. He is busy because he is sad, and he does not want to feel it. He would rather keep moving. Figure 2-1. My dad as a young man 11 12 First Responder Emotional Wellness Because first responders are excellent at compartmentalizing, symptoms of depres­ sion may never show up externally; nevertheless, they are present. In a quiet moment, the first responder may feel sad, anxious, empty, hopeless, guilty, worthless, helpless, irritable, restless, or uninterested in formerly pleasurable activities, according to the American Addiction Centers. They also note that the first responder may experience fatigue, difficulty concentrating, trouble remembering details, early-morning wakeful­ ness, trouble sleeping or excessive sleeping, overeating or appetite loss, thoughts of sui­ cide, suicide attempts, persistent physical pain all over, headaches, or other physical distress.' Looking back, I think my dad had more of these symptoms lurking beneath the sur­ face of his life than he would have liked to admit. Like most first responders, he had moments of strong anger that signaled something more was happening beneath the surface. He could be the most charismatic, friendly, big-personality person on the planet. He was often away from home, but when he was around, his communication was sup­ portive. His eye contact and body language were focused on me like I was all that mat­ tered. I was a daddy's girl growing up, and he could be funny, encouraging, and kind. But Dad also had another side. Below the surface, he was a highly anxious, truly angry person. I was never scared of him physically because I knew he would not lay a hand on me or anyone in our family, but I was scared of his loud voice, his anger, and his unpre­ dictability. What I understand now that I did not at the time is that he was living with depression and post-traumatic stress disorder (PTSD). My dad hid his pain well, but I realize now that when he got angry, it was because he was in crisis. Anger can feel like a way to fight instead of being vulnerable and victimized. My dad always had three or four jobs going on at the same time. He owned a laun­ dromat and a pool hall, and he rehabbed houses. When I was a young girl, the pool hall was bringing in a great deal of money. The laundromat was also successful and was responsible for laundering all of the towels for the local public schools. He also worked a great deal of overtime at Stateville. He was an incredibly successful man by all finan­ cial standards, but he was an incredibly impoverished man at heart. My dad grew up in poverty. When he was a child, his family was regularly evicted from apartments when they could not pay their rent. He was born in 1923, during the Great Depression. His dad could not find work to support his family of five, which meant they literally went to bed hungry at times. This childhood poverty was accompanied by the vulnerability that my dad felt and the abuse that he experienced growing up. Dad carried his poverty into adulthood. He oriented his real estate business around his ability to endure quite uncomfortable living situations. He bought houses that needed a great deal of work. Even though these houses were nearly uninhabitable to most people, my dad and mom and I would actually move in while he fixed them up. When the repairs were finally completed, he would sell the house, and we would move into another home, just to make that home livable for someone else. We kept doing this, and I kept trailing along on his wild ride. He was like a miser who has plenty of money but lives in a house that is falling apart. My dad's idiosyncrasies were like ashes from his traumatic child­ hood that were daily stirred up, just to leave a film of dust over his freshly built life.  Chapter 2 Rescuer's Depression 13 The Unique Kind of Depression First Responders Develop In my experience as a first responder counselor, I have discovered that there are two fac­ tors that can tip a person over from emotionally balanced to depressed. When these fac­ tors are combined, they can overwhelm the psyche. The first factor is negative childhood experiences, and the second is trauma. First responders have a boatload of traumatic or potentially traumatic memories to draw from on a daily basis. Many first responders have childhood pain as well. Combine them, however, and the brain may link contemporary traumatic situations to similar feelings of helplessness experienced in the past from adverse childhood situations. Together these present and past experiences surround the first responder with a sub­ conscious sense that the world is a dark place to live. Add to this our society's expecta­ tions for first responders, and the result may be what I term rescuer's depression. Across the board-EMS, fire service, law enforcement, dispatch, and so on-depres­ sion rates are high among first responders. A study of Japanese emergency workers in the wake of the 2011 East Japan earthquake found that 21.4% had clinical depression.2 According to another study, 6.8% of EMS professionals reported struggling with depres­ sion.3 The list goes on, and I suspect these numbers are mere shadows of the true number of first responders who struggle with rescuer's depression. In my experience, rescuer's depression is more widespread than clinical depression. It is just harder to spot because sufferers try to hide the symptoms. In my work as a first responder counselor, I encounter rescuer's depression frequently. It can be a hidden depression. Most of my clients are so busy that it takes a number of meetings together before we begin to pinpoint that there is more going on than meets the eye. Many of my clients come to me for more obvious reasons-marital problems, alcohol problems, job problems-only to discover the lurking depression that motivates many of their actions. My dad was actually in therapy for quite a while, and he found it to be helpful. He initially went after getting a divorce from his first wife because he had so much guilt about leaving his two sons from that marriage. My brothers were much older; there is nearly a 15-year age gap between the younger brother and me. My dad was always work­ ing and was not around for them. Like many first responders, his thought was, "If I'm a good provider, that's what I need to do, and that's how I show my love." He learned the hard way that making a lot of money is not the same as connecting with family, and I think it hurt him deeply to recognize that he was absent emotionally for his sons. I am proud of him for starting to address his sadness over his failed mar­ riage and emotional absence by going to counseling. Pain needs to be talked about to be healed. It is like unwrapping a bandage on a flesh wound. The wound needs to be unwrapped, looked at, cleaned, and stitched back together correctly in order to heal. Emotional pain is the same, which is why keeping it a secret or avoiding it altogether by staying too busy to feel anything will prevent it from healing. 14 First Responder Emotional Wellness Secret pain, whether from childhood or adulthood, festers until it becomes darker and darker, and your heart becomes sicker and sicker. Running from it will not heal it. You need light to shine on it. Avoiding Emotion in First Responder Jobs My dad was the king of avoiding emotion. I understand now that this is a survival tactic. Avoiding emotion to focus on action is powerful for helping first responders be effective in high-intensity situations. It is essential for survival at work. When first responders continue to ignore emotions off the job, however, it can create a pattern of shutting down painful thoughts and memories, making it hard to connect with oneself and with others. Emotion was not a part of how my dad raised his children. Both of my half brothers used drugs and alcohol from an early age. They did not live in our home, but they did live nearby, and my dad did whatever he could to help them, at least financially. He gave and gave and gave money to his boys, but tragically discovered that money does not solve everything. Providing for his sons was my dad's way of showing love to them, but what they really needed was emotional availability. People need vulnerability to establish trust. Running away from emotion and vulnerability not only creates shallow relationships but also allows no outlet for pain. So first responders may develop a hidden sadness that they may find confusing. They may think there is something wrong with them, or they may feel numb to their pain, making it difficult to identify and express their emotions at all. A literature review conducted by E. C. Nielson and others found that many first responders and military personnel feel they must adhere to society's picture of mascu­ linity, which means self-reliance, strength, and avoidance of emotion. This same study found that restriction of emotion in both male and female firefighters has been linked to higher rates of PTSD. Nielson and others found that, in reality, the idea that first responders need to control their emotions to become the best they possibly can be at their jobs, relying only on themselves, sets them up for a very conflicted experience when they witness traumatic calls, various forms of abuse, or even moral injuries. They may feel powerless and helpless in the face of difficult experiences. 