Work-Related Suicide: Understanding the Causes and Prevention Strategies

1. Work-Related Suicide and Workplace Suicide Prof. Craig Jackson Head of Psychology Division BCU craig.jackson@bcu.ac.uk health.bcu.ac.uk/craigjackson

2. Suicide Media Stories “A teacher who set herself alight had complained about pressure of work, an inquest has been told. Janet Dibb, 28, had complained to her father about overwork.” 20 March 2004 “A family doctor hanged herself because of stress at work, an inquest has heard. Bury coroners' court was told Dr Dawn Harris, 38, who worked at the Lever Chambers practice in Bolton, became ‘angry, very distressed and quite hurt’ by problems at the busy medical practice.” 22 May 2004 1. Over-emotive 2. Blames “extreme stress response” 3. Always best when involving females!

3. Workplace and Work-Related Suicide • Death with “underlying cause of intentional self-harm or injury or poisoning” • Work-Related Suicide (WRS) and Workplace Suicide (WS) not the same • WRS has element attributed to workplace • Workplace suicides defined by location of decedent when passed away • Location-based method of WS may inflate counts of WS • farmers’ high Workplace Suicide rate • self-employed high Workplace Suicide rate • UK estimates 100-250 WRS per year – but could be way off the mark

4. Suicide and Seafarers Roberts et al. 2009 Methods Examination of seafarers’ death inquiry files The suicide rate (for suicides at work and unexplaineddisappearances at sea) in UK shipping fell from 40–50per 100 000 in the 1920s to <10 per 100 000 in recent years,with an interim peak during the 1960s. Suicide rates were higherfor all ranks below officers forLascars (Asian seafarers) than for British seafarers forolder than for younger seafarers were typically lower thanthose in Asian and Scandinavian merchant fleets The suiciderate among seafarers was higher than the overall suicide rate in the general population from 1919 to 1970s, but following reductionsin suicide mortality among seafarers, it has become more comparablesince.

5. Suicide and Seafarers • Roberts et al. 2009 • Conclusions • Although merchant seafaring was previously a high-riskoccupation for suicides at work, there has been a sharp fallin the suicide rate in the past 40 years. • Likely reasons forthis include: • reductions over time in long intercontinental voyages • (2) changes over time in seafarers’ lifestyles.

6. Suicide and Physicians & Dentists Petersen & Burnett 2008 Some studies have shown that physicians and dentists have elevated risks of suicide, while other studies have not. Using all deaths and corresponding census data in 26 US states, they examined the suicide risk for working physicians and dentists. Death and census data for working people were obtained from 1984-1992. Age standardized suicide rate ratios (SRRs) were calculated for white male and white female physicians, and white male dentists.

7. Suicide and Physicians & Dentists Petersen & Burnett 2008 Comment Petersen and Burnett say that health professionals have high performance expectations. Suicide occursin other professional groups who put in significant effort tobecome established in society. Authors left out many factors which may have influencedthe data Marital status of doctors? self-poisoning? Addiction? Psychiatric disorders? The working atmosphere is very important in the causation ofsuicide. Overwork and burden of work are the precipitating factors.

8. Suicide and Physicians & Dentists Petersen & Burnett 2008 White female physicians - suicide rate elevated compared to the working US population (SRR 2.39, 95% CI 5 1.52–3.77). White male physicians and dentists - suicide rates were reduced (SRR 0.80, 95% CI 5 0.53–1.20 and 0.68, 95% CI 5 0.52–0.89, respectively). Older white male physicians and dentists, observed suicide rates were elevated Conclusions White female physicians have an elevated suicide rate. Only older white male physicians and dentists have elevated suicide rates, which partially explains the varied conclusions in the literature.

9. Case – PT: Bullying • PT (female armed response officer, 37) suicide in 2004 • hanged at home • 2003 Dismissed from firearms duties - poor proficiency • One of two female firearms officers in 90-strong unit • One of first female snipers in UK • Complained of colleagues viewing pornographic video on a residential course • Felt victimised in macho culture of firearms unit. • Fell out with a number of influential male colleagues • Sefton Coroner Christopher Sumner: “Paula Tomlinson killed herself at a time that she was suffering from stress, a contributory factor of which was work related.” • IPCC found no evidence of bullying or intimidation • Did acknowledge management failings and an “in-crowd culture”

10. Workplace Prevention Policy Observable in 75% of decedents in few weeks before death Suspecting a colleague is contemplating suicide is difficult Uncertain of what help to get Not knowing where to send the sufferer Reluctance to pry The problems associated with suicide – drink, drugs, depression, bi-polar disorder require professional assistance One of the most important things that workplaces can do for someone who may be considering suicide is to help him or her find professional help.

