Aspiring to a Zero-Suicide Mindset - Journal of Employee Assistance Vol. 48 no. 1 - 1st Quarter 2018

By Sally Spencer-Thomas


EAPs are an important link in the chain of survival for employees. EA professionals are often the first line of assessment for a given client and thus have the opportunity to provide critical prevention services. In addition, they can advise the HR departments of their client companies on how to implement suicide prevention initiatives in the workplace. This article will address how EAPs and their client companies can aspire to a zero-suicide mindset.

Leading a Zero-Suicide Mindset
When it comes to suicide prevention, bold leadership makes all the difference. EAP managers who understand this can make a big difference in the behavior of their counselors, their affiliate network providers, and the workplaces they serve. Leaders must push back on the idea that suicide is inevitable. Instead they can aspire to achieving zero suicide (Coffey, 2007).

One such leader is Ed Coffey M.D., former Vice President and CEO of Behavioral Health Services, Henry Ford Health System in Michigan. In 2001, the Henry Ford Health System submitted a proposal within the Robert Wood Johnson Foundation’s "Pursuing Perfection National Collaborative” by developing “Perfect Depression Care” to better serve their 200,000 patients (Henry Ford Health System, 2006; Coffey, 2016). Their Behavioral Health Services Division Team asked themselves, “How would we know when depression care was truly perfect?” In a watershed moment, a psychiatric nurse boldly raised her hand and stated, “If depression care was truly perfect, no patient would die from suicide.” 

It was a transformative moment for the department, and ultimately, for the world.

At this time suicide prevention care at Henry Ford, like in many places, was mostly reactive. When patients came in talking about suicide, health providers took notice but there really was no suicide specific care plan in place other than a “no-suicide contract.”
Henry Ford failed to win the Robert Wood Johnson grant, but the health system went ahead with the proposed changes anyway, and their inspirational leadership has created an international movement.

“Zero suicide” has become a galvanizing metric.

The overall outcome of the care delivery overhaul that resulted from this paradigm shift was a dramatic and statistically significant 80% reduction in suicide, maintained for over a decade, including one year when the perfection goal of zero suicides was actually achieved (Hampton, 2010). Collaborative, patient-centered, and suicide specific care emerged. Near misses occurred when under the microscope – not for the purposes of blame, but to provide a supportive, learning culture that focused on continuous quality improvement in order to save lives. By focusing on continuous quality improvement of services, leaders can begin to see what is working and what is not. Leaders within the “zero suicide” effort learn to listen closely to the experiences of the people receiving the care and learn from their lived expertise.

In the last few years three international summits (http://zerosuicide.org/) have been held to share the lessons learned. Many large healthcare systems are implementing this leadership mindset and the set of practices that accompany it and are seeing substantial change emerge.

There is magic in aspiring to zero suicide – it ignites and provokes conversation and thinking.  If we don’t have an ambitious model, we are not going to achieve it. While it may be true that if someone wants to die by suicide strongly enough they may find a way, EAP managers have an opportunity to implement training for both their line counselors and the companies they serve to ensure employees are not going to do it on their watch.

Applying a zero-defect standard of care to suicide means that the entire organization reviews adverse outcomes related to suicide and adjusts performance accordingly. Robust performance improvement focused on the goal of zero suicides must become a central ingredient to managing EAP systems.

The following are specific recommendations regarding suicide prevention that EA professionals can help implement in the workplace.

Offer Suicide Prevention Training and Programming to Workplaces
Throughout the year, EAPs can offer outreach programming that helps workplaces be partners in suicide prevention. One new tool EAPs can provide to help clients is to have employees complete the new gap analysis tool by Resilience at Work (www.ResilienceAtWork.net) called, “Is Your Workplace Mentally Fit?”

