Tag Archives: Suicide

New Guidelines for Preventing Suicides

The American Association of Suicidology (AAS), American Foundation for Suicide Prevention (AFSP) and United Suicide Survivors International (United Survivors), announced their collaboration and release of the first National Guidelines for Workplace Suicide Prevention on World Mental Health Day (Oct. 10, 2019). The guidelines — built by listening to the expertise of diverse groups like HR, employment law, employee assistance professionals, labor and safety leaders and many people who had experienced a suicide crisis while they were employed — aim to jump start the ability for employers and workplaces to become involved in suicide prevention in the workplace. For employers and professional associations ready to take the pledge and become vocal, visible and visionary, please visit WorkplaceSuicidePrevention.com.

Justification

Over two-thirds of the American population participates in the workforce; we often spend more waking time working each week than we do with our families. When a workplace is working well, it is often a place of belonging and purpose — qualities of our well-being that can sustain us when life gets unmanageable. Many workplaces also provide access to needed mental health resources through employee assistance programs and peer support. If we are ever going to get in front of the tragedy of suicide, we need to widen our lens from seeing suicide only within a mental health framework to a broader public health one. In other words, when suicide and suicidal intensity are seen only as the consequence of a mental health condition, the only change agents are mental health professionals, and the call to action becomes a “personal issue” that people take care of with their providers — but not all problems will be solved by getting a bunch of employees to counselors. When we understand suicide through a public health framework, many additional solutions are available. Through this broader lens, workplaces now understand the importance of a culture that contributes to emotional resilience rather than to psychological toxicity, and they can take steps to create a caring community of well-being.

Guidelines Development Process

After the CDC’s 2018 report that ranked suicide rates by industry, some employers started to feel more of a sense of urgency and requested tools to protect their workers from this form of crisis and tragedy. The Workplace Committee of the American Association of Suicidology resolved to do something more important: to create a set of National Guidelines for Workplace Suicide Prevention. Over the next two years, the group enrolled over 200 partners into the effort and subsequently forged a core partnership to conduct an exploratory analysis (the full 100-page report of findings can be found at www.WorkplaceSuicidePrevention.com). The ultimate purpose of this needs and strengths assessment was to guide the development an interactive, accessible and effective on-line tool designed to help employers and others achieve a prevention mindset and implement best practices to reduce suicide intensity and suicide death. Some of these best practices are about supporting despairing or grieving employees, and others are about fixing psychosocial hazards at work that can drive people to suicidal despair.

Goals and Target Audience

The collaborative partners’ goal is to enroll workplaces and professional associations to join in the global suicide prevention effort by building and sustaining comprehensive strategies embedded within their health and safety priorities. Across the United States, workplaces are taking a closer look at mental health promotion and suicide prevention, shifting their role and perspective on suicide from “not our business,” to a mindset that says “we can do better.” We hope this ground-breaking effort helps provide the inspiration and the road map to move workplaces and the organizations that support them from inactive bystanders to bold leaders.

See also: Blueprint for Suicide Prevention  

Many different employer roles can benefit from these guidelines, including leadership, HR, community collaborators who will partner in the process, investors who can contribute resources for the development and sustainability of these guidelines, evaluators who can assess the effectiveness of workplace suicide prevention, peers (co-workers, family and friends) who want to help and many others.
The newly developed guidelines, designed to be cross-cutting through private and public sectors, large and small employers, and all industries will:

  • Give employers and professional associations an opportunity to pledge to engage in the effort of suicide prevention. Sign the pledge here: WorkplaceSuicidePrevention.com.
  • Demonstrate an implementation structure for workplace best practices in a comprehensive, public health approach.
  • Provide data and resources to advance the cause of workplace suicide prevention.
  • Bring together diverse stakeholders in a collaborative public-private model.
  • Make recommendations for easily deployed tools, training and resources for short-term action inside of long-term change.

Nine Recommended Practices

The exploratory analysis also uncovered a number of suggestions for nine areas of practice. They are:

  • Leadership: Cultivate a Caring Culture Focused on Community Well-Being
  • Assess and Address Job Strain and Toxic Work Contributors
  • Communication: Increase Awareness of Understanding Suicide and Reduce Fear of Suicidal People
  • Self-Care Orientation: Encourage Self-Screening and Stress/Crisis Inoculation Planning
  • Training: Build a Stratified Suicide Prevention Response Program
  • Peer Support and Well-Being Ambassadors: Set Informal and Formal Initiatives
  • Mental Health and Crisis Resources: Evaluate and Promote
  • Mitigating Risk: Reduce Access to Lethal Means and Address Legal Issues
  • Crisis Response: Prepare for Accommodation, Re-integration and Postvention

See also: Social Media and Suicide Prevention

Conclusion

This exploratory analysis is a starting point to develop guidelines and best practices to help employers and professional associations aspire to a “zero suicide mindset” and implement tactics to alleviate suffering and enhance a passion for living in the workplace. The process identified high-level motivations for (predominantly around worker safety and well-being) and barriers (lack of leadership buy- in and resources) that prevent the establishment of national guidelines for workplace suicide prevention.

To learn more and take the pledge, please visit WorkplaceSuicidePrevention.com and follow along on Facebook, Twitter, Instagram and LinkedIn.

Workplaces Coping With Suicide Trauma

“The workplace is the last crucible of sustained human contact for many of the 30,000 people who kill themselves each year in the United States. A co-worker’s suicide has a deep, disturbing impact on work mates. For managers, such tragedies pose challenges no one covered in management school.” 
~Sue Shellenbarger (2001), Impact of Colleague’s Suicide Is Strongly Felt in Workplace, Wall Street Journal

Overview

The majority of people who die by suicide are of working age, and almost all of them are employed, previously employed or a family member of someone employed at the time of death; however, workplaces are often ill-equipped to provide grief and trauma support after such a tragedy. Many workplaces, if they provide grief support at all, do not usually take into account the complexities or duration often needed to cope in the aftermath of suicide.

