What Can Psychiatry Learn from Firefighting?
The metaphor is striking. Is it true? In 2016, there were more than twice as many suicides as homicides in the U.S. and more deaths from suicide than from breast and prostate cancer combined. Suicide was the second leading cause of death for people aged 10–34, behind only accidents, and rates of death by suicide have gone up 30% in half of states across the U.S. since 1999.
Scientific progress has almost entirely eradicated some of the great destroyers of the 19th-century body and mind — i.e. smallpox and polio — but has not yet eradicated a single mental illness in the seventy years since the discovery, in the first half of the 20th century, that neurons are the fundamental units of the brain.
In other words, yes — our house is still on fire. And the fire is spreading. What can we do about it?
Can we learn any lessons from the long history of firefighting, and import them into psychiatry, neuroscience, and care for the mentally ill? How do we put out the fire The metaphor is more than just cute: fire and suicide have one thing, primarily, in common. They are hounds of entropy, seeking most, above all else, to break the ordered bonds of life. Their goals are the same: a body, turned back to dust.
The major focus of modern firefighting is prevention, but this was not always the case. If you close your eyes and take an imagined tour of in and around a modern building, and notice just how fire-obsessed we are: automatic sprinklers, red curbs, EXIT signs, hydrants, manual alarms, inspections, fire escapes, well-mapped escape routes, pre-incident and pre-action plans, materials bans, universal lockboxes. Each detail, of course, postcedes a tragedy and the long, slow lesson is that environmental conditions matter. As far back as even 1631, wooden chimneys and thatched roofs were outlawed, in Boston, due to their fire risk.
But it was a long, suffering journey to get to today. Firefighting was first formalized in Rome, under the emperor Nero, as an answer to local fire fighting gangs who would show up to a fire and extort a fee from business owners as they watched their shops burn. So Nero formed and armed the vigiles, the first “bucket brigade”, with buckets, poles, and pumps. (Rome under Nero would still burn, in 64 AD, but at least there was less extortion.)
Is the mental health crisis about to get even worse? Will there be a mental-health equivalent of the 1666 Great Fire? (Are we in it already?) If we plotted psychiatry today onto a timeline of the history of firefighting, I’d argue we are still in the bucket brigade era. It was common in centuries past to expect to lose an entire home; today, we tolerate a loss of the patient. The buckets were used mostly to, hopefully, buy enough time to salvage a few belongings, but the house was always destroyed.
If only we treated people with as much care as we do buildings.