First responders honor those that lost their lives on September 11 during the second annual San Antonio 110-9/11 Memorial Climb. Photo by Scott Ball.
Two firefighters hold hands during a prayer at the second annual San Antonio 110-9/11 Memorial Climb. Credit: Scott Ball / San Antonio Report

Yvonne Garcia has been working as a San Antonio Fire Department paramedic for nearly 20 years. High-intensity, life-or-death situations are regular occurrences.

She recently responded to an accident in which a 21-year-old motorcyclist was involved in a collision and fell off an exit ramp from Loop 410 onto U.S. Highway 281. When paramedics arrived, the young man was barely breathing and one of his arms was completely severed. Garcia’s EMS unit took him to an area hospital, where he died.

In the waiting room, Garcia watched as a man around her age rushed to the reception desk, saying he was looking for his son who had been involved in an accident. She knew it was likely the father of the young motorcyclist.

“I turned around and walked out – I was in tears,” said Garcia, whose own son is 21. “It was the emotional attachment that stuck with me. I put myself in that position every time [I hear] something like that – What it would be like if something happened to one of my children.”

For first responders like Garcia, caring for their own mental health and receiving support when they need it have long been taboo subjects. Police officers, firefighters, and paramedics work in a culture that separates the helper from those in need of help.

“It’s the whole, ‘I’m here to help, I can take care of this, I can do [things] for other people,’ strong helping mentality,” Garcia said.

But who do the helpers turn to for help? A survey of more than 4,000 first responders found that 6.6% had attempted suicide, which is more than 10 times the rate in the general population, according to a 2015 article published in the Journal of Emergency Medical Services.

In 2016, friends, family, and coworkers reported 132 first-responder suicides nationwide to the Firefighter Behavioral Health Alliance, an Arizona-based nonprofit that promotes expanding mental health support for first responders. The voluntary reports are some of the only data available on the deaths and likely only capture a percentage of deaths by suicide.

For decades, first responders have kept silent about the toll trauma takes on them, their families, and their careers. The San Antonio Fire Department (SAFD), which consists of both firefighters and EMS workers,
has focused efforts on early mental health intervention in hopes of preventing first responders from becoming overwhelmed by the demands of the job and turning to harmful behaviors such as drug abuse and violence toward themselves or others. 

Psychologist Darrel Parisher has been with SAFD for almost 30 years and is a consultant for the local park police and airport police. He believes today’s first responders are more open to seeking help from him.

“I’ve had people who tell me they were told not to talk to me, and it took some time to get through that,” Parisher said. “Mostly that’s all gone. It wasn’t easy. They never had anyone working in mental health before me, and no one knew what it was about. That has changed.”

Psychologist Darrel Parisher.
Psychologist Darrel Parisher. Credit: Roseanna Garza / San Antonio Report

The perceived stigma toward mental health within the world of first responders has subsided over time due to departmental emphasis on wellness and making sure that those seeking help feel safe knowing that their information remains confidential, he said.

The department now boasts critical incident stress debriefing (CISD) teams, active chaplains, and peer support workers who provide services to firefighters when needed.

Now, when a high-stress incident occurs – such as the death of firefighter Scott Deem in May – critical incident stress debriefings, where first responders gather to digest the incident as a group, take place immediately.

During a CISD, mental health professionals work with officers involved in a traumatic situation to talk about what they are experiencing emotionally.

Fifteen-year emergency medical technician (EMT) Joe Arrington calls a CISD “hot wash,” a moment for everyone to gather and realize that they aren’t alone. No one is required to talk, but it provides the opportunity to learn about emotional processes and what kind of support services are available through the department.

Peer support workers are first responders who have received specialized mental health training to help others deal with traumatic on-the-job experiences, as well as everyday stressors such as marital, financial, or legal issues. They attend debriefings and are always available in fire stations to talk about stressors around a pot of coffee at the kitchen table.

