Suicide may be an individual tragedy, but it can also be compounded, or even caused by, poor management practices, inappropriate behaviours by colleagues and poorly implemented organisational changes. Employers and occupational health practitioners have a vital role to play in both preventing suicide and responding to mental health crises, argues Andrew Kinder.
Completed suicides globally are estimated to be between 500,000 and 1.2 million people each and every year (United Nations, 1996), although this does not include people who receive injuries from self-injury that do not result in death.
However, the actual figure for completed suicides is estimated to be 50% to 60% higher than the official rate because of the reticence in recording death as suicide, rather than “death by misadventure” or “unexplained”. The reason for this relates to stigma and possibly insurance, since pay-outs are sometimes reduced when an individual dies from suicide
About the author
Andrew Kinder is professional head of mental services at Optima Health
These figures suggest that suicide is a major public health policy issue, especially when taken into account that it exceeds the death-toll because of road traffic accidents in the UK, and that in 2016 there were more suicides than deaths from homicides within the US.
However, even given this context, suicide receives less attention than physical health issues; it gets less research funding compared to other health conditions and generally is not well understood. As an illustration, it is estimated that in the UK £8 is invested in research per person affected by mental health, 22 times this amount is spent on research into cancer.
Unfortunately, the phenomenon is not going away and, worryingly, remains high – in the US, according to the Centres for Disease Control and Prevention, suicide rates have actually increased by 25% when comparing 1999 to 2016. Within the UK we have a slightly more positive trend in that suicide rates peaked in 1981 (14.7 deaths per 100,000) and reduced in 2017 (10.1 deaths per 100,000 population) as recorded by the Office for National Statistics (ONS). Even so, these rates are still of concern.
And yet, the workplace is a key area where a real difference can be made.
There has been recent publicity and awareness raising of mental health conditions which has been prompted by well-known figures in the UK through charities such as Heads Together, Mind and The Samaritans, as well as a number of well-known companies in the UK who have recognised the importance of supporting people with mental health issues as documented in the Thriving at Work (2017) report.
Understanding the risk factors
When approaching the subject of suicide, a good starting point is to gain greater insight into its risk factors so that any response can be targeted. It is well-known that men have much higher rates of suicide compared to women and are estimated to have completed rates of 75% compared to 25% of women (Office for National Statistics, 2007). In terms of age, suicide is the most common cause of death for men aged 20-49 years in England and Wales and men working in the lowest skilled occupations had a 44% higher risk of suicide than the national average. Within the construction industry, the statistics are particularly concerning where the number of suicides are now six times higher than deaths from falling from a height.
Men are more likely to use more fatal means such as hanging, shooting or jumping, whereas women are more likely to make a suicide attempt and to use less “effective” methods such as poisoning such as taking overdoses.
Also, men tend to avoid seeing their GP until they are forced to because their physical or mental health issue has become critical. There remains a stigma regarding mental health, and this is perhaps felt more keenly by men as they find that talking about mental health concerns particularly difficult because of cultural stereotypes that they need to “be strong” or “boys don’t cry”.
Men also often have a smaller social support network than women and find it harder to ask for support such as from friends, work colleagues or even accessing employee assistance programmes (EAPs).
Suicide rates are higher for those with pre-existing mental health problems and it is estimated that 70% of recorded suicides are by people experiencing depression, which often can go undiagnosed (Mental Health Foundation, 1997).
Health professionals, including occupational health, HR and EAPs, have a particular responsibility here in that the majority of people who die by suicide have contact with a health professional within a short time before their death (Pirkis & Burgess,1998).
When assessing whether an individual is suicidal or not, healthcare workers should receive training in how to carry out a suicide risk assessment. Apart from the gender of the individual there are a number of other factors that point to an elevated risk of suicide. These include:
- past suicide attempts/behaviours;
- current symptoms of suicide, including having a specific plan and intention to carry it out;
- life stresses, including whether they are off sick from work or have high anxiety related to the workplace;
- degree of psychological disturbance, such as depression, anxiety, substance abuse, hopelessness and helplessness;
- degree of self-control in overcoming desire to take suicide actions; and
- lack of social support and alternative coping strategies.
Therefore, a male employee who is currently off sick with a mental health condition, who has a history of suicide attempts, and who has a specific plan about taking their life in the immediate future should be particularly risk-assessed with a robust support package put in place.
Practitioners working in organisations need to increase their confidence in carrying out risk assessments. They need to think through how they can refer suicidal clients on to support services as well as what other therapeutic intervention they can make bearing in mind professional issues such as boundaries and confidentiality. The needs of practitioners should also not be overlooked as their psychological wellbeing can be affected when one of their clients commits suicide (Kapoor, 2002).
Suicide in the workplace
There is a website (www.hazards.org) that links to trade unions and has highlighted the suicides that are down to excessive work, stress and harassment.