4 Instead of getting help, many firefighters suffer from rescuer's depression in silence. With this flawed perception, military and first responder men (and women with instru­ mental personalities) often self-medicate to feel better or to avoid pain altogether, often with "exaggerated stereotypical male behaviors, such as aggression and increased sexual behavior, to compensate for the injury the trauma had on their identity." 5 But self-medication will never heal the pain. Running from pain only buries it deeper. It will eventually erupt as anger instead of surfacing in a way that allows the person to heal.  Chapter 2 Rescuer's Depression 15 Firefighters: Heroes and Humans Firefighters often carry around what I like to call a "hero mentality." They love helping people. They are wired for it. It invigorates them. Though they do not often like to be called "heroes," they love this job specifically because they get to help and rescue people. They truly are heroes! In a one-sided career like firefighting, individuals are accustomed to serving without getting anything in return. But this can fuel the idea that first respond­ ers do not need anything from others, which simply is not true. The truth of the matter was stated well by neuroscientist R. Douglas Fields, who noted, "People commonly refer to those who engage in dangerous or heroic actions as 'fearless,' but this is rarely the case. If you ask them, they will tell you that they do feel fear, but they persist by deter­ mination in spite of it."6 Yes, firefighters are heroes, but they are also humans. Humans have feelings. Humans can be strong, brave, and powerful, but they also can be hurting, afraid, and unable. Humans are both. Both types of emotions are perfectly acceptable. But because firefight­ ers believe they have to be "tough," they often "stuff it" when it comes to emotions. They hide their emotions and run from feeling sad. I have seen this in both men and women first responders. Sometimes the women have an even greater burden to hide their emotions on the job because of the fear of being seen as weak. Instrumental Personality Type Many firefighters-male and female-have a personality type called instrumental per­ sonality. This personality type is characterized by a fascination with things and how things work. This concept of instrumental personalities is discussed throughout the rest of this book. Instrumental personalities are less emotionally expressive and more inde­ pendent, ambitious, and self-sufficient.7 Instrumental individuals are focused, competi­ tive, and great at making objective decisions. They gravitate away from emotion and toward competition and achievement. Many individuals with instrumental personalities were athletes in the past. I have observed that this is particularly true of women with instrumental personalities. Often they have learned to train their bodies to deny pain and emotions and leverage adrena­ line for increased performance and to block out unnecessary information. Frequently they have fathers, grandfathers, or other family members who were in the military or who had instrumental personalities themselves. In their lives and careers, those with instrumental personalities avoid expressing feelings and see emotion as "weak." They "suck it up" and keep pressing forward inde­ pendently toward their goals, impervious to pain and never showing vulnerability. 8 The instrumental personality type, combined with cultural perceptions of what it means to be a first responder, a hero, or a "real man," make many first responders feel 16 First Responder Emotional Wellness that they have no space to experience pain, sadness, hurt, fear, or any other sort of vulnerability. When our children dress up for Halloween, they choose both superheroes and first responder costumes, as if the two are interchangeable. We teach our children what a hero looks like, but we forget that real heroes are not superhuman. Superheroes are not real. Real heroes are human. They are a powerful connection of strength and caring, and they do not have to be bulletproof. Self-Medicating the Feelings Away Instead of showing vulnerability within trusted relationships to keep themselves emo­ tionally balanced, many firefighters choose independence and achievement.9 In fact, researchers V. D. Ojeda and S. M. Bergstresser note that men have far greater trouble than women reaching out for help from medical and mental health professionals. 10 I believe the instrumental personality type is the real factor here. Men and women with instru­ mental personalities have trouble reaching out for help from others because their per­ sonality type is prone to self-reliance. When they are in pain, these independent fire­ fighters turn to isolated ways to self-medicate. One self-medicating behavior I see in first responders is adrenaline-seeking. Stan McCracken, Crown Family School of Social Work, Policy, and Practice, University of Chicago, calls it the " veteran dilemma,''11 and I would add that it should also be called the "first responder dilemma." In combat, as on high-intensity calls, people's bodies ramp up for action. Adrenaline is one of the hormones released in response to emergencies, and it raises the threshold for first responders concerning what "alive" feels like. In those moments, first responders feel powerful and capable. They have enhanced performance resulting from adrenaline, and they feel on top of the world. But after the call is over and their bodies calm down, they often feel bored, purposeless, and uninterested. The rest of their lives may seem extremely dull compared to the adrenaline highs they expe­ rience at work. In their bored moments, they often feel depressed, sad, and lonely. To fight that, fire­ fighters often turn to workaholism, busyness, alcohol, gambling, affairs, illicit drugs, pornography, and other risky behaviors. These behaviors are effective in that they can help temporarily to ease the pain, calm them down, make them feel better about them­ selves, or fill emptiness. But numbing behaviors are an endless loop in which the indi­ viduals merely mask over their feelings without appropriately recognizing them and dealing with them. Many of these self-medicating behaviors make the first responders seem even more like heroes. Workaholism usually looks impressive to others-an indication that worka­ holic is committed to the job. Excessive working out can seem like health consciousness because the individual is outwardly "taking care" of himself or herself. Pornography use is sometimes excused as, "He's just being a guy." Alcohol use may be viewed as, "She's  Chapter 2 Rescuer's Depression 17 just chilling out." Such assumptions can make it difficult to identify when a first responder is struggling with rescuer's depression. Under these masks, it can be difficult to recog­ nize when the firefighter is suffering from hidden rescuer's depression. Unfortunately, much of this behavior may have started long before the first respond­ er's career began. According to psychologists Sissy Goff, David Thomas, and Melissa Trevathan, many children fail to develop the robust emotional vocabulary that they will need throughout their lives to communicate their feelings. When children, espe­ 12 cially boys, have not developed an emotional vocabulary, they often misidentify their needs and fail to communicate their feelings with others, which only increases their sense of isolation. First responders who did not develop an emotional vocabulary as children have to reprogram their ability to conduct emotion-based conversations as adults. This task is not impossible, but it requires intentional action. I think this is what happened to my half brothers. Jerry, the younger one, got married and found his place as a fireman. He straightened out his act at that point and stopped drinking and doing drugs. He was proud and excited to be a firefighter. In his depart­ ment, Jerry was known as the quiet guy who knew his stuff. When things were going well, he medicated with work. When things fell apart in his life, he was unable to express