“Postvention” is psychological first aid after a suicide crisis. In the workplace, like many other systems in communities, this response is about both providing hope and community and mitigating the impact of suicide grief and trauma. For this article, 13 people were interviewed about how their employers handled their suicide loss experiences. Here is a case study to demonstrate what happens when postvention is inadequate.

Case Study

Going through the motions – when suicide postvention is superficial  

A federal agency of almost 1,000 people experienced a suicide of a high-level, well-liked, well-known and visible leader. Close to the time of his death, he was seen escorted out of the building among gossip of scandal and failed management. In the absence of information from the executive staff, speculation about contributing factors ensued, and rumors ran rampant. Employees looked to senior management to provide direction during the crisis; the leaders appeared guarded and unwilling to talk about the fact that it was a suicide. In the days that followed, the response seemed like “giving lip service” to the confused and grieving employees. As one said, “We went through the motions but didn’t do the work. People didn’t want to face the fact that a suicide could happen. Shame prevented us from talking about it at all.” The organization attempted to move back to business-as-usual quickly. No plan was created on how to manage roles the deceased person played; the vacuum created led to more speculation, distrust, anger and a lack of closure. 

Trauma and Grief after Suicide at Work

Given that the majority of people who die by suicide are working-age adults, most of whom are employed, hundreds of thousands of workplaces around the globe are affected by the suicide death of an employee each year (World Health Organization, 2014; Lytle, 2015; Milner et al, 2014; Paul & Spencer-Thomas, 2012; Spencer-Thomas, 2012). Furthermore, knowing that job loss can be a contributing factor, suicide deaths of recently terminated employees can still have a profound effect on their previous places of employment (Milner et al, 2014; Spencer-Thomas, 2014). When leaders within an organization take their lives, the chaos and trauma resulting from this loss can be immense (Spencer-Thomas, 2011). In addition, suicide deaths of family members of employees, vendors, clients and associates all can take a toll on employees; the number of workplaces affected is very high. Suicide grief support in the workplace often involves two scenarios: suicide of a work colleague or a suicide death outside the work environment.  

Unfortunately, most workplaces do not anticipate needing to respond to suicide. Many find themselves reacting in crisis mode, often making decisions that do more harm than good. Models and protocols of how to understand grief, trauma and the impact of exposure to suicide are integral to understanding the way workplaces respond to suicide death. This article creates a framework for understanding and providing effective suicide postvention, provides insight into the way that grief and loss affect workplaces and offers concrete strategies for an effective postvention response at work. [For a full chapter on this topic, please read Spencer-Thomas, S. & Stohlmann-Rainey, J. (2017). Workplaces and the aftermath of suicide. In Andriessen, K., Krysinska, K. & Grad, O. (Eds). Postvention in Action. Hogrefe: Boston, MA.]

See also: 15 Top Apps for Mental Health  

Trauma reactions and grief are often at odds with each other. According to the American Psychological Association, “trauma is an emotional response to a terrible event…. Immediately after the event, shock and denial are typical. Longer-term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea.” (APA, n.d.). On one hand, the trauma can often result in survivors of loss constantly replaying the events surrounding the suicide in their minds. That is, survivors of suicide loss can’t stop thinking about the death scene (even when they are dreaming), and disturbing images may flash before the mind’s eye when they least expect it. The horror can be overwhelming, and the natural impulse is to stay away from anything that reminds them of the trauma. Sometimes, survivors of suicide loss develop post-traumatic stress disorder (PTSD) in the aftermath of a violent or unexpected death (Young, et al, 2012).  

By contrast, the grief journey for survivors of suicide loss is often a “moving toward” experience. As they come to accept the reality of the loss, the tendency is to move toward things that remind them of the deceased, holding close memories, places and mementos that help preserve and honor the life lived. Thus, for coworkers left behind there is often simultaneously a desire to mourn and openly embrace the memory of the deceased and a desire to suppress the thoughts about the deceased because they are too disturbing, such as the often horrifying notion that someone they cared about died in isolation and despair, often in a violent manner.

Organizations are often ill-equipped and ill-informed to handle grieving employees; this is particularly true for the suicide-bereaved, who experience the double silencing of workplaces ill-equipped to cope with grieving employees and stigma related to the type of loss. 

One of the people interviewed for this article was a mother whose son died by suicide the day after he was discharged from his military service. She shared, “I had only been at my present position for 90 days, my probation period. I was given some money, they had collected. Other than that, nothing. I was hurting very much. When the holidays came, I put a candy cane and a note asking for prayers in everyone’s mailbox. Nothing. No words, no notes, no nothing. One day I was walking down some steps, and I just wanted to let go of the railing [and fall to my death]. I talked to my supervisor and asked if I could just come in a little later on the Saturday mornings. I said I would stay late and be the last one to leave. She said to me, ‘I thought you were already over that.’ I wanted to ask her which one of her three sons she would ‘be over’ in less than two years.”