The site also highlights a number of organisations where suicides have apparently been caused by poor management practices, inappropriate behaviours by colleagues and poorly implemented organisational changes.
These cases, of course, affect not just the families, the workforce and the local community but also lead to significant time spent by managers dealing with the aftermath and damaging publicity for the organisation.
One example would be the Foxconn electronics company in China, where in 2010 it was estimated that at least 13 company employees took their own lives during the year because of “sweatshop” conditions – by throwing themselves off the building.
In 2011, a whole package of measures was then put in place, including better local conditions, counselling, an anti-suicide agreement and nets designed to deter suicide jumpers.
These measures have led to fewer “work-related” suicides. It also prompted the chief executive of Apple to visit, who said that, with 400,000 people employed, the actual suicide rate was less than the US.
The point here is that any such suicides attract a lot of attention and therefore it is clearly far better to put in place preventative measures rather than reacting to such tragic news.
Managers and HR are at the frontline of all this, and need to know what to do if, for example, a member of the team is distressed and is threatening to harm himself or herself.
The key point here is the manager needs to decide whether the employee is actually an immediate danger to themselves and then to either phone for an ambulance or arrange for them to be taken to a local Accident and Emergency department.
For less immediate cases they may need to make an occupational health referral or contact the EAP, which can assess and progress the case.
An important principle to emphasise here is that, even if the OH/EAP is involved, the NHS has a clinical duty of care, and the employee’s GP is key to “taking ownership”. Once the employee is stabilised, then usually it is the task of occupational health to advise on the employee’s rehabilitation or temporary “reasonable adjustments”, which can be put in place.
Mental health first aiders
In recent years many organisations have put in place “mental health first aiders”. These are specially trained individuals to provide emergency first aid to their co-workers who may be suicidal and to work alongside the manager or HR.
Whilst this initiative is a welcome boost to the importance of mental health in the workplace, it is important that their role is carefully designed alongside clear clinical governance. This is to ensure the first aider is supported with difficult cases and does not stretch their role into becoming a workplace counsellor.
An OH/EAP provider would be well positioned to put in place this governance role, especially if they already engaged with the organisation in providing support services to its employees. They would be aware of how to fast-track cases within their services and the mental health first aiders could be trained in how to make good quality referrals.
I’ve been involved in supporting both individuals and organisations on the subject of suicide for more than 20 years. It feels as if there is a growing awareness of the issue, and I passionately believe organisations have a vital role in both preventing suicide and responding to mental health crises.
We know that unemployment is a predictor of poor mental health, and so organisations have a vital role to support employees who are off sick back into the workplace and to make reasonable adjustments to facilitate their return.
In recognition that male suicide is of particular concern, I have recently co-authored a book with Dr Shaun Davis, global director of safety, health, wellbeing and sustainability at Royal Mail Group, called Positive Male Mind: Overcoming Mental Health Problems and published by Lid Publishing.
It is aimed at men and also those interested to help men take more care with their psychological health. It is a self-help guide focused on the workplace and includes how organisations can be more proactive in this important area. All royalties from the sale of this book are donated to the Rowland Hill Fund and Action for Children.
Hopefully with many organisations now taking up such initiatives, together we can make a difference and significantly reduce the scourge of suicide in our society.
‘UK mental health – how much do we spend on research?’, MQ, https://www.mqmentalhealth.org/articles/research-funding-landscape
Thriving at Work: a review of mental health and employers: An independent review of mental health and employers, by Lord Dennis Stevenson and Paul Farmer, Department for Work and Pensions and Department of Health and Social Care, October 2017, https://www.gov.uk/government/publications/thriving-at-work-a-review-of-mental-health-and-employers
‘“Mass suicide” protest at Apple manufacturer Foxconn factory’, The Daily Telegraph, January 2012, https://www.telegraph.co.uk/news/worldnews/asia/china/9006988/Mass-suicide-protest-at-Apple-manufacturer-Foxconn-factory.html
‘Foxconn suicide rate is lower than in the US, says Apple’s Steve Jobs’, The Daily Telegraph, June 2010, https://www.telegraph.co.uk/technology/steve-jobs/7796546/Foxconn-suicide-rate-is-lower-than-in-the-US-says-Apples-Steve-Jobs.html
Kapoor, A. (2002). Suicide: The effect on the counselling psychologist. Counselling Psychologist Review. 17, p28-36.
Kinder, A and Davis, S. Positive Male Mind: Overcoming Mental Health Problems. Part of The Positive Wellbeing series, Lid Publishing, 2018.
Mental Health Foundation. (1997). Briefing No. 1 – Suicide and Deliberate Self-Harm.
Office for National Statistics. (2007), Mortality Statistics, Series DH2 no 30 + no 32.
Pirkis, J, and Burgess, P. (1998). ‘Suicide and Recency of Health Care Contacts’, British Journal of Psychiatry 173, 462–474.
United Nations (1996). Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies. New York: United Nations.