his emotions in healthy ways. He then medicated with drugs and alcohol. The older of my half brothers, Jimmy, never really found his place. Jimmy used drugs and alcohol, and he never developed a connection with my dad like Jerry had. Jerry and my dad had bonded over first responder experiences. Lacking a commonality with my dad, Jimmy self-medicated with risky behaviors, alcohol, and drugs. People who self-medicate with alcohol or drug abuse, addiction to pornography, affairs, gambling, and so on often do so because they just want to feel something-anything. Their hidden depression leaves them paralyzed by a feeling of numbness. Rather than feeling numb, they seek a "drug" or stimulant of some kind, whether it is a substance, sex, or gambling, to continue to mask their feelings of depression. Both the negative and positive activities of people with rescuer's depression help them perform the ultimate defense and cover-up desired by society: to make the feel­ ings go away. Psychologist and suicide expert Thomas Joiner believes that male depression is often a symptom of man's pursuit of independence (again, I would include instrumental women in his assessment). In the process of accumulating wealth and accolades, he often neglects to develop deep relationships in which he is free to be honest, human, and self-reflective. Instead, he steels himself and comes across as a tough guy, depriving himself of the depth of connection that he could have if he were authentic with those around him. This "I've got this under control" mentality and pursuit of independent success often leaves men lonely and isolated when the going gets tough.13 Rather than allowing success to pull men away from deep, meaningful relationships, Joiner advocates a balance between the two: This balance, I'm arguing, is more of a male problem than a female problem because, in part, the allure of fierce independence woos men more successfully 18 First Responder Emotional Wellness than it does women. The balance is made all the more precarious by a companion process, represented well by the cliched but nevertheless fairly accurate image of men's reluctance-or is it failure?-to ask for directions. To 'keep your head when all about you are losing theirs.' 14 The good news about people who walk themselves into depression as a result of a voracious pursuit of independence is that they have control over their choices as they move forward. They can invest in deep relationships and begin to heal, or they can shut down further and continue to wrestle with depression or worse emotional wellness struggles. The Difference Between Clinical Depression and Hidden Depression When we think of depression, we may think of acute and dramatic episodes that make it impossible for the individual to function. This is called clinical depression. In contrast, hidden depression is a state of depression that we find more often in men, but also in women with an instrumental personality. These individuals are motivated to medicate through action, even if they are not aware of it. In clinical depression, individuals may avoid doing the things they formerly loved. Symptoms of clinical depression often include the following: Having low energy Overeating or not eating Having sad thoughts Losing interest in career or hobbies Sleeping more than usual Having a decreased sex drive Having increased thoughts of drinking Having insomnia Engaging in addictive behaviors Stopping an exercise program Avoiding social activities Having major feelings of boredom, irritability, or anger Experiencing crying spells Stopping normal activities like cleaning or work But hidden depression is not the same. In hidden depression, a person often answers the problem with action. If the person keeps busy, he can disconnect from his feelings and will not have to deal with them. This is one way of basically "faking good."  Chapter 2 Rescuer's Depression 19 In general, men have a societal pressure to be stoic, keeping their feelings hidden and remaining unshaken by circumstances around them. As a man, displaying feelings and sadness is frowned on. Add to that a paramilitary career, and firefighters feel like they must be invincible. The pressure to reject emotion is hammered into them their whole lives and is reinforced by their career choice. All that is left to feel is "faking good." To keep "faking good," they turn to working, compulsive gambling, substance abuse, and other behaviors. Depression and Anger The "real man" persona drives many men to feel angry instead of letting themselves feel sad. Constant anger-hidden or obvious-can be a sign of depression. It is easier to feel angry than to face other emotions. According to research conducted by William Riley and Frank Treiber, Medical College of Georgia, and Gail Woods, Medical College of Virginia, rather than feeling sad or lonely, many people choose to feel anger, while trying to keep it suppressed as much as possible. Riley, Treiber, and Woods note that this anger can erupt easily, however, because the emotion is right beneath the surface. 15 Anger shows that there is something more going on. Men, and women with instrumental personalities, typically show anger instead of sadness when they are depressed. Riley, Treiber, and Woods note that the frequency, duration, and intensity of the anger are more indicative of their depression than the person to whom their anger is directed. 16 Although anger is effective at pushing people away, it has less to do with the people and circumstances and more to do with depres­ sion. But this is where the danger grows for firefighters. People who have difficulty coping with their anger may turn it inward, and it can become anger toward oneself. If left unchecked, this can stir up suicidal ideation. Warning: Men are four times more likely than women to die by suicide. 17 If you are feeling particularly angry, talk to someone-a counselor, a friend, or even the National Suicide Prevention Hotline: (800) 273-8255. (More information about suicide is presented in chapter 5.) Depression and Sleep Disturbances One possible explanation for the prevalence of depression among firefighters can be found in first responder sleep patterns. First responders are often called on to wake up abruptly in the middle of the night for an emergency response. And they often have to work shifts that include being awake all night. Getting sufficient sleep is often a low priority for firefighters. After all, civilians need help at all hours of the day. But what does this irregular sleep do to the brain? 20 First Responder Emotional Wellness Researchers have asked the same question. In a report published in the Journal of Clinical Sleep Medicine, researchers studied 880 active and retired American firefighters, asking them to report their experiences with depression, insomnia, PTSD symptoms, and any difficulties in regulating their emotions. Of the 880 firefighters: 39% reported experiencing depression symptoms, 52% reported experiencing insomnia in some form or another, and 19% reported having nightmares.1 8 What they found was that insomnia and nightmares both strongly impacted the ability of firefighters to regulate their emotions. They also discovered a strong associa­ tion between sleep disturbances and increased likelihood of experiencing depression. Further studies found that the greater the severity and frequency of sleep disturbances, the higher the likelihood of developing depression or suicidal ideation.'9 Previous research linked insomnia to depression, but it was believed that depression caused insomnia. In fact, the opposite may be true for firefighters. The lack of sleep common to firefighters may be at the root of the depression epidemic. Add to that many years of emergency-level cortisol surges in the middle of the night, and retired first responders commonly have difficulty sleeping even when they are no longer being jolted awake by emergencies. Sleep disturbance potentially may become a lifelong problem. Rest, as with all self-care actions in the first responder support web, is critical for emotional wellness (see fig. 1-1 and chapter 1 for additional discussion). This involves both rest in the form of good sleep and rest in the form of taking time off from work, projects, and the need to be busy. What Happens When First Responders Stay Busy Work keeps first responders extremely busy. They are constantly on the move. Even when they are sleeping, they are ready to hop up and go whenever a call comes in. When first responders are not working, even their days off are busy. Days off may represent an opportunity to go on an adventure with family or with the guys. They may offer a chance to finish a project around the house. First