Sometimes, bereaved employees believe they can return to their previous level of functioning at work and do not want to take time off because work provides structure, social support and a sense of purpose. Thoughtful employers help their grieving staff members find creative ways to balance these competing demands. One interviewee who was a teacher at the time of her teenage daughter’s suicide shared, “The principal called me into his office [the day after the suicide]. The two assistant principals glared at me as I walked in. The principal told me that they did not want me to come to school the next day or when school began. I was very insulted. I argued and told them that I had shown up every day, I had done my job and I needed to be in the classroom for the children. They just listened stone-faced. Finally, one of the assistance principals told me that no one could bear to look at me because the pain in my face and eyes was so terrible. That shocked me. I had no idea that my grief showed. (I guess I had not really looked in the mirror). So then I gave in, and I told them I would stay home for one week. They assured me they would get a professional retired teacher for my class and to stay home as long as I needed. I assured them I would be back in one week. I left school then and drove home very upset. After I got home, though, I suddenly felt a great relief, and I ended up staying home for seven weeks. It turned out that they knew best after all. After I returned to work, there were days I could not make it, so I called in sick. They never complained about me staying home too much. There were a few times I’d look at a little girl in class who reminded me of [my daughter], and I’d break down. If I sent word to the office, they immediately sent a substitute teacher down so I could go home.” 

Another interviewee shared how his son’s suicide affected his work performance, “I returned to work one week after [my son’s suicide]. I was under the illusion that I could suppress my pain and go on with my life as if nothing happened. The day I was placed on involuntary leave, I was facilitating a class of about 100 people. Someone interrupted me with an off-topic question. Rather than gently deflect and move on, I went into an uncontrollable rage, comparing that person’s inane question to my pain over my son’s suicide. I was replaced in the classroom immediately. When I went to the corporate offices, they acknowledged my loss; however I was told to take a month off and see if I could return to full performance. Oddly, now that I’ve ‘cleaned up my act,’ there is a bit of empathy from management.”

Because grieving will happen in the workplace, it is important that the culture in the workplace is supportive of reintegrating bereaved people with compassion and flexibility. In the case of an employee who is bereaved by suicide, all of the same recommendations apply. One of the major pitfalls in organizations is to treat an employee bereaved by suicide differently from other bereaved employees. For example, when an employee dies from cancer, a workplace’s common practice may be to circulate a sympathy card and attend the memorial service, but, when someone dies by suicide, the grief support is often neglected. Consequently, the person bereaved by suicide who would likely need additional support coping with grief, trauma, guilt and shame that may accompany this taboo form of loss will actually get less support.

NAMI New Hampshire (2006), a U.S. leader in suicide postvention indicates that although suicide postvention includes principles of critical incident response and stress debriefing, it has a larger scope with a narrower focus. While critical incident response and critical incident stress debriefing is designed to support workplaces in managing the crisis phase of a workplace incident, suicide postvention is a long-term strategy that addresses the needs of the workplace as a system. Elaine DeMello of NAMI New Hampshire shared (personal communication August 15, 2015) after responding to many workplace postvention cases, “[Because of the intensity, complexity and duration of the grief and trauma reactions] loss survivors are at risk for losing job; what helps is an advocate or conduit who can pave the way for the person to come back to work.”

Tensions in Postvention in the Workplace

The goals of suicide postvention in the workplace is really not that different than other crisis responses (Carson J Spencer Foundation et al, 2013), i.e., to support people through the trauma and help restore functioning to a disrupted system (Suicide Prevention Resource Center, 2010). The process is about managing the inherent balance of needs and safety components that can sometimes be at odd with one another. On one hand, workplaces acknowledge something really significant happened, while on the other hand leaders are pressured to get back to business as usual. On one hand, grieving employees need to share stories to grieve and honor a life that was lived, while on the other hand workplaces practice safe messaging seek to minimize glorification of the deceased and the divulgence of too many details about the death. On one hand, employees need information that is quick and accurate, while, on the other hand, privacy and investigation concerns can slow the process.

A complicating issue for workplace suicide postvention is that getting fired, laid off, humiliated or disciplined at work can be a precipitating event for some suicidal employees. When this occurs, residual bitterness, anger and mistrust for leadership can have a profound effect on the intensity and duration of the employee’s response. 

One interviewee shared this story, “My husband, an employee for 18 years, and supervisor for the last 15, was let go from his position the day before he died by suicide. While this was the third suicide with the company, there was no crisis plan in place. Employees were notified when his death was posted on the lunchroom TV. Management chose not to attend the visitations or funeral to ‘keep the peace,’ but quite frankly I would have preferred to see them there. There was a lot of hostility because he was let go from his position as a supervisor, and, when word of his death got out, there was more hostility from the people who worked with him in the plant. Management let the dust settle over time with no comments.”

Few workplaces plan for a suicide by having access to a postvention guide like the Manager’s Guide to Suicide Postvention, because too often the daunting nature of suicide throws people into reactive or avoidance mode. As a first step, managers benefit from reflecting on the question, “What do you usually do when there has been a trauma or death in this workplace?” Usually, there are already cultural norms and policies in place to address grief and trauma, and any deviation from this cultural standard is likely to cause confusion and additional hardship.

Case Study

When an Employee Loses a Family Member to Suicide

“I am a pharmacist at a grocery store and had been there eight years when my teenage son died by suicide. I knew all my customers by name, and many of them knew my son. When word reached the store, my store manager called everyone together to break the news. With tears streaming down his face, he explained that my son was dead. Work was suspended, people were allowed to go home or take the time they needed to pull themselves together. For a grocery store, this is huge, as we are all about customer service in a community where the competition is fierce. By the afternoon, I had cards, a gift basket and messages from so many of my workplace family. Many of the staff were able to take the day off to attend my son’s memorial, and the store was generous in their contributions. Since my return to work, I have been given free rein to cry when I need to, hug when I need to and talk with others when I need to. My store management and fellow staff continue to be a source of support and comfort.