The site features a free, 24-point quiz that ranks an organization’s state of mental fitness. Statements include, “Mental health benefits are accessible, offered to all employees and are covered at the same level as physical health.” Participants are then asked to choose from the responses “not at all”, “partially true”, or “completely true.” Results will indicate the level of mental fitness of a client company, and thus the degree to which the EAP may be able to assist in incorporating suicide prevention training in the workplace. 

Oversee Peer Support Programs
EAPs can also help workplaces develop and supervise peer support programs. A peer supporter acts as a trained and empathic liaison to EAPs. An example of a peer supporter would be an employee leader passionate about wellness willing to advocate for their co-workers’ mental health. Peer supporters act as trained and empathic liaisons to EAPs. They do not serve as counselors, but they can offer to accompany the employee to their first EAP session or in making the initial call to EAP. 
EAPs can provide guidance on the selection processes of workplace peer supporters, helping to ensure that nominated peers understand the role of the EAP. EAPs can also provide training on the need for boundaries and confidentiality. 

Ask the Suicide Question Effectively
Most mental health professionals have not been trained in what Dr. Shawn Shea describes as the “practical art” of asking the suicide question (Shea, 2011). Thus, many ask indirect questions in a way that communicates they really don’t want to know the truth.

Instead of, “Are you thinking of harming yourself” or, “You are not suicidal, are you?” EA professionals can learn to ask direct questions that are much more likely to elicit truthful answers.

Starting the conversation with observations and empathy is always a good step. For instance, “I’ve noticed (insert observed mood, behavior or life circumstance changes), and I’m concerned. Sometimes when people experience these things they think about suicide. I am wondering if you are thinking about suicide.”
Using the word “suicide” is important because when clinicians use direct language they model comfort and confidence, and are more effective at opening the door to the conversation.

Dr. Shea offers additional tactics:

* Self-normalization: “If I was going through this I might consider…” 
* Behavioral incident (frame by frame): “Describe to me your worst point when you were overwhelmed, and walk me through step-by-step how your thinking changed. Tell me what happened when you experienced thoughts of suicide, even if just fleeting in nature…and then what happens…and then what…”
* Shame attenuation (learned behavior for survival): “Given your past (insert specific childhood trauma or neglect), I wonder if you ever found it necessary to (insert judged behavior like lying, stealing, exaggerating) to…just get through.”
* Gentle assumption: “What other ways have you thought of killing yourself?”
* Symptom amplification: Set upper limits of quantity in question at a high level, for example, “Do you think about suicide 1,000 times a day?”
* Denial of the specific: List specific means one by one, for instance, “Have you thought of killing yourself by jumping? By hanging? By firearms? Etc.”

What should anyone do if they say “yes”? The first words out of the counselor’s mouth should be, “Thank you.” Expressing gratitude for the client trusting the relationship and for being courageous are important steps in reassurance. Then offer collaboration, “We will figure this out together” or, “I have some ideas that might help.”

Say “No” to “No-Suicide” Contracts 
“No-suicide contracts” “attempt to assure that the client makes a commitment not to inflict self-injurious behavior while in the care of the provider. Almost every mental health provider has been trained to do this when a client expresses suicidality.

Yet there is no evidence that “no-suicide” contracts actually work. In fact, evidence exists that they don’t work. In one study of people who attempted suicide in an inpatient mental health facility, 65% had signed a “no-suicide contract”. A survey of psychiatrists who used “no-suicide contracts” found that 40% had a patient die or make a serious attempt after signing one (Freedenthal, 2013).

Clients who receive such contracts often become mistrustful of clinicians because the contracts are seen as being more about protecting the clinician rather than serving the client. By engaging a client in a “no-suicide contract” a dynamic sometimes emerges whereby the client becomes hesitant to bring up the issue of suicidal thoughts or behaviors for fear of breaking the contract.