responders are always moving, and they are adept at switching from one task to the next. A busy life makes a first responder feel connected, empowered, and needed. In our society, people respect those who are busy by saying things like, "You have so many talents!" and "I know you are busy, so thanks for taking the time to help me with that." Being busy is a badge of honor. And whenever first responders find a minute to squeeze in one more thing, they get a little boost of satisfaction. There are so many ways to spend your time. How do you decide? Fun has a strong appeal, and so does productivity. But every time first responders say yes to something, they are essentially saying no to something else. Sometimes they feel great about it, and  Chapter 2 Rescuer's Depression 21 sometimes they are frustrated by all the demands people put on them. First responders often finish their days just exhausted. Being busy takes a lot of energy. So consider this picture. At the end of a busy day, the first responder may sit down on the couch and watch a show so he can "let off steam" or "have some cave time." But what he never gets-the thing he is surrendering that he may not even realize is lost­ is space. The Downside of Being Busy Being busy can be good. It can be productive and satisfying, but it lacks space for first responders just to be, to breathe, and to think. Citing an assessment from researchers M. A. Bentley and others, 20 the Substance Abuse and Mental Health Services Administration (SAMHSA} explains the danger behind the quick-paced first responder life, noting, One of the core risk factors for first responders is the pace of their work.First responders are always on the front line facing highly stressful and risky calls. This tempo can lead to an inability to [mentally] integrate work experiences.For instance, according to a study, 69 percent of EMS professionals have never had enough time to recover between traumatic events....As a result, depression, stress and posttraumatic stress symptoms, suicidal ideation, and a host of other functional and relational conditions have been reported. 21 Without this space, first responders forfeit the chance to find emotional wellness and balance. Space is where your best thoughts arise. Space is where you gain clarity on your past memories. Space, if used wisely, allows people the opportunity to reconnect and find themselves again. Powerful things happen when people open up their schedules and allow themselves to go to bed at a reasonable hour, ideally with time to lie in bed and think or to enjoy pillow talk with a spouse. When they slow down their pace and connect with their family, even allowing themselves to be a little bored, or when they talk to a friend over coffee or meet with a coworker to talk, they are giving themselves the opportunity to figure out their thoughts. Space is where self-awareness grows. Self-awareness contributes to your resilience in the face of a highly stressful career. When you take time now to step back from the day-to-day stresses of your job and family life, you will find perspective and a new sense of who you are. You may find pain, but you will also find strengths and situations you are proud of handling. As Ian Robertson from the Center for Brain Health explains, Exercising self-awareness can be a painful process, and many people find subconscious avenues to avoid it, including throwing themselves into work, 22 First Responder Emotional Wellness drinking excessively or compulsively exercising. [To become more self-aware], make time to clear-mindedly assess your strengths and limitations. Taking time to self-reflect and gain perspective activates the brain's right frontal lobe, releasing noradrenaline-a powerful chemical that can build the brain's gray matter and give us the mental strength to solve new problems better. 22 What If I Do Not Want to Sort Through My Thoughts? A busy schedule can be an effective source of self-esteem and identity. After all, a busy body produces endorphins and adrenaline to complete all the things that must be done. This physiological "high" created by endorphins is a way that some first responders medicate pain and attempt to dodge rescuer's depression. Eventually you will have time on your hands, however, and self-awareness will rise to the surface. It may occur when you retire or are sick or injured, but eventually you will have space, and your thoughts and emotions will rise to the surface. In the mean­ time, if you continue to "suck it up," you may find that you are irritable or downright angry, hard to be around, anxious, excessively focused on performance measures, or possibly not even able to contribute to your relationships in healthy ways when you finally do slow down. Busy is not always helpful. What would happen if you chose to become "un-busy" for even one week? Does it scare you to think about it? Studies show that children who have less programmed activ­ ity and are allowed the time and space to occasionally become "bored" are often more creative, better at solving problems, and stronger at self-motivation later in life.23 Staying Busy and Neglecting Yourself People with instrumental personalities, the personality type of most first responders, enjoy projecting the image of competence and self-reliance. This can lead to an unhealthy denial of personal needs and problems. By nature, the career of a first responder requires that you "give-give-give." When you get home, you are still expected to love your family and give to them as well. Your whole life seems to become a measure of how much and how well you can give. It is nice to be needed, but what if you have nothing left to give? What if you have emptied the tank, and there is nothing left in it? My dad's schedule was booked to the minute. His work shift as a correctional officer extended from 3 p.m. to 11 p.m. He liked that shift because it gave him almost an entire workday to take care of his businesses. His real estate ventures, laundromat, and pool hall all demanded daily ownership from him. Sometimes he let me follow him around  Chapter 2 Rescuer's Depression 23 when he was doing business. We went to the bank, carried out miscellaneous errands, and sat in many meetings where he cooked up new business deals. He was so busy deal­ ing with three jobs, two sons who were struggling, and one housing remodel after another, that for the life of me, I cannot remember a time when he took a minute to sit on the couch. I have no idea when my dad took care of himself. My guess is that he did not. When you do not take care of yourself, it is like running on empty in both your job and your family life. When you are always busy without any rest or space, you end up wearing yourself out emotionally, spiritually, and mentally. You can hide from depres­ sion for a long while by staying busy. I wanted my dad to know how much I loved him, so I made myself his busy little helper. I saw my role in the family as being well-behaved and being as helpful as pos­ sible. Many children of first responders feel that way. My dad taught me about courage, resilience, hard work, adapting to difficult situations, and finding pure joy in nature. But I saw him constantly neglect his own needs. How to Stay Intentionally "Un-Busy" Emotional wellness starts with protecting your time. Your time equates with your heal­ ing. Start by planning ahead. Before you jump into a project, allow yourself space to think about it from different angles, even allowing yourself to say no when someone wants something from you. Did you know that one of the primary struggles of people with addictions is their inability to relax in healthy ways? Stress piles up in first responder careers. Your prior­ ity is finding ways to destress, relax, and give yourself space to be healthy. Maybe you like to run. Maybe you like to take walks in nature. Maybe you like to hunt or fish. Maybe you like to play golf or basketball. Maybe you like to work on an old car. Maybe you like to read, or you just need to sleep. Maybe you need some time to medi­ tate. Maybe you need to stretch or do yoga. The main thing about giving yourself space is not what you are doing; it is about what you are not doing. What are you saying no to that will allow you to have the space you need to think, care for yourself, and heal? Your time is precious. Do not fill it all up. The Overwhelming Experience of Facing Trauma On and Off the Job A first responder is subject to many things that can lead to depression: bad calls, pres­ sures from family and spouses, interdepartmental strife, potentially traumatic events, pediatric death, the death of a coworker, and city politics. Combine the events first 24 First Responder Emotional Wellness responders see on a daily basis with the childhood trauma or neglect that many first responders grew up with (see chapter 3 for more information), and you have a whole group of people who are wrestling with psychological injuries that they need to talk about. They are unsure, however, about where to go or if they are safe to talk. Joiner explains that male depression is a combination of vulnerability and a psycho­ logical injury, such as trauma or a childhood event. 