Preventing Suicide in the Workplace: New Guidelines, Recommendations Issued

By Jodi Frey, PhD, LCSW-C, CEAP; Sally Spencer-Thomas, PsyD; & Amanda Mosby, MA

With over 47,000 suicide deaths in the U.S. last year, suicide has become a major public health crisis. This deadly trend has significant implications for the workplace and EAPs as pressure mounts on employee assistance (EA) and other behavioral health professionals to take a more active role in suicide prevention.

Incorporating Suicide Prevention Strategies in the Workplace
As EA professionals, we are in prime positions to help workplace leaders develop strategies to prevent suicide, while also working one-on-one with employees to help them through a potential suicide crisis.

The authors of this article have been working to develop and issue the first “National Guidelines for Workplace Suicide Prevention”, which were released during September 2019 – Suicide Prevention Month. The guidelines are supported by three leading suicide prevention organizations including the American Foundation for Suicide Prevention, the United Suicide Survivors International, and the American Association of Suicidology.

They are research based, incorporating recommendations and feedback from hundreds of stakeholders, including many leading EAPs and professional organizations like the Employee Assistance Professionals Association (EAPA). They also outline actionable steps that EAPs and workplaces can take to improve suicide prevention programming in their work organization and/or professional organization.

As a first step, the authors encourage EAPs to work with workplace leaders to publicly take the pledge to make suicide prevention a health and safety priority. Click here to read how to take the pledge.

Cultivating a Caring Culture
One of the key strategies from the guidelines is for managers to “cultivate a caring culture focused on community well-being.” EAPs, especially programs that are strategically positioned within work organizations to have the ears of upper managers, are in a prime position to partner with work leaders to influence development of policies and communication messages that demonstrate care and concern, while also providing access to support services.

As an example, the “Intensive Care Unit” (ICU) program initiated by DuPont’s EAP was successful in helping workplace leaders communicate messages designed to reduce stigma about mental health and foster a culture that supports emotional health and well-being. ICU is now available to the public at no cost through the American Psychiatric Association’s Center for Workplace Mental Health.

The program includes a 5-minute video designed to be shared with all employees, in addition to a written guide for leaders with sample emails and other communications designed to reduce stigma about mental health problems and encourage help-seeking behavior among employees.

The program also provides surveys that EAPs or other workplace leaders can disseminate to evaluate changes over time within the work organization once ICU has been implemented. 

Expanding Guidelines
The new workplace suicide prevention guidelines recommend employee screening as part of the overarching self-care orientation guideline. EAPs have long been involved in employee screening at the workplace. Many offer free depression screenings to reduce stigma and connect with employees who might otherwise be suffering in silence and isolation.

One suggestion in the guidelines is to add questions about suicide risk to depression screening. For example, using the PHQ-9 (Kroenke, Spitzer, & Williams, 2001) provides EA professionals with a specific question, the 9th item of the screen, that asks, “Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself?”

In another example, recent research on suicide prevention with working-aged men demonstrated an effective method for EAPs to integrate online depression screening for the workplace with a more detailed online suicide screen, such as the Columbia-Suicide Severity Rating Scale or C-SSRS (Posner et al., 2011).
 
This project, “Healthy Men Michigan,” which is run by the second author of this article, showed that online anonymous screening for depression and suicide were effective methods for reaching out to working-aged adults at risk for suicide.

The online program not only provided immediate feedback to individuals who took the screening, but connected them to critical resources, including but not limited to their EAP. To learn more about this integration of depression and suicide risk screening only, please contact Dr. Frey directly.  

ISPs: Promoting Self-Assessment
Another example of how EAPs can promote self-assessment is through a relatively new program called the Interactive Screening Program or ISP. The ISP is an online and anonymous assessment program that helps to reduce stigma about suicide and mental health, while providing increased access to anonymous screening, professional support and referral through the EAP.
The ISP is based on a number of suicide theory and evidence-based intervention principles, including identifying and addressing an individual's personal barriers to treatment. It was recently adapted for use in the workplace.

The ISP incorporates questions from the PHQ-9, mentioned above and other evidence-based screening questions available upon request, which asks about suicidal ideation and attempts; problems related to depression such as anger and anxiety; alcohol and drug abuse, and eating disorder symptoms. The ISP is designed to connect employees with EAPs to encourage additional help-seeking through their existing workplace and community-based services. 

Finally, EAPs can decrease stigma about mental health and support services by including suicide specific resources such as promoting the National Suicide Prevention Lifeline (1-800-273-8255) or crisis text line for employees who would prefer to text a counselor rather than talk (Text HOME to 741741). These should be posted on EAP websites and other communications offering employees 24-hour support, in addition to the EAP, whenever they might need to talk with someone.

More Training Needed
EA providers need to be adequately trained to effectively assess and respond to suicide risk. Unfortunately, the majority of clinicians in the U.S., and elsewhere, do not receive formal training in comprehensive suicide risk assessments and response.

A number of available skills trainings can improve this situation. Training focused on evidence-based counseling practices like restriction of access to lethal means (e.g., Counseling on Access to Lethal Means or CALM), emotional regulation skills (e.g., Dialectical Behavioral Therapy or DBT), collaborative safety agreements (e.g., Collaborative Assessment & Management of Suicidology or CAMS and Suicide Safety Planning), and follow-up contacts are great examples of continuing education that EAPs should be encouraging and even requiring of their counselors. 

* CALM is an online and free evidence-based training that provides mental health professionals with skills-based learning on how to assess access to firearms and to work with clients and families to provide counseling to reduce access, especially when suicide risk is high.

* DBT is a popular and well-researched clinical intervention that is based on cognitive behavioral therapy, which is used successfully in EAPs. DBT blends behavioral problem-solving with acceptance-based strategies to help clients enhance their efficacy and ability to regulate emotions and come to acceptance.
It is a complex intervention that requires specialized training, but it is one of the few talk-therapies that has been shown to have significant impact on preventing future suicide behaviors.

* CAMS is an approach that also has strong empirical support to help reduce suicide risk. While there are trainings that one can take to learn key components, CAMS is a broader framework that focuses on developing a therapeutic relationship in which the clinician engages the client in a “highly intervention assessment process” and involves the client in all aspects of safety planning and treatment.

This approach might be better suited for EAPs that have a more robust session model; however, many of the techniques included in the CAMS approach can be adapted to short-term EA models such as integration of motivational interviewing, suicide safety planning and suicide teachable moment brief interventions. 

Suicide-specific Trainings
Additionally, more general skills-based suicide-specific trainings that offer one- or two-day skills based training in suicide assessment and response include Recognizing and Responding to Suicide Risk, offered by the American Association of Suicidology, and Assessing and Managing Suicide Risk, offered by the Suicide Prevention Resource Center.

Both of these trainings provide mental health professionals with an introduction to assessing acute warning signs of suicide, chronic risk factors and protective factors, while teaching methods to conduct a comprehensive suicide assessment and risk formulation and working with the client to develop a suicide safety plan. 

These essential skills are paramount to EA professionals whose direct practice work focuses primarily on early intervention with assessment and referral, coupled with short-term counseling.

For clients struggling with suicide, a referral outside of the EAP would be essential to provide the employee with additional support; however, the EAP can and should have a role in supporting that employee to create an initial suicide safety plan until additional help is available, and working to support the employee, and the manager when appropriate, to work through the suicide crisis and transition back to work.

Gatekeeper Trainings
Furthermore, EA professionals can offer brief suicide prevention gatekeeper training to employees at all levels of the work or professional organization. Gatekeeper trainings are akin to teaching CPR to provide life saving techniques in healthcare. Programs such as QPR (Question, Persuade & Refer), safeTALK, and Working Minds do a great job preparing lay people to feel more comfortable asking about suicide and referring another person to a resource for additional assessment and support.

Specifics about each program are discussed briefly below, but they all incorporate role-playing into their training to help individuals feel more comfortable asking questions about suicide risk and practicing listening for other risk factors that might signal a need for a formal referral for assessment and possible treatment. 

QPR offers a variety of training options - at the individual, organizational and professional levels - which can also be completed online, a popular option for busy workplaces.
SafeTALK is a four-hour in person workshop where participants learn to recognize the signs of suicide, engage someone in crisis, and connect them to an intervention resource for more support.

Working Minds is designed to help workplace administrators and employees better understand and prevent suicide with two- and eight-hour training options.
These programs, which can be taught to professionals and peers alike, help to further support the idea that “Suicide Prevention is Everyone’s Business!” (quote from American Association of Suicidology) 

All three of these programs focus on:
* Training employees to feel more comfortable asking questions directly about suicide risk;
* Reducing stigma about suicide help-seeking, improving awareness of referral resources, like the EAP and National Suicide Prevention Lifeline, and 
* Teaching when to call outside resources, including emergency services such as 911 for additional support. 

Suicide Postvention
When a death by suicide occurs at the workplace or involves an employee who dies offsite, it is critical that employers respond in an empathic and caring manner. To accomplish this, we recommend that EAPs reach out to workplace leaders following a suicide death to offer support to help ensure safety and a quick return to regular operations. 

Following a workplace crisis such as an employee suicide, EA professionals are often asked to partner with leaders in human resources to review and revise policies and programs that support surviving family members and grieving coworkers. The “Manager’s Guide to Suicide Postvention in the Workplace” is available at no cost and has been evaluated and used by EAPs and HR managers with diverse work organizations, earning positive feedback.

By utilizing this guide, EA professionals can collaborate with workplace leaders to assess needs and then plan and facilitate supportive interventions such as psychological first aid, crisis intervention and other psychological and social support as needed. EA professionals can review the guide for ideas on how to advise the workplace to prepare for anniversaries or other important times during the work year that might trigger emotional responses related to the employee who died by suicide.

Summary
The EA profession has a responsibility to educate the workplace about the magnitude of suicide in the U.S. By taking a stronger public health approach to suicide prevention, EA practitioners can help implement approaches that prevent suicide and use interventions such as gatekeeper training and universal screening to identify adults struggling at work and connect them to community-based resources that can provide the support they need. 

We must couple substantive, evidence-based care while working to help change the culture of the work organizations we support to allow for more open and honest conversation and a perspective that suicide prevention is everyone’s business.

Jodi Jacobson Frey, PhD, LCSW-C, CEAP is an associate professor whose teaching and research focus on adult behavioral health including Employee Assistance, suicide prevention, substance use and adult well-being. Connect with Dr. Frey at jfrey@ssw.umaryland.edu or follow her on Twitter @JodiJFrey

Sally Spencer-Thomas, PsyD is a Clinical Psychologist and inspirational international speaker who helped develop the nation’s first initiative for suicide prevention in the workplace, Working Minds. Spencer-Thomas has held leadership positions for the International Association for Suicide Prevention, the American Association for Suicidology, United Suicide Survivors International and the National Suicide Prevention Lifeline. Connect with Dr. Spencer-Thomas at www.SallySpencerThomas.com and on Facebook (@DrSallySpeaks), Twitter (@sspencerthomas) and LinkedIn.

Amanda Mosby, MA is a Program Manager at the University of Maryland Baltimore. She has more than 15 years of experience coordinating research studies and academic projects targeted toward improving the behavioral health and well-being among individuals and families.


References

Carter, G. L., Clover, K., Whyte, I. M., Dawson, A. H., & Este, C. D. (2005). Postcards from the Edge project: Randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self-poisoning. British Medical Journal, 331(7520), 805.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ‐9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613.

Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of post-crisis suicide prevention. Psychiatric Services, 52(6), 828-833.

Office of the Surgeon General (US); National Action Alliance for Suicide Prevention (US). (2012). 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington (DC): US Department of Health & Human Services (US). Available from: https://www.ncbi.nlm.nih.gov/books/NBK109917/.

Osteen, P. J., Frey, J. J., & Ko, J. (2014). Advancing training to identify, intervene, and follow up with individuals at risk for suicide through research. American Journal of Preventive Medicine, 47(3), S216-S221.

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., & Mann, J. J. (2011). The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-1277.
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Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R., Yuan, K., Holland, K. M., & Crosby, A. E. (2018). Vital signs: trends in state suicide rates—United States, 1999–2016 and circumstances contributing to suicide—27 states, 2015. Morbidity and Mortality Weekly Report, 67(22), 617.

EAP Case Study on Suicide Ideation, Risk

It was not long into her EAP job that Jane Doe received a positive response to Question 9 on the Patient Health Questionnaire (Kroenke et al., 2001) that asks about suicide ideation. A positive response to this item signaled to Jane that she needed to conduct a more thorough suicide assessment.

While trained to use the Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011), she had recently attended a training at the American Association of Suicidology where she saw Dr. David Jobes present the CAMS approach to suicide assessment and clinical work (approach is briefly described in the main article, under the heading More Training Needed). 
During this presentation, Dr. Jobes focused on the use of collaboration to elicit information through conversations about suicide risk and to work in partnership with a client at risk on a suicide safety plan. One of the main things she remembered about the collaborative approach was to balance how she asked questions from the assessment form with more open-ended questions, using skills such as active listening and empathic probing.

Therefore, while she prepared to ask the client questions from the C-SSRS, she first asked, “Please tell me about where you hurt and what hurts.” The client responded, “No one has ever asked me that question before” and from that point forward, the “assessment” was more relaxed for both the client and for Jane, and the client talked more openly about his suicide intensity and other risks.

Jane then worked collaboratively with her client to identify what he would do in the next 24 and 48 hours should his thoughts of suicide return.
Their collaborative safety plan included building a hope box (e.g., physical reminders of reasons for living), creating a list of people to call, practicing coping and distracting tactics, and reaching out to crisis resources like the 24/7 National Suicide Prevention Lifeline (1-800-273-8255).

Follow Up is Crucial
While follow up has historically been one of the key components of EA practice, pressure to do more with less has unfortunately led many EAPs to forego active follow-up with clients. When it comes to responding to suicide risk, follow-up is even more critical after a clinical emergency and is actually one of the most effective clinical interventions that we have to prevent suicide (Motto & Bostrom, 2001; Carter, Clover, Whyte, Dawson, & D’Este, 2005).

As an EA professional, Jane made sure to follow up a few days after this appointment to make sure her referrals and safety net for her client were in place and that he continued to use his suicide safety plan to manage suicide ideation and ongoing risk.