The Suicide Postvention Process

Postvention is psychological first aid, crisis intervention and other support offered after a suicide to affected individuals or the workplace as a whole to alleviate possible negative effects of the event (Smith, Romero, & Cimini, 2010). In the center of the response are often managers who are guiding bereavement support, trauma reactions and a transition back to work. Effective managers in these circumstances communicate empathy and respect and offer permission for people to take care of themselves. They offer a range of support options and know not everyone will need the same types of resources in the same timeframe. Many managers find themselves in the middle of complex and competing factors. Just like other employees, leaders are often affected by the tragic loss and in need of support, but sometimes become targets of anger and blame by other employees. Leaders may feel overwhelmed and immobilized by the shock, and yet they are charged with returning the workplace to health and productivity. 

“A Manager’s Guide to Suicide Postvention in the Workplace: 10 Action Steps for Dealing with the Aftermath of Suicide” organizes recommendations to guide employers in the immediate aftermath of a suicide death, in the short-term, and in the long-term, sometimes over months and years. The duration of these recommendations was intentional because, in many workplaces, immediate needs may be considered, but, often within just a couple of weeks, bereavement support drops off. For example, one of the interviewees for this article reported, “… there was no ‘return to work plan’ that I know of…The employee assistance program I found worthless. I contacted them one evening very stressed and received a lukewarm response. There has been no follow-up contact from them at all to see how, or if, I am managing.”

Immediate: Acute phase

  • Coordinate: Having the right point person coordinating the efforts around suicide postvention. This person should be decisive and compassionate, knowledgeable about crisis response and suicide grief and able to juggle many high-stress demands at once.
  • Notify: Communication after a suicide is difficult. On one hand, those left behind have a strong desire for facts, so quick and accurate communication regarding, “here is what we know, here is what we don’t know and here is what is going to happen moving forward,” can do much to quell anxiety and damaging speculation. On the other hand, workplaces must be mindful to protect and respect the privacy rights of the deceased employee and the loved ones during death notification.
  • Communicate: As communication regarding the suicide is disseminated, spokespeople should be mindful of the safe and effective messaging guidelines (National Action Alliance for Suicide Prevention, n.d.) to reduce the risk that people who are already vulnerable to suicide might become more at risk for suicide contagion.
  • Support: In the immediate aftermath, most people do not benefit from counseling in its traditional format. Instead, what is often needed more is practical assistance. Many grieving families can benefit from the practical support of transportation, food and everyday life tasks.

Short-term: Recovery phase

  • Link: After the initial intensity of the crisis has passed, a smaller group of affected individuals usually surfaces. Workplace managers need strategies to identify and link these employees to additional support resources and refer those most affected to professional mental health services.
  • Comfort: Usually, what most people need during the short-term phase of suicide postvention is support, comfort and an environment that promotes healthy grieving. This can be done within the workplace through professionally facilitated debriefing sessions, or managers can find community resources for employees in the form of suicide grief counselors or suicide loss peer support groups.
  • Restore: While providing support, managers also must restore equilibrium and optimal functioning in the workplace. Returning to the familiar schedule can be healing for some, but the timing needs to be sensitive to individuals who may not have the capacity to perform their jobs at the levels they did before the tragedy.
  • Lead: Leadership messaging is critical during both the immediate and short-term phases of suicide postvention at work. Effective leaders build and sustain trust and confidence in organizational leadership by acknowledging the impact of suicide – on the company, and on them personally, by offering compassion to employees and by helping the team move from an immobilization state to a state that returns to or even supersedes previous levels of functioning. Effective leaders are “visible, vocal and visionary” during this time and are able to successfully pull people together to draw upon the collective resilience of the work team culture (Spencer-Thomas, 2014).

Workplace postvention practices should also take into account the fact that leaders need support, too. One interviewee who worked at a large school where there were multiple suicide losses reported, “The top leadership went from being ‘Principal of the Year’ to not coming to work because of trauma and depressed [after the cluster of suicides]. She was not able to get out of bed and go to work. Our crisis team leader couldn’t quit crying and was told, ‘If you can’t get yourself together, we’re going to have to reassign you.’”

See also: Top 10 Ways to Nurture Mental Health  

Longer-term: Reconstructing phase

  • Honor: With many deaths, the honoring rituals that usually happen at the funeral or memorial service help provide structure as people mourn. For suicide, this intense period of grief and trauma is often protracted (Jordan & McIntosh, 2010), and workplaces are advised to prepare for anniversary reactions and other milestone dates. For example, milestone dates might include when a work team completes a major project in which the deceased played a role. Again, this level of response may be just for a handful of employees most affected, but managers are better off preparing for these days than reacting without a plan. Honoring practices for suicide loss are best if they are integrated into the company’s overall grief practices. One interviewee shared how this experience was successful in bringing together family members and employees most affected by a suicide death of a long-term employee: “While she was working for this company, she had started a plant exchange. On her birthday they dedicated a memorial garden and built a beautiful deck for all employees who had died. Her plaque added to others who had died at this company. The family was invited, and together with the employees they shared memories and the importance of workplace friendships at the dedication service. The project gave employees a sense that they could do something. The process helped turn a negative into a positive event. Now, every year the workplace conducts a butterfly release in September. The company president says a few words for people (employees and family members) who we have lost. New butterfly bushes are planted to attract new butterflies in honor of those who have died.” A large mental health provider in Canada reported on an annual “Celebration of Life” ritual to honor the grief process of clinicians whose clients had died – from all causes — over the previous year, “We celebrate the life that was lived and the work we provided to help them. We walk along individuals in their journey, practice rituals of remembrance, sing inspirational songs and pray together.”
  • Sustain:  Finally, managers are charged with providing guidance in moving the workforce from a postvention state to suicide prevention. Sometimes, in an acute grief reaction, employees might want to put together an awareness event or start a suicide prevention training. Thoughtful managers navigate this need to “do something” with encouragement to create space to move through the oscillating experiences of grief. When an appropriate time has past, and the workforce is less reactive and more reflective, managers can help them build a comprehensive and sustained strategy to make suicide prevention a health and safety priority.