24 First responders carry a heavy burden of responsibility to "save the world." Even when they are off-duty, they feel the responsibility to protect and save people. But the off-duty first responder who witnesses an accident or horrific event right before his eyes might be unable to do anything about it simply because he does not have his equipment and gear on at the time. Deputy Chief Art Zern, Sycamore (IL) Fire Department, explains, "While the average civilian that witnesses an event is surely traumatized, the first responder also feels guilt, responsibility, and shame for being unable to 'save the day' as is expected of him from the public and himself. We can deal with losing a fair fight, but it's very hard to deal with when the deck is stacked against you."2 s Healing means starting to talk about that psychological injury. In order to start talk­ ing about the psychological injury, however, a firefighter must move from the safe, socially accepted confines of his or her hidden rescuer's depression out into the vulner­ able, somewhat uncomfortable, and unpredictable state of feeling the pain and loss. The injury may be from psychological trauma or neglect, either from the deep past or some­ thing more recent. Whatever it is, it must be acknowledged and discussed for healing to begin. How Can I Begin Healing from Depression? I believe the first step for first responders as a whole to break the bonds of rescuer's depression is for all of them to change their language toward emotional wellness. Joking, making fun of emotions, talking about people who cannot cut it as first responders, and so on only breed a culture that makes it unsafe for people to talk about their emotions. Instead of creating a toxic environment, we need to begin creating a safe environment, and that starts with the leaders. Leaders who share pieces of their story with others create a culture of vulnerability in which people can bond over their humanity, genu­ inely caring for one another and becoming stronger as a unit together. People who do not bond over vulnerability often bond over scapegoating, and one person becomes the outsider. Choosing vulnerability at the top is critical for the wellness of the whole depart­ ment and the fire service at large. In addition to changing first responder rhetoric about emotional wellness, you can begin to find personal healing by slowing down and allowing yourself to recognize your feelings; opening up with safe family members, your spouse, or friends; and starting to live an emotionally aware, connected life. This means you allow yourself to rest, restore balance in your life, get healthy sleep, address traumatic memories, and overcome the need to be needed. Connection is where healing lives.  Chapter 2 Rescuer's Depression 25 I wish my dad had taken the time to slow down and face his pain. I think he would have been so much happier if he had given himself the grace to need others and the courage to be vulnerable. Right before he passed away, I told him that I was traveling all over the country presenting about emotional wellness and peer support to first respond­ ers, and he smiled a deep, relieved smile at me (fig. 2-2). I think he died happy, knowing that I was doing what I loved. I smiled back, hopeful and passionate that first respond­ ers can become genuinely happy, reconnected people as they begin to open up about their pain. Reflection Questions - 1. Have you ever felt the pressure to be unshakable or emotionless? 2. Based on this chapter, do you think you struggle with rescuer's depression? 3. When you are alone and quiet, what is your primary emotion? 4. Have you observed yourself acting out of anger this week? 5. Do you think your anger is an active emotion to mask a more passive emotion? If so, what emotion is hiding behind your anger? 6. What has your personal time looked like this week? Have you had any time to be alone? 7. When is a time this week that you could go for a walk? Figure 2-2. My dad shortly before his death, 2017 SUBSTANCE ABUSE AND ADDICTION Brett's Story B rett grew up with little emotional connection with his parents. His father was a first responder, and like many children raised by first responders, Brett,dealt with pain in his life by achieving and "sucking it up." Brett taught himself to self-soothe in isola­ tion because nobody seemed to care. As he got older, Brett's favorite self-soothing mea­ sure became alcohol. At first it was just a tool he used to calm down or when he wanted to take a break or reward himself for making it through a hard day at work. But when he retired from the fire service, his schedule changed, his time with others decreased, and he had more time on his hands. He found himself increasingly turning to alcohol. He had not intended to develop an addiction. It started as a "harmless" habit, but Brett's drinking quickly got out of hand, distancing him from his wife and kids, and ultimately leading him into an affair. When Brett came to me, he was ready to find free­ dom, so we began by recognizing what his struggle really was, what purpose it served in his life, and what he needed more than his relationship with alcohol. What Is Addiction? Addiction is a psychological as well as a physiological dependence on something. It is often the manifestation of a deeper problem, such as depression or childhood pain. Rather than confronting the pain, many firefighters escape to wherever they find comfort: sub­ stances, behaviors, or activities that will generate approval from others. Seemingly productive activities such as overachievement at work, workaholism, excessive exercising, and obsession with diet become like drugs because they provide social approval. People think of these as "good" addictions, but they are most definitely harmful in that they distract from the pain instead of healing it. The addictions often take the place of the genuinely intimate relationships where healing actually resides. For others, alcohol or drug abuse, pornography, gambling, extramarital affairs/sexual promiscuity, overspending, domestic or verbal abuse, violence, or multiple of these are 47 48 First Responder Emotional Wellness the means they use to distract from their pain or to destress. Canadian physician Gabor Mate also includes shopping, eating, Internet usage, relationships, work, and extreme sports in his list of addictive behaviors.' These vices promise comfort but never truly deliver because there is never enough to make the pain go away. Addiction is more than physical. It is a psychological response to life's stressors. As Mate stated in an interview with the late Richard Simon, clinical psychologist and editor of Psychotherapy Networker, and coauthor Lauren Dockett: I don't medicalize addiction. In fact, I'm saying the opposite of what the American Society of Addiction Medicine asserts in defining addiction as a primary brain disorder. In my view, an addiction is an attempt to solve a life problem, usually one involving emotional pain or stress. It arises out of an unresolved life problem that the individual has no positive solution for. Only secondarily does it begin to act like a disease. 2 I agree with Mate, who identifies addiction as a solution to a life problem. For most people with an addiction, the substance or behavior is a way to escape temporarily from a problem in life. But addiction is a cycle of craving, experiencing the "high," suffering consequences from use, and having trouble giving up the substance/behavior.3 This cycle leaves the individual exhausted, trapped, and still as unhappy as he was before. Addiction is less about getting hooked on a substance or behavior and more about solving an emotional pain problem. Addiction is less about being genetically predisposed to addictive behaviors and more about the ways that people learned to self-soothe in response to their upbringing. Addiction is less about what the addiction is and more about why the person is addicted. Consequently, this forces us to admit that just about anyone is capable of developing an addiction. 