Collaborate in Safety and Wellness Planning
Instead of a “no-suicide contract,” clinicians should become familiar with structured safety and wellness planning. There are several tools that can help in this process. One is my3app (http://my3app.org/), another is SAMHSA’s Suicide Safe (https://store.samhsa.gov/apps/suicidesafe/), and a third is the Virtual Hope Box (https://itunes.apple.com/us/app/virtual-hope-box/id825099621?mt=8), which reminds people of their reasons for living.

Each of these tools walk people through a graduated hierarchy of things they can do instead of attempting suicide, beginning with low-level self-soothing, distracting, or behavioral strategies. The next stage is reaching out to friends and family or trained peer supporters. If these efforts are not effective, individuals should seek professional or crisis support. Each of these steps is spelled out in great detail, with names and numbers for easy access.

When talking to people who are living with suicidal thoughts, many have told me their goal isn’t to be “safe” – that is the goal of the clinician – rather, their goal is to live fully-engaged lives. Once the white hot crisis of suicide has passed, working on wellness planning can help the person transition from staying safe to rebuilding his or her life.

Predictive Suicide Risk Assessment is a Fallacy
How good are clinicians at predicting suicide risk? Not very good, according to suicide risk researchers. Two recent studies concluded that 95 percent of so-called “high-risk patients” will not die from suicide, while roughly 50 percent of suicide deaths were among people in the lower risk categories (Murray & Devitt, 2017; Lange, et al, 2016; Chan, et al, 2016).

Researchers found that multiple risk factors were no more predictive than a single risk factor. In fact, they concluded that relying on these instruments to predict risk may even be a harmful practice, as it takes the focus off of rapport building and treatment formulation. Instead of trying to predict behavior, assessments should be used to help develop treatments.

Summary
EA counselors need to avoid relying on out-of-date suicide risk assessment protocols, and instead be offered training in state-of-the-art interventions. Together with our client companies we must aspire to “zero suicide”.

Dr. Sally Spencer-Thomas is a clinical psychologist, inspirational international speaker, impact entrepreneur, and survivor of suicide loss. She may be reached at sallyspencerthomas@gmail.com.

References

Chan, M., Bhatt, H., Meader, N., Stockton, S., Evans, J., O’Connor, R., Kapur, N. & Kendall, T. (2016). Predicting suicide following self-harm: systematic review of risk factors and risk scales. The British Journal of Psychiatry, 209(4), 277-283.

Coffey, E. (2007). Building a system of perfect depression care in behavioral health. Joint Commission Journal on Quality and Patient Safety, 33(4). Retrieved on September 17, 2017 from http://ntap.us/wp-content/uploads/2015/01/PerfectDepressionCarearticles.pdf. 

Coffey, E. (2016). Zero suicide as model for community transformation. Rotary Club of Madison. Retrieved on September 17, 2017 from https://youtu.be/FKbehPHmvuc. 

Freedenthal, S. (2013). The use of no-suicide contracts. Speaking of Suicide. Retrieved on September 17, 2017 from https://www.speakingofsuicide.com/2013/05/15/no-suicide-contracts/. 

Hampton, T. (2010). Depression care effort brings dramatic drop in large HMO population’s suicide rate. Journal of American Medical Association, 303(19), 1903-1905.

Henry Ford Health System (2006). Pursuing perfect depression care. Psychiatric Services, 57(10).Retrieved on September 17, 2017 from http://ntap.us/wp-content/uploads/2015/01/PerfectDepressionCarearticles.pdf

Lange, M., Kaneson, M., Myles, N., Myles, H., Gunarantne, P. & Ryan, C. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: Heterogeneity in results and lack of improvement over time. PLOS ONE 11(6): e0156322. https://doi.org/10.1371/journal.pone.0156322.

Murray, D. & Devitt, P. (2017) Suicide risk assessment doesn’t work. Scientific American. Retrieved on September 17, 2017 from https://www.scientificamerican.com/article/suicide-risk-assessment-doesnt-work/.

Shea, S. (2011) The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Stoddard, NH: Mental Health Presses.