Case Study

When Postvention in the Workplace Works

In contrast to the opening story of a leadership response of “shutting down,” in the aftermath of a leader’s suicide, the following story of an insurance company of over 50,000 employees demonstrated a far more compassionate response. 

Like in the opening example, the suicide death was of a senior-level manager – a man running a 500-700-person division of company. In the weeks leading up to his death, he became distraught and reclusive. “Leaders didn’t say much, but they lived every word,” one employee said. “Their response was value-driven, not just checking a box.” Immediately after the death, executives pulled together all of the managers and briefed them on concrete information about what happened and said that the first priority in the aftermath was to insure the health of all staff. They then assigned Employee Assistance Program staff to specific managers to support all managers and make sure they had what they needed to follow up to provide resources to the employees. The leaders communicated through a press release that was straightforward and honoring of the man who died, using words like “long and distinguished career” and “provided excellent service to customers.” “They didn’t glorify suicide, but they didn’t diminish person,” one employee recalled. “This organization was a family, and we became closer through this experience. It was a teachable moment on how we support one another.”

Conclusion

Workplaces are often not well-prepared to respond with a compassionate, long-term strategy of grief and trauma support to employees and surviving family members in the aftermath of a suicide affecting the workforce. New practices and policies are needed to give employers a better plan so the survivors of loss can better manage the oscillating grief and restoration processes that are frequently disruptive to work performance demands and overall health.

15 Keys to Mental Health Safety Net

Acknowledgment: Thank you, Dr. Jodi Frey and Jon Kinning, for assisting in the preparation of this article.

The employee assistance program (EAP) might be one of the best-kept secrets for many employers. Instead, EAPs should be resources widely publicized to help encourage managers, employees and often their family members so that support services for personal and workplace problems can mitigate risk and promote vibrant workers. Many employers simply “check the box” when signing up for the EAP benefit, figuring health insurance will cover the mental health needs of their employees; however, most employers really don’t know what the EAP services entail or the value the services can bring to a workplace.

With that said, not all EAPs are created equal. EAP services vary greatly, including some or all of the following::

  • biospsychosocial assessments, including substance use assessments
  • individual and family counseling
  • financial and legal coaching and referrals for counseling
  • referrals for additional services, with follow-up
  • psychoeducation through workshops, newsletters and other communication for personal and workplace concerns, including stress management, parenting, mental health literacy, relationships and organizational change and individual crisis prevention, crisis response and support
  • mediation and team development
  • leadership consultation, coaching and development
  • fitness for duty evaluations
  • suicide risk assessment, treatment and “postvention” (i.e. what to do after a suicide)
  • staff training on best practices on how to support someone in distress
  • and more

Sometimes, the services are cursory, such as a brief telephone assessment and referral by a contracted outside provider. Other EAPs provide robust and high-touch services like 24-hour support; on-line assessment and information; telephone and in-person assessment and counseling; on-demand crisis consultation; on-site workshops; mental wellness promotion; and much more. As with many things, you get what you pay for, so employers need to decide how much they are willing to invest in the mental wellbeing of their workers and conduct a cost-benefit analysis. However, EAPs, even more customized programs with onsite services, have been shown to be cost-effective to employers through the years.

Are EAPs Effective?

While the research on the effectiveness of EAPs is limited, studies have found that employees’ use of EAPs enhanced outcomes, especially in “presenteeism” (how healthy and productive employees are), life satisfaction, functioning and often absenteeism (Joseph, et al., 2017; Frey, Pompe, Sharar, Imboden, & Bloom 2018; Attridge et al., 2018; Richmond, et al., 2017). In one longitudinal, controlled study, EAP participants were more likely than non-EAP participants to see a reduction in anxiety and depression (Richmond, et al, 2016). Another matched control study found that users of EAP services often reduced their absenteeism more quickly than non-EAP users experiencing similar challenges (Nunes, 2018). In another longitudinal study (Nakao, et al, 2007), 86% of people who were suicidal when they engaged with their EAP were no longer suicidal at two years follow-up. Researchers have concluded that, while not all EAPs are created equal, they often provide accessible services that are effective at improving employee mental health and well-being.

See also: Impact on Mental Health in Work Comp  

Are EAPs Prepared to Support an Employer Facing an Employee Crisis With Suicide?

When it comes to the life-and-death issue of suicide, EAPs have the potential to provide evidence-based suicide prevention, intervention and postvention services to employers. The EAPs’ contribution to the comprehensive workplace suicide prevention strategy is essential, and many would benefit from annual state-of-the-art training in evidence-based methods of suicide risk formulation and treatment to help distressed employees get back on their feet. Social workers, who provide the majority of EAP clinical services in the U.S., often report having no formal training in suicide formulation, response and recovery (Feldman & Freedenthal, 2006; Jacobson et al., 2004), so annual continuing education on suicide intervention and suicide grief support is often helpful to providers. Once trustworthy and credentialed providers have been identified, they should be highlighted in the “suicide crisis” protocol, so that companies are not trying to do this leg work in the midst of a crisis.

If one of the main messages in suicide prevention is “seek help,” we need to make sure the providers are confident and competent with best practices approaches to alleviating suicidal despair and getting people back on track to a life worth living. Thus, dedicated employers will evaluate and even challenge their EAP providers to demonstrate continuing education in the areas of suicide prevention, intervention and postvention skills. In fact, some states are mandating that all mental health professionals, including licensed providers of EAP services, have some sort of continuing training in suicide risk formulation and recovery.