4 If it is possible for anyone to develop an addiction, I advocate we should be careful not to call those with addictions "addicts." These are people. They are humans who need support as they learn that they do not need their addiction anymore. They are people who need to fight to relearn how to meet their needs in appropriate ways, and they deserve respect, connection, and care as they find freedom. What Does Addiction Do for the Individual? In my experience working with first responders, I have found that firefighters like to keep themselves busy. When they have a lull in their schedule, when they have to take a break from work due to an injury or trauma, or when they retire, they are abruptly confronted with thoughts, memories, and feelings that they have never had to deal with before. This can make anyone uncomfortable, and many pursue an outlet for this dis­ comfort. If alcohol, other drugs, or risky behaviors are within reach, they become tempt­ ing in times like this because they seem to promise comfort and distraction.  Chapter 4 Substance Abuse and Addiction 49 People do not just engage in addictions for the fun of it. Rather, as Mate advocates, addictions serve a highly specific purpose in the individual's life. People run to their addictive substance or behavior in an attempt to find comfort, pleasure, stress-relief, connection, and distraction from pain.5 And if the individual does not learn to calm down or reduce stress in healthy ways, relapse becomes easy and frequent because his only outlet is the addiction. In an addiction, an individual will seek to meet his intimacy and relational needs with his addictive substance or behavior until it becomes his most important relation­ ship, according to researchers Chad Cross and Larry Ashley, University of Nevada-Las Vegas. Because the experience of using the addictive substance or behavior can change a person's mood from stressed to calm or from angry to happy, for example, the indi­ vidual may perceive that his needs have been met. Cross and Ashley note that the indi­ vidual will then begin to shut out people and turn to the addictive substance or behavior instead of friends and family. They observe that although the individual actually needs a connection with other individuals, 6 the addiction remains the individual's primary relationship. Licensed clinical social worker and certified sex addiction therapist Robert Weiss notes that instead of trusting others who might potentially let them down, those with addictions begin to trust more and more in their addictive behavior or substance. According to Weiss, instead of turning toward people for connection and healing, they begin to mistrust people and become less accustomed and tolerant of working through the ups and downs of real relationships, preferring the addiction over people.7 Firefighters who struggle with addiction need to build a robust support web around themselves so that they can select a healthy means of destressing instead of turning back to their addictive substance or behavior. (See fig. 1-1 and chapter 1 for further infor­ mation about the firefighter support web.) When a firefighter quits drinking, it usually results in an entire lifestyle change. Not drinking puts new strain on the social life. Connecting with others is highly important in overcoming addiction, but first responders often hang out in alcohol-inclusive situa­ tions, such as at a bar, a barbecue, and so on. Most first responder social gatherings have alcohol connected with them, so often sobriety results in unintended isolation. Thus, a firefighter should be intentional to build up the relational part of his support web by spending time with others in healthy environments. The Development of an Addiction What starts out as a healthy relationship with alcohol-or another substance or behavior­ can escalate over time. Firefighters may get in the habit of reaching for alcohol after a tough call. The intense situations faced daily by first responders leave residual cortisol (the stress hormone) and adrenaline in the body. This can cause lingering stress and anxiety, and many first responders tell me they were physically shaking after an intense so First Responder Emotional Wellness call. This shaking is the body's way of working the excess cortisol out of the body and is actually a good thing. But it can feel like weakness, which first responders do not like, so it is common for them to reach for a drink as a way of "chilling out." When this hap­ pens repeatedly, the brain rewires itself for an alcohol-assisted chill out, and it can become increasingly more difficult to calm down without the use of alcohol in the future. Additionally, I see many active first responders have a drink after work before their spouses get home. They believe that with the help of alcohol, they will be more relaxed and less likely to get in a fight with their spouses. I also hear firefighters tell me they drink to be able to sleep. Many first responders admit to drinking every night before bed. The problem with drinking before bed is that it interferes with rapid eye movement {REM} sleep, a period during which memory is consolidated and the body truly rests. When REM sleep is not achieved, it affects an individual's ability to process stress and trauma, avoid anxiety and depression, and feel rejuvenated. Patterns like these form dependencies in which the neurotransmitters in the brain literally adapt to the depress­ ing and calming effects of alcohol and become addicted. They actually become unable to produce the regular balance of neurotransmitters that they had in their healthy brains. When they feel their neurotransmitters out of balance, they soothe with more alcohol. But it is not only active firefighters who struggle with alcohol. I often see retired first responders come through my doors or check themselves into inpatient facilities to find freedom from addictive behaviors. Retired first responders often have flashbacks and dreams of things that happened decades ago, and they often experience sleep distur­ bances starting about a year into retirement. (More about retirement is discussed in chapter 18.) As the firefighter continues to turn to alcohol or other substances or behav­ iors for an escape from the anxiety, flashbacks, or memories, he or she becomes depen­ dent on that substance or behavior. The delicate balance of firing neurotransmitters in the brain adjusts to find a new normal based on the inhibiting substance of alcohol. This provides only a temporary escape, however. People who did not intend to become addicted find themselves unable to stop. The Biology of Addiction All addictions have seven factors in common, according to Mate: 1. Compulsive behavior 2. Craving 3. Temporary pleasure or relief 4. Negative consequences 5. Denial 6. Shame 7. Brain circuits (dopamine released during the "hunt") 8  Chapter 4 Substance Abuse and Addiction 51 An addiction is thus more than a short-lived act. Addiction is the process of think­ ing about the substance or behavior, desiring to act on these thoughts, feeling excite­ ment or a rush during the "hunt," or the time on the way/just before engaging in the addiction. Then the person feels a temporary sense of pleasure or relief before an onslaught of consequences, denial, and shame set in. The person may especially feel shame over his or her inability to resist the addictive substance or behavior. In this process, the person continues to reinforce that the addiction is his or her primary rela­ tionship. The person's neurotransmitters orient themselves around the addiction, so the individual becomes dependent on the experience, unable to escape because of what it does for him or her. Drugs and alcohol trigger a release of dopamine in the brain that causes a "high" feel­ ing. The stronger and quicker the release, the more the reward centers in the brain remember that as a pleasurable event. Thus the more dopamine, the more likely to lead to physiological addiction. More exposure to this substance or behavior means the indi­ vidual begins to build tolerance to it. The brain learns to release less dopamine, which means the brain needs more of the addictive substance or behavior for the same result. This is why people with addictions are always "chasing the high." They have developed tolerance to their substance or behavior, and the brain has adjusted to having that sub­ stance or behavior as the new normal. This is why people with addictions feel a lack of control and compulsion when around their addictive substance or behavior. Their brains literally need the substance or behav­ ior to feel a sense of normal, and these people begin to believe that they truly could not live without their chosen vice. Risk Factors for Addiction There are a series of factors that often place a person at risk of addiction. If you have addictive tendencies, or if you know someone