11. Workplace Aftermath Traumatic for surviving staff Even if not Workplace Suicide Guilt over what could have been done Some workers experience depression and consider suicide themselves Grief counselling offered for those who want it (post-vention) Let individual worker decide about post-vention The need for Workplaces to Develop (i) Suicide Prevention and (ii) Aftermath Policies

13. France Telecom Case Privatised in 1998 40,000 jobs gone since 1998 186,000 employees 45% of those outside France Used to be public sector employer new working conditions modernisation cultural & organisational changes needed internal job transfers 4.3% fall in profits in 1Q of 2009 182 million customers in 5 continents

14. France Telecom Case

15. France Telecom Case • Between Feb 2008 – Sep 2009 • 23 staff committed suicide • 9th Sept: 49 yr old male employee stabbed himself in meeting – told he would be undergoing internal job transfer • 11th Sep: 32 yr old female employee leapt to death from office window • 14th Sep 53 yr old senior manager overdosed • 1st Oct: 51yr old male employee jumped from road bridge – note blamed work “atmosphere” • French suicide rate: 26.4 per 100,000 male deaths • 9.2 per 100,000 female deaths • 17.8 per 100,000 all deaths

16. France Telecom’s Defence • France Telecom’s two-point defence: • “There were 28 suicides in the company in 2000, so 23 suicides over 17 months is actually an improvement and not evidence of an epidemic” • 2) “Most suicides caused by personal problems not professional ones”

17. France Telecom Case Oct 2009 Deputy CEO Louis-Pierre Wenes (second in command) resigns CEO Didier Lombard – vowed to end the “Spiral of death” Phone helpline Counselling Suspending job transfers French Labour Minister, Xavier Darcos wants: 2,500 biggest companies to plan “anti-stress” strategies Plan it with Unions Govt has 27% stake in FT Health & Happiness now on “National Agenda” in France

18. Foxconn and the iPad Manufacturing giant in China Renowned for efficiency – 300,000 employees Laptops, mobiles - Nokia, Apple, Dell HP 13 suicide attempts since Jan 2010 – 10 deaths

19. Foxconn and the iPad

21. Foxconn and the iPad Compensation for families in poverty Working conditions – long shifts, rigid, Oppressive, poor pay Company asked workers to sign a letter promising not to kill themselves (now withdrawn) Building giant safety net to prevent jumpers from Dorms and Workshops Hiring counsellors and Buddhist monks

22. Research limitations • Suicide multi-causal • End-stage of complex process • Attracts emotive reporting in media • Workplace suicide received little / no academic attention • Occupational attribution straightforward in many cases • Workplace factors ascertained by • Notes • Recorded trouble at work • Coincidence with unusual workplace situation / landmarks • Compounded home-life complications • Occupational health history

23. Case – TB: Overwork / Depression TB (male engineer, 28) suicide in 2002 – hanged at home Been working for 1 year in Singapore Had party celebrating end of contract 2 suicide notes: First addressed work colleagues “unfortunately the game has got the better of me – give my apologies to all the lads” Second addressed his parents “I have been depressed for a while now – pressure of work has turned my mind into a ticking time bomb” Cardiff Coroner – Mary Hassell: “It is hard to understand why someone described as happy-go-lucky should choose to end their own life over pressure in work.”

24. Complications to Stats • FACTITIOUS INJURY • Deliberate self-harm to be discovered or hidden • A wish to “escape” rather than to end life • PARASUICIDE • Non-successful overdoses written off as cry for help • Very hard to secure death in a non-painful and non-traumatic way • Distinction between suicidal attempt and suicidal “gesture” is hard • Conversely, death from suicidal “gesture” can occur • Some fake suicide to avoid problems e.g. debt, law, marriage

25. Complications to Stats SUICIDAL ATTACKS Classified as Murder or Homicide “MESSY” CASES Michael Todd case Suicide following being caught after several affairs Work-related???? ASSISTED SUICIDE Hot topic Over 100 UK citizens No prosecutions Murder?

26. Epidemiology of World Suicide • 1 million suicide deaths per year worldwide • 10 – 20 million attempts (huge variation) • Suicide ideation / rumination even higher • WS comprises 3.5% of workplace fatalities worldwide (Pegula 2004) • Nearly 50% of first-time attempts fail • Those with history of repeated attempts X 23 likely to die by suicide

27. World Wide Attitudes

30. Epidemiology of Suicide

31. Epidemiology of Suicide in the UK Males Females 30 suicides per 10 suicides per 100,000 deaths in Scotland 22 suicides per 6 suicides per 100,000 deaths in Wales 18 suicides per 5.6 suicides per 100,000 deaths in Northern Ireland 16 suicides per 5.4 suicides per 100,000 deaths in England Ages 15-44 have highest suicide rate in males Ages 75+ have highest suicide rate in females

32. Epidemiology of Suicide in the UK

33. Epidemiology of Suicide