Do Employees Know About the Benefit of Their EAP?

In addition to making sure the providers have the needed skills, companies need to make sure that their employees know when and how to access the care. Recently, the American Heart Association and CEO Roundtable worked with experts in the behavioral health field to develop a white paper for employers, which includes seven specific actions employers can take to improve the mental health of their employees (Center for Workplace Health, American Heart Association, 2019). The report can be viewed online here. Dr. Jodi Frey, expert panelist for the report and internationally recognized expert in the EAP and broader behavioral health field recommends that “employers need carefully consider their workplace’s needs when selecting an EAP, and then should work with their EAP as a strategic partner to develop programs and communications that encourage utilization of the program and continued evaluation to improve services over time.” (Dr. Jodi Frey, personal communication, March 18, 2019).

Employers that are mindful of their workers’ well-being will continually promote well-vetted and employee-backed resources throughout the career of the workers. Leadership testimonials of the efficacy of the resources after the leaders have used them for their own mental health would bring credibility to the resources and model appropriate self-care to the employees. Bringing the resources on-site to the workers (and not waiting until the workers stumble upon the resources) is another way to break through the barriers to care. The Employee Assistance Society for North American (EASNA) developed a guide to help employers evaluate EAPs and determine appropriate vendors. The guide also can be used to help employers evaluate their current EAP and decide if needs are being met or if more attention to what services should be offered needs to be addressed. The guide can be downloaded free.

Are There Different Types of EAPs?

Much diversity exists in EAP structure and quality (Frey, et al, 2018). Some companies use internal EAPs, where providers are also employees of the company. This arrangement often provides the benefit of having an immediate resource that has clear knowledge of the company and industry culture. Evaluation of internal EAPs has found increased utilization, customization and supervisor referrals (Frey, et al, 2018); however, there are some drawbacks. Internal EAPs, because they are so closely connected to the company, run the risk of being perceived as having blurred lines of confidentiality and objectivity. By contrast, external EAPs are often more diverse and can respond 24/7 across a vast geography. Because of these benefits and consequences, many companies have moved to a hybrid model to get the best of both models.

Hybrid EAPs often have an internal employee to manage the EAP and to work with managers and employees on critical incident response, strategic planning and organizational change, and to provide onsite assessment and problem resolution. They can be an important ally for the employer to understand the potential for an EAP and to help evaluate whether EAP providers are effective in their response and offering high-quality services (Frey, 2017).

See also: What if They Say ‘Yes’ to Suicide Question?  

EAPs are most effective when they understand the industry and organizational culture, have business acumen and can adapt to changes in organizational structure (Frey, et al., 2017; Frey, et al., 2018). Thus, employers seeking to find a best fit for their employees will interview mental health providers about their knowledge of the unique stressors and strengths in the industry. Some industries (e.g., emergency responders and aviation) have gone so far as to credential mental health providers as being specialists in their industry to avoid a mismatch.

Case Study From the COO of a Construction Contractor

“We had an issue where our EAP was referring counselors outside of our healthcare providers, so, after the three free sessions, the participant learned they could only continue with the suggested provider at $150 a session; so the employees would drop out. My understanding is that counseling often takes around seven sessions to have a sustained impact, so, I put in a mandate with our HR team to renegotiate our EAP to ONLY refer in-network counselors, or they would pay for the continued care.

“We then incorporated our EAP into our safety program. When there is a serious accident, we deploy counselors and have our EAP involved for post-accident assistance to our employees. Accidents can bring up traumatic responses from our employees, and these experiences bring up memories from other accidents they may have been involved in or around. This cumulation of trauma can be highly distressing for them.

“In the early years, we had to work through the skepticism that the EAP would notify management of anyone that used the service. Since HIPAA came into play, we have less of this skepticism. The employees thought they would get fired or laid off first if they had issues.

“I’ve worked with our safety and wellness groups to actually pick up and call the EAP for someone in distress and get them on the phone. Once they lay the groundwork with the counselor, they hand the phone over and leave and let the employee get the help they need. This helps break down the stigma, and some people just don’t have the courage or have a mental block about picking up the phone for help. This has been VERY effective to get those in need the help they need.

“We promote our EAP in our weekly newsletter, and we also have business cards with the information, and we utilize hard-hat stickers that have all the information. This helps it be available when they need it.

“I’ve also encouraged our managers to use the system so they can promote it from their point of view. This also has helped remove the stigma around using the EAP. I also talk when in front of our employees about the program and educate them so they will use it. Our utilization rate is the highest in our EAP network, and I think this is the reason why.”

15 Questions Workplaces Should Ask to Strengthen the Mental Health Safety Net

Employers should remember they are the customers of their EAP, and they should do the due diligence to make sure they are getting the best benefit possible. Here are 15 questions employers should ask their EAP to get the best services possible:

  1. What services does your EAP cover? Are these services available 24/7?
  2. Who answers the calls of the EAP, and how are they trained and supervised? What professional and educational preparation and certifications do they have? Are they licensed?
  3. How are counselors selected and trained? Are certain licenses and other credentials required to be a part of the EAP provider network?
  4. What types of training have EAP providers received? Specifically, when was the last time they received training in suicide risk formulation and treatment?
  5. How is your EAP reporting utilization? How does your workplace’s utilization rate compare with others in your industry and what can be done by the EAP and by you as the employer to encourage more utilization?
  6. Do your employees know about your EAP services and how to access them?
  7. For those who have used the EAP, how satisfied were they with the services? Did the services help with the problem for which they were seeking support?
  8. When employees completed EAP services, did the EAP follow up (or attempt to follow up) with the employee to make sure all needs were met?
  9. How does your EAP interact with health plans? Are EAP providers also providers of outpatient mental health, and, if not, are they well-versed in the benefits of employees to make effective and seamless referrals?
  10. How is your EAP measuring outcomes? Can they also provide you with a return-on-investment (ROI) or other cost-benefit analysis?
  11. How is the EAP promoting upstream mental health efforts like prevention, resilience, positive psychology and work-life integration?
  12. Are there general mental health screening or other wellness tools the EAP can offer the workers to help them understand and monitor their mental wellness? Does the organization also assess its own culture of system-level mental wellness?
  13. Does the EAP have experience serving clients in our industry? If yes, what are some recommendations to improve how EAP services are promoted and offered at our workplace?
  14. Is the employer receiving regular reports (i.e., bi-annual, annual) from the EAP on utilization, presenting problems, satisfaction and other workplace outcomes?
  15. Does the EAP provide manager or HR training on how best to support an employee experiencing a mental health or suicide crisis? Are there additional staff training on skills needed to identify and assist employees in distress?

What if They Say ‘Yes’ to Suicide Question?

What if you ask someone if they are thinking about suicide, and they say, “yes”? What do you say? Here are four responses that can make a difference.

  • Express gratitude

The first words out of your mouth: “Thank you.”

“Thank you for trusting me.”

“Thank you for your courage to be vulnerable with me.”

“Thank you for valuing our relationship.”

Often, when people express daunting thoughts about suicide, they expect to be judged. They anticipate that others will react in negative ways such as fear, anger, minimizing or shaming. When they hear a genuine expression of gratitude, often they are put at ease. This honoring response creates a safe space to move into next steps. Starting here is starting from a place of dignity and respect.

  • Reassure with partnership

Second words to share: “I am here for you.”

“I will stay with you as we figure this out together.”

“I am on your team. You are not alone.”

“I will persist with you until we have a viable plan to get you the support you deserve.”

“I’ve got your back.”

“It’s my honor to be here for you. I know you’d do the same for me.”

“I don’t know exactly what you are going through, but maybe I have had some similar experiences. My heart is with you. Let’s figure this out together.”

Because rejection and discrimination are real outcomes for people living with mental health conditions and suicidal thoughts, reassurance can be very grounding. Too often after disclosure, people who are suicidal experience the “hot potato effect.” Well-meaning people (and this includes many therapists) get scared, so they bounce people to someone else, who then does the same. Each time the person in despair is passed along to someone new to “help,” they must start over, telling their painful story, recounting symptoms and so on. All the time, no one is actually helping them solve problems and recover. The hot potato effect is demoralizing and often feeds into a narrative of “I am worthless and unlovable” or “no one can help me.” Bouncing people around worsens the suicidal crisis rather than helps resolve it.

Working in partnership lets people know they have an advocate, someone who is in their corner. Another way to express this part is the idea of reciprocity. “I am helping you just as you would help me.” This statement lets the person know he or she is not a burden, but that this is just what friends and family do for one another out of love.

Finally, this step emphasizes the importance of an empathic connection. You must reach inside your own memories of experiences and tap into something you have gone through that may give you insight into the other person’s current emotional state. By doing this, you will be more likely to respond as you would want to be treated.

See also: Suicide and the Perspective of Truth  

  • Offer hope

Hope is the antidote to suicide. The most effective way to offer hope is through action.

“If you were less miserable, you would probably be less suicidal, yes? I have some ideas to help you alleviate your suffering.”

“I know some resources that might help.”

“Let’s call the National Suicide Prevention Lifeline (or let’s text the Crisis Textline) together, so they can help us make a plan to keep you safe for now.”

“This is important. Let’s talk through some ways to help you cope. I know of an app (My3App.org) that can guide us.”

With compassion and collaboration, you can help the person consider options for developing a personal plan for healing. Offering hope is NOT about championing change (e.g., “You better see a doctor!”) or proposing reasons for living (e.g., “But you have so much to live for!”). Offering hope is about helping a person craft his or her own plan for safety and wellness by providing possibilities to help the person figure out what is best for him or her.

Building in choice and empowerment is key in this step. Offer options at every turn (e.g., “We can take a walk and talk about this or go to the coffee shop.”). Have the person identify coping strategies and wellness tactics and write them out in his or her own handwriting. Say, “You are the expert in your own resilience. Let’s write down what has worked for you in the past.”

Let the person know that you would like to be considered part of the safety net, and for you to be effective in that role, you would like help, too. Say, “If it’s okay with you, I’d like to go with you to your first appointment, so I can also get coaching on how best to support you.”

Other resources to engage in this step might include your local mental health center, employee assistance programs or HelpPro.com’s suicide prevention therapist finder resource.

Suggest that you call or meet with these resources together, at least as a first step.

While you don’t want to inject your own ideas for the person’s reasons for living, you may listen to and reflect back the reasons for living you hear the person say. For example, you can say something like, “On one hand, I hear you say you feel so overwhelmed, you don’t know if you can go on. On the other hand, I am hopeful when I hear you say things like you want to be a good role model for your kids. The way you say that it sounds like a part of you is fighting against this despair.”

Another way to offer hope is to hold it for them. You can say something like, “What you are telling me is that you feel hopeless. I, however, see positive things in you and your future. I know you can’t feel this, but I can. I will hold on to your hope until you can feel it again.”

See also: New Approach to Mental Health  

  • Follow up

Before ending the conversation, make a plan to reconnect.

“I will send you a note tomorrow to see if things are moving along.”

“Let’s schedule a coffee for next week, so you can update me on whether or not the plan is working for you.”