in your life who is struggling with an addiction, it may help to start pinpointing some of the factors contributing to the onset of an addiction. Place a check mark next to the factors that you identify in your own life or in the life of someone you care about: Experiencing trauma/traumatic incidents Negative peer influences Feelings of insecurity, loneliness, or being different Difficulty using positive emotions such as love, joy, or intimacy in times of trouble An inability to sit with stressful feelings or emotions Adverse childhood experiences/lack of connection in childhood/childhood emotional neglect9 52 First Responder Emotional Wellness Do any of these seem familiar to you? Many first responders have adverse childhood experiences. These experiences can leave firefighters exceptionally vulnerable to addic­ tive substances and behaviors. At the beginning of this chapter, I introduced you to Brett. Brett admitted that he could check a number of these boxes. He had grown up with an emotionally absent father. He did not have any negative peer influences at the time because he found him­ self quite alone after retiring. His feelings of insecurity, loneliness, and unproductivity weighed on him, and he had difficulty expressing his emotions because he had grown up with an emotionally absent family and a weak ability to articulate what he was feel­ ing and express that to others in a heathy way. Every addiction has multiple factors con­ tributing to it, but I would say that for Brett, his lack of connection in childhood had significantly played into his long-term struggle with alcohol. When Brett came to me after his retirement, he had reached rock bottom, gone through a 30-day treatment program, and come to me for continued support. He wanted a way to rebuild his marriage after his affair. He desperately wanted connection. He wanted to find freedom, but he had no idea where to start. Instead of starting with the alcohol, we started with his relationships. Childhood Emotional Neglect According to clinical psychologists Jonice Webb and Christine Musello, behind every addict is a child whose emotional needs were neither identified nor met. If you can get people with an addiction to open up, it is surprisingly common to hear that they grew up with no one asking how they were doing or helping them pinpoint their feelings. This neglect was usually not overt. In fact, Webb and Musello note that children who are emotionally neglected are often well cared for physically, which can make it diffi­ cult to identify childhood emotional neglect (CEN).10 When a child's parents never care to hear why he was sad and never help him prac­ tice using tools to identify emotions, soothe, de-stress, or regain control of his emotions, it can be a dangerous path for him to travel. What this child needed was someone to ask about and listen to his feelings, but what he got was a closed door and a room to himself. So he "manned up" and coped the only ways he could find to cope.11 As an adult, he now has less self-awareness to recognize which specific emotion he is feeling and a limited menu of self-care tools to downshift from "overwhelmed" to "at peace." Addictions were his self-soothing mechanism to face a world that just did not care. The opposite of addiction is not sobriety. The opposite of addiction is connection. -Johann Hari Author and TED Talk speaker Johann Hari notes that connection with others is vital in the process of overcoming addiction.12 Connecting with others and allowing yourself to be surrounded by your support community is the way to move toward freedom.  Chapter 4 Substance Abuse and Addiction 53 What Brett needed most was emotional self-awareness and safe relationships. Talking to me was a start, but rebuilding his marriage was his most challenging and fulfilling pursuit. As he fought for connection in his marriage and to deepen his friend­ ships and his relationships with broader society, he simultaneously fought against his addiction. Addiction is a relationship with a substance or behavior that served as a coping mechanism for the individual to face a tough and uncaring world. But connection with real people in deep, meaningful ways is the way to move toward freedom. What Scientists Discovered About Rat Parks and Addiction Scientists have been perplexed by addiction for decades. Many have endeavored to study addiction by observing how rats have interacted with addictive substances. In study from 1969, researchers provided rats with two water feeders-one with cocaine-laced water and one with plain water.'3 Hands down, all of the rats chose the cocaine-laced water over the plain water and became addicted. A more recent study looked at the rats and asked, "What would happen to the rats if they were placed in a cage with other rats?" Rather than putting the rats in isolated cages and offering them an addictive substance, they wanted to see what would happen if they were surrounded by community and then offered an addictive substance.'4 To their surprise, the rats who were in cages surrounded by other rats, and all the things a rat society needs to be interesting, almost always avoided the cocaine-laced water. Those who tried the cocaine-laced water almost never used the drug regularly or developed an addiction.'5 So what was their conclusion? Rats are social animals. They need a community and relationships around them to remain emotionally well. Denying them their social connections drove them to self-soothe in isolation, and addiction set in. But those who were surrounded had no need of addic­ tion because it offered them nothing. They did not need an addiction. Obviously humans are much more developed than rats. But consider that humans are also social creatures. We were made for deep connection and meaningful relation­ ships with others. When we are taught to isolate ourselves and ignore emotions, we still need somewhere to turn to find comfort, so we can turn to addictive behaviors or sub­ stances. But when we seek community, talk to someone, and develop supportive rela­ tionships, we can live in freedom from addictions. Instead of looking at someone with an addiction and thinking that there is some­ thing wrong with that person, consider thinking instead that the person likely feels all alone and needs someone to trust on the path toward freedom. The thirst for an addic­ tive substance rightly should be seen as a thirst for real connection. 54 First Responder Emotional Wellness How to Identify an Addiction To help determine whether or not your behavior is an addiction, answer the following questions with either "true "or "false." __Before engaging in the behavior/substance, I feel low, insecure, or anxious. __The substance/behavior makes me feel better about myself. __When I am craving the substance/behavior, I am usually bored, stressed out, or lonely. __Without the substance/behavior, I am just angry all the time. __It stresses me out to think about my life without the substance/behavior. __I think about the substance/behavior every day. __When I am alone, the substance/behavior comes to mind. __I do not know what I would do without the substance/behavior. __ Whenever I am around the substance/behavior, I have to do it. __The substance/behavior keeps my demons at bay. __I just feel calmer and more relaxed when I engage in the substance/behavior. __This substance/behavior is the one thing that gives me a chance to check out from the world around me. If you answered the above statements with more "true" answers than "false," you may have an addiction. I always recommend talking to a trusted friend or counselor if you think you may have an addiction. Talking about it is the first step to being able to find freedom. The second step is to begin taking active steps toward freedom from addiction. The two most powerful tools in the journey toward freedom from addiction are connection with others and self-care. Connection: What People with Addictions Actually Crave I am happy to say that Brett has been sober for more than a year now, and he is reestab­ lishing his relationships and reconnecting with his family. He is back together with his wife and children, but he is having to rebuild his self-image at the same time. Brett struggles with shame for his drinking and for having an affair, so he is choosing to focus  Chapter 4 Substance Abuse and Addiction 55 now on talking, being more present, and enjoying his family, rather than focusing on his past. What we have found now is that Brett is afraid to have a voice in his family. He cannot put his foot down or be assertive when he needs to because he feels that if he makes one false move, he will be kicked out. He realizes how important family is to