“Most of us feel comfortable talking to our peers because they have seen things, been there, and done it,” Arrington said. “This is where most of us will start.”

The San Antonio Police Department (SAPD) has three staff psychologists, including Melissa Graham. She said that SAPD has “come a long way” in terms of supportive services for officers, which included a culture change toward prioritizing mental health. Graham said the department has been recognized by the International Association of Chiefs of Police, a research and education organization aimed at improving police practices, as having one of the best peer-support programs in the country.

Graham told the Rivard Report that she has worked one-on-one with police officers who have had a traumatic experience doing exposure therapy, a specific kind of cognitive-behavioral therapy used to help a person overcome the anxiety and fear associated with post-traumatic stress disorder (PTSD) or phobias.

San Antonio Police Department Psychologist Melissa Graham.
San Antonio Police Department Psychologist Melissa Graham. Credit: Bonnie Arbittier / San Antonio Report

In one instance, an officer participated in therapy following a terrifying car wreck he was involved in while driving his patrol car. The officer struggled to go back into the field due to extreme fear and anxiety he would experience while in the vehicle. Through therapy, they made steps toward overcoming fear through exposure.

Graham said they started by going out to the police driving track and sitting in the car. The second time they exposed the officer to the patrol car, they turned on the engine, slowly working up to driving the vehicle on the course, and eventually on the streets. After each exposure, Graham and the officer processed the challenging experience and discussed how he could manage his emotional responses in the future.

Parisher said that most first responders get help for “cumulative stress,” experiences that build up over time. Firefighters often enter the academy in their early 20s, and stay in the department until they retire.

“Since you deal with the lifespan, everything might be fine when someone enters into the fire department at age 22. But when they are 52, the variables change quite a bit,” Parisher said. “We are very good at screening out people who should not get in, but what can develop when you’re in the department – that’s more unknown.”

PSTD, depression, anxiety, sleep disorders, and substance abuse issues among first responders may develop over time as the demands of the profession continue to push them to their emotional and physical limits. Coupled with everyday stressors, behavioral health issues become an even greater risk to health and well-being.

“We see things that regular people just don’t see. That alone brings stress to your life,” Garcia said. “I have gone through low periods – personal issues, divorce, raising kids, being a single mom. I was having trouble at home and I brought it to work, which made my job harder.”

Garcia told the Rivard Report that she had to learn the value of self-care over time. “Our job is to help people, so we can kind of neglect ourselves.”

Arrington believes that the increased access and light shed on the prevalence of behavioral health issues among first responders both locally and nationally has reduced the perceived stigma surrounding mental health services.

“PTSD, or the stress brought on by this job, is getting the justice that it deserves,” he said. “Most everyone who hears PTSD thinks of the military. We aren’t seeing war, but we are seeing things that affect us. You can’t help it. And for years we internalize that. It’s just what you [do].”

Both Parisher and Graham believe that their departments have made great strides toward promoting mental health, but because services are voluntary (save for CISD, which first responders are required to attend) there will always be individuals in need of help who do not receive it. Similar to the general population, perceived stigma surrounding mental health and “needing help” to take care of personal problems prevents many who would benefit from therapy from seeking services.

“If you hit a breaking point, you were ignoring the signs early on,” Arrington said. “There’s a difference between having fun and doing drugs and drinking to cope. That’s the message that has to be spread. You may be a crossfit junkie in great shape, but if your mental health isn’t in order, you aren’t in great shape.”

Arrington says that he believes SAFD is doing a good job providing treatment opportunities, both internally and externally with referrals.

“There is nobody here who regresses to the mean. Everyone wants to do their best and they want to win. They take everything quite personally,” Parisher said of first responders. While that mindset helps save countless lives every year, Parisher was quick to point out its not-so-obvious downfalls.

“There is no mediocrity here. They take it very [hard] when things don’t go well – they take it personally and blame themselves,” Parisher said.

Roseanna Garza reports on health and bioscience for the San Antonio Report.