“I will call you by Friday to see how that therapy appointment worked out. Sometimes, things don’t seem like the best fit on the first pass, so, if that is the case, we can try again.”

“You matter to me, so I’m going to let you know when I am thinking of you.”

“I am feeling good about the steps you are taking to get back on track. I will reach out from time to time, and I’d love to hear about your success and any challenges you are experiencing.”

It turns out following up is one of the most effective ways to prevent suicide. Sometimes these communications can be “checking in” to see if the person has hit a roadblock. Other times “non-demand caring contacts” are all that is needed.

What are non-demand caring contacts? Just what they sound like. No asks. No telling what to do. Just “I’m thinking of you” messages. They could come in the form of pictures, “what I appreciate about you” thoughts or even funny cat videos.

By following up, you are letting the person know he or she is not a hot potato, but that you are there standing shoulder to shoulder, walking with the person out of the darkness together.

When someone discloses thoughts of suicide, treat it as a gift. The person has invited you in to a vulnerable part of their world, and you are a guest in this space. While it can be very scary to hear that your loved one is in such a desperately painful situation, your presence can make a huge difference in their recovery. So, when the person says “yes” to the suicide question, take a deep breath and follow these steps. You might just be the one to help the person save his or her life.

15 Top Apps for Mental Health

For many people, apps are a part of our everyday living – from Uber, to conference schedules, to how we find our restaurants. They can also be part of our resilience toolkit.

When we consider a comprehensive strategy to suicide prevention and mental health promotion, it’s helpful to segment approaches into “upstream” (preventing problems before they emerge through self-help), “midstream” (catching emerging problems early and linking people to least restrictive support) and “downstream” (helping people with more serious mental health challenges and suicidal thoughts) tactics.

Thus, for this article, I have organized some of the most popular, best-researched and most innovative apps into these three categories.

Upstream: Resilience Self-Help Apps

  • Positive Activity Jackpot

Developed by t2health, this app uses the phone’s GPS system to find nearby enjoyable distractions. It comes with a clinician’s guide:

  • Calm

Calm is designed for people new to meditation – starting with guided practices from three to 25 minutes in length and focused on a variety of topics from sleep to gratitude.

  • Breathe to Relax

Another t2health app, Breathe2Relax, offers portable stress management focused on diaphragmatic breathing skill-building that helps with anger management, mood stabilization and anxiety reduction.

  • MoodKit

Based in cognitive behavioral therapy, MoodKit helps people improve their mood by engaging them in over 200 mood-enhancement activities like thought checking and journaling.

  • Pacifica

Pacifica is designed to help people who live with anxiety through soothing meditation and other personalized self-help strategies. Check out the science behind this strategy.

See also: Impact on Mental Health in Work Comp  

Midstream: Early Detection and Peer Support/Life Coach Apps

  • Life Armor

Another t2health app, this brief assessment tool helps users manage emerging symptoms like depression, sleep deprivation and post-traumatic stress. Videos share personal stories from warriors and military family members.

  • DBT Diary Card and Skills Coach

Through this app, users can master the skills of dialectical behavior therapy (DBT), known for its effectiveness in regulating emotions and interpersonal relationships. Users remind themselves of skills they are trying to develop and track skill use.

  • TalkLife

Developed by folks at Harvard and MIT, TalkLife is a peer support platform that engages an online community when people just need someone who’s willing to listen. Posting can be done anonymously. Here is some research behind TalkLife.

  • Koko

Also developed by researchers at MIT, this app provides help for people in all states of distress from bullying and harassment, or even thoughts of suicide and self-harm. Koko provides evidence-based supportive interactions with users while referring users in crisis to international lifelines for immediate help.

  • Lantern

Lantern is a subscription service offering daily on-one-one coaching sessions and simple exercises combining cognitive behavioral therapy (CBT) and advice from real “professional coaches” trained in CBT. Recommended plans are personalized based on the user’s initial self-assessment.

See also: Top 10 Ways to Nurture Mental Health  

Downstream: On-Line Mental Health Services and Suicide Prevention Apps

  • Virtual Hope Box

The original non-app version of the Hope Box was developed as a tool to help therapists in clinical practice work with their suicidal clients so they can find reasons for living. Clients would find something like a shoe box and fill it with future goals, pictures of loved ones, bucket list experiences and the like. When clients felt their suicidal intensity increase, they would bring out the box to remind themselves of these things.

The Virtual Hope Box (VHB) does this and more. Still designed as something to augment treatment, the VHB helps people live through painful emotional experiences through distraction, inspiration, relaxation, coping, support and reasons for living.

  • BetterHelp

BetterHelp is a monthly subscription on-line counseling app that matches people with licensed mental health professionals and gives them unlimited access to these therapists.

  • My3App

My3app is a safety plan tool that helps people who are at high risk for suicide. It helps people develop a written list of coping strategies and sources of support. This app is based on content developed by B. Stanley & G. Brown (2008) and the Department of Veterans Affairs and is owned and maintained by Link2HealthSolutions, the administrator of the National Suicide Prevention Lifeline created in partnership with the California Mental Health Services Authority and was funded by the California Mental Health Services Act.

  • MyVAApps — Safety Plan for Veterans

Part of the MyVAApps suite of apps, the Safety Plan app helps users create or co-create with their therapist a safety plan that outlines specific steps to take when they face crises, including connecting to Veterans Crisis Line.

  • SAMHSA — Suicide Safe

This app is designed to help healthcare providers reduce patient suicide risk and is based on the SAFE-T Approach.

I am interested to hear about your experiences with these apps! What else have you used? What do you find to be most helpful in managing your resilience, mental health and emotional crises?