him, so now we are working on ways to handle some of the lingering resentment his family feels. Resentment is one of the main reasons that relapses can happen. His wife is very hurt and angry. They have been married for more than 30 years. He is sober now, which helps with the disconnect that initially led to the affair, but he is having a hard time finding his voice. I have respect for his self-awareness. He is aware that a relapse could happen as a result of resentment, and he is choosing connection and self-care instead of shame and escaping to alcohol. Brett is also working on his developing friendships. Like many first responders, he struggles with social anxiety. He gave up a significant part of his life when he retired. He lost the brotherhood and the connection of the fire service, which left him lonely. His wife still works. Retirees need to connect with a group of other retired first responders or peer supporters. You still need friends, maybe even more now than you did while you were working. Building trust with others can be a very healing part of overcoming an addiction. And trusting others in some form is essential for recovery. For those who have experi­ enced neglectful or adverse childhoods that left them with deep emotional wounds or an inability to deal with emotions in a healthy way, trusting others can be new and scary territory. It can be easier to trust a substance or addictive experience than a person. But connection with others is the key ingredient in recovery. This could be a therapist, accountability partner, partner, peer supporter, or a higher power. As Simon explained, "Unless the [person with an addiction] learns to connect with themselves and others, long-term recovery will not occur. Understanding emotions is foundational to learning how to connect."16 Not talking about or dealing with emotions in childhood is a major contributor to addiction. But building your "emotional vocabulary," as authors Sissy Goff, David Thomas, and Melissa Trevathan call it, '7 in adulthood is a powerful way to connect with yourself and others. Here are some categories of emotions that you may feel on a daily basis (fig. 4-1). Take a minute to look over the Feelings Wheel, which is an updated version based on one originally created by Gloria Willcox. Try to think of a time when you felt some of these emotions. Sometimes it is easiest to start at the core and work your way out. Start by identifying the core feeling and then work that out into the specific feeling you are experiencing. Sometimes it is easiest to start at the outer part of the Feelings Wheel and work your way in, identifying your core feeling later. Either way, the more you practice expanding your emotional vocabulary, the more you will be able to identify what you need in that moment and meet that need in a healthy way. This will also help you to communicate your feelings and needs with a spouse, trusted friend, or even fellow firefighter. 56 First Responder Emotional Wellness Figure 4-1. The Feelings Wheel can help you communicate with family, friends, and fellow first responders. Identifying and naming feelings and learning to express them to others is essential for emotional wellness. If you have an instrumental personality, you may need to make a conscious decision to allow yourself to respect emotions. This may be a drastic shift from the past. Building your emotional vocabulary is the first step in learning how to connect with yourself and others and learning to regulate your emotions in a healthy way. Having a robust emotional vocabulary-being able to recognize when you are angry, sad, happy, insecure, ashamed, afraid, bored, anxious, stressed out, calm, content, proud, frustrated, rejected, burdened, surprised, disgusted, disappointed, resentful, or hurting, for example-is a foundational part of addiction recovery. Here is an activity that might help you build your emotional vocabulary. Next time you are watching TV or reading a book, pause for a minute and ask yourself, "What is this character feeling?" This practice will help you begin to expand the language you use to talk about emotions.18 Connecting with others starts with being able to recognize and talk about your feelings, and connection is key to healing.  Chapter 4 Substance Abuse and Addiction 57 With the help of a support team, the next step is to remove the addictive substance or behavior. I must warn you that when the substance or behavior is removed, an inevi­ table depression or feeling of loss will set in as the brain no longer receives the excitatory or inhibitory messages. But research shows that neurotransmitters can and do regulate over time. Eventually the individual can resume a normal, addiction-free life if given the space to process childhood issues or a difficult trauma and the support to walk away from an addiction. Self-Care: What People with Addictions Need to Prioritize The second greatest contributor to success in addiction recovery is self-care. Individuals struggling with addiction are "masters of self-neglect," according to Webb and Musello, and in order to recover, they must learn "consistent and effective self-care."19 Research shows that exercise, sleep, healthy eating, and mindful breathing increase self-control (more about self-care is presented in chapter 11). Those with addictions "demonstrate an almost complete inability to relax and enjoy themselves." 20 Individuals need to give themselves permission to slow down. Self-care requires dealing with uncomfortable feelings in healthy ways, healthy relaxation, and having fun apartfrom an addiction. It also means practicing self-compassion and ending self-criticism because a "self-critical mindset decreases one's ability to suc­ cessfully change," according to psychologist Kelly McGonigal. Self-criticism increases chances of repeating behavior, and self-critical people have less control and motivation. McGonigal explains that "it's unlikely that true change will occur when self-criticism remains the default."21 Healthy brains are a large part of healthy living. When people take care of themselves and their minds, they can succeed at breaking free from an addiction. This includes healthy movement (exercise), healthy rest (sleep and mental breaks), healthy nutrition, healthy play (laughter), healthy learning (learning new things, growing), and healthy relationships with healthy people. (For more information on self-care for first respond­ ers, see chapter 11.) Relapse and Triggers When people struggle with an addiction, there are risks that can increase the likelihood of relapse. The first risk factor is boredom. Those who stop engaging in addictive behaviors may find that lives can seem uneventful and lacking in emotions. Add to this the fact that their brains are not being stimulated by the substances/behaviors used in the past, and 58 First Responder Emotional Wellness their lives may begin to seem boring to them. So be aware when they start spending a lot of time alone, lacking structured activities, or saying things like, "I have nothing to do," or "Life just seems so boring." When individuals have these thoughts and possibly too much free time, they may be at risk of returning to their addiction. The second risk factor for relapse is illness. Illness makes a person weaker and drains the body and mind of energy that is important for focusing on recovery. Simple illnesses like colds, the flu, or other infections can make it much more tempting for a person in recovery from an addiction to want to relapse. Even surgery or dental work can require recuperation that saps their energy and tempts them to use. The third risk factor for relapse is a major life change. Major life changes are disrup­ tive to the structured lifestyle that is critical to a successful recovery. These can include divorce, break up of a relationship, the death of a friend or family member, moving, a child moving away to college, or even the change of a job or retirement. When people experience change, the new patterns created can set them up for excellent recovery, or it can be a risky time for them to relapse. The fourth risk factor for relapse is anger. Often the process of getting clean results in increased emotions and irritability, which can instigate rage and anger. When those who are struggling with addiction say things like, "It just gets me so angry," or "I feel so pissed off," it is a warning sign that their emotions are becoming more intense. When people are not able to control their feelings or to calm down, they are making it abun­ dantly clear that they need support and are at risk of relapse. Remember, their addictive substance or behavior is most likely what they formerly used to calm themse