JEA Q. 2 2019

Special Report: Suicide Prevention in Korea

By Jongmin Woo, MD, MPH, PhD

The recent globalization of economies has had a significant negative impact on workplace stress in South Korea. Especially after the economic crises in 1997 and 2007, professional and educational environments have turned into pressure cookers, and it is customary to work long hours into the night.
In addition, social support systems that could serve as a buffer against stress have been weakened recently. Increasing stress and decreasing social ties can lead to negative behavioral habits and poor mental health, which in turn can impact the suicide rate. 

Suicide in Korea
The life expectancy of 81.5 years in South Korea is among the highest in the world, however, it also has the highest suicide rate among the OECD (Organization for Economic Co-operation and Development) countries for 13 consecutive years. It is the only OECD country whose suicide rates have increased since the 1990s. Suicide is the most-common cause of death among people in their teens, 20s, and 30s, and it is the second most-common cause of death among people in their 40s and 50s.
On average, 35 people commit suicide every day. South Korea’s peak suicide rate was 31.7 per 100,000 in 2011. The rate has been decreasing slightly since then and it was 25.6 per 100,000 in 2016, a 17.7% decrease from 2011.
Nevertheless, the suicide rate of males in their 30s and 40s had continued to increase significantly from 1993 to 2016. The suicide rate was almost two-and-a half-times higher in males than in females, 36.2% for males and 15.0% for females in 2016. 
In 2017, the Korean government set up the goal of decreasing suicide rate as one of four main national agendas and increased the financial and human resources commitment in this area. The initiative also included setting up a 24-hour crisis response system and training gatekeepers as part of a national suicide prevention plan.

“Emotional labor” and Unemployment
In 2013, the number of deaths by suicide among employees was 5,209, accounting for 36.11% of total suicide deaths. The occupation group with the highest number of deaths by suicide since 2012 was workers in service and sales. This statistic reflected the intense level of stress from “emotional labor,” a type of work that involves showing company-approved superficial emotions when interacting with customers including excessive kindness while suppressing one’s genuine feelings.
Call center employees, jobs in services or sales, bank tellers, healthcare personnel are occupations that often require “emotional labor.” 
In 2018, the National Assembly of Korea passed legislative amendments to the Occupational Safety and Health Act to protect emotional labor workers. The amendment specifically makes it an employer responsibility to protect employee health, taking necessary measures to protect emotional labor workers from abusive customers.
Employers must also take necessary steps to provide relief to employees who have suffered health problems as a result of the abusive acts of customers such as granting temporary leave or full reassignment. Failure to do these duties can lead to imprisonment or criminal fine. Cases of mental trauma and depression resulting from emotional labor have been defined as occupational injuries.
A nationwide campaign is underway to improve the awareness of the hazards caused by emotional labor and job stress at vulnerable worksites such as call centers. EAPs have been tasked with providing relevant educational programs and consultation services to client companies.
For example, KEAPA (Korea EA Professionals Association) developed an assessment tool to measure the impact of emotional labor in the service & sales industry and provide consulting services to support management and organizations. 
Unemployment rates are also associated with suicide rates. The increase in the suicide rate among young people appears to be related to a rise in unemployment following the economic crisis in 1997 and rising economic inequality in Korea. Specifically, massive layoffs had a major impact on the lives of workers and their family members.
After the Ssangyoung Motor Company conducted a large scale layoff in 2009, almost 90% of the laid -off workers and their spouses reported symptoms of depression and about half of them had suicidal ideation, while 30 of them went on to suicides over the course of 9 years. Since 2015, massive layoffs at shipbuilding industries are under way and the suicide numbers in those industries has increased from 53 (2015) to 90 (2016). 
The Korean government designated six cities as “Employment Crisis Regions” and arranged contracts with dozens of external EAP vendors to educate occupational health nurses and expand a ‘Psychological Stabilizing Program’ at local employment centers to provide suicide prevention programs and counseling services to the unemployed and their family members at risk. 

Three Categories of Suicide Prevention 
KEAPA uses a comprehensive model of suicide prevention using three categories: primary, secondary and tertiary (Table 1).
* Primary prevention aims to prevent suicide before it ever occurs. This is done by preventing exposures to hazards which can lead to a suicidal event, altering risky behaviors, increasing resiliency and shoring up support systems.
* Secondary prevention is done by detecting and managing suicidal individuals as soon as possible and helping victims and their organizations to prevent long-term complications.
* Tertiary prevention refers to helping victims, their organizations, the bereaved and witnesses to improve their function and quality of life.

A combination of these three levels of intervention are needed to achieve a meaningful degree of prevention. KEAPA uses this model when consulting with client organizations to set up efficient intervention strategies. 

Table 1. 
Primary    Secondary    Tertiary
Subjects: All employees    Subjects: High risk employees and suicide attempters    Subjects: Suicide attempters, witnesses, and the bereaved
Managing risk factors
-    Reducing bullying and harassment
-    Raising awareness of mental disorders and stress at work 
-    Improving access to mental health and substance use treatment
-    Anti-stigma campaign     Before meeting an attempter 
-    Intake: managerial or self-referral 
-    Assigning and dispatching a counselor (within 24 hours)
-    Telephone call by the assigned counselor with direct manager or related peer (and HR if needed)     Urgent psychological support
-    Witnesses to the self-inflicted violence and suicide
-    Managers and colleagues of the same team/department
-    Bereavement counseling: usually 1~4 sessions / month
-    “Observe-Listen-Tell” program
-    1-hour suicide prevention education as an on-the-job training for newcomers and middle managers 
-    Life respect education     On-site intervention
-    Interview with a manager/peer/HR
-    Helping peer supporter
-    Interview with attempter:  Assessing imminent suicide risk, general check-up, comprehensive psychological assessment if needed, psychiatric consultation    Suicide attempter
-    Fitness for duty evaluation
-    Monthly follow up by the assigned counsellor 
-    Discussion with HR regarding job position, relocation, and return to work program 
Gatekeeper training
-    Training peer supporter and in-house instructors to detect risk groups early and help them effectively
-    Training for counselors and occupational health nurses    Referral to external professional facilities    Counseling service for the bereaved family
-    Extended number of sessions as needed

With respect to gatekeeper training, in 2012, KASP (Korea Association for Suicide Prevention) developed a three-hour gatekeeper program including video materials from sample cases, which teaches early detection of suicide warning signals, a proper understanding of suicide risk, and how to link to professionals and other resources for help.
Since 2015, KEAPA has worked in collaboration with KASP to develop the workers’ version of the gatekeeper program and distributing it to workplaces around the country. This program was officially certified by the government in 2017 and is very well accepted by employees and counselors.
Specialized care is needed for some occupational categories. Statistics show that the military, police officers, firefighters, and post office workers have twice the risk of committing suicide compared to other categories of civil officers. This can compromise the safety and health of the people they serve.
To address these issues, the Korean National Police Agency has expanded its counseling centers nationwide and is providing suicide prevention programs for police officers in collaboration with KEAPA. Intensive psychological autopsies of suicide cases and onsite crisis intervention have also been provided to firefighters, post office workers, and the military. (Editor’s note: See the accompanying story for a case example.)

Jongmin Woo, MD, MPH, PhD, is a founder of KEAPA and has served as an advisor. Dr. Woo is a psychiatrist and a certified SIY (Search Inside Yourself) teacher with focus on mindfulness-based emotional intelligence leadership program. He may be reached at


Woo JM, Postolache TT. The impact of work environment on mood disorders and suicide: Evidence and implications. Int J Disabil Hum Dev 2008,7(2):185-200

Case Example
Here is an example of a suicide intervention case. 

A 48-year-old male police officer voluntarily called KEAPA. He suffered from tightness in his chest, weight loss, insomnia, anger, loss of interest, depressed mood, and recurring suicidal ideation after a series of workplace events he perceived to be unfair. He felt that he was falsely accused of being negligent of his duties. He was so frustrated that he made several suicidal attempts in an effort to demonstrate his innocence and restore his honor.
A counselor was assigned and dispatched to his office within 24 hours. Before the session, the counselor had a meeting with his direct supervisor and HR manager. They reported that he used to be a man of honor and loyalty but now exhibited his anger and despair to the organization. 
Suicide has long been a way to preserve one’s own or family honor in Asia. Some people see suicide as an honorable means of atoning for any dishonorable event or public disgrace. The tradition of choosing suicide instead of perceived shame is deeply entrenched in the organizational culture especially for military and police. 
During the first session, the counselor empathized with his frustration and loneliness. After he was stabilized, he was advised to use the “Decision Making Scale” to identify ambivalent (e.g. conflicting) feelings toward suicide and to weigh up pros and cons of a decision quantitatively.
First the client described the positive and negative consequences of attempting suicide again, rating each item using a ten-point scale. Then he added up the scores in each column and subtracted the total cons from the total number of pros.
A negative overall score indicates that the individual should scrap the decision. The client became stabilized and continued to find more rational strategies to deal with his situation. This enabled him to decrease his suicidal behaviors. 
For an example of how this scale works, go to An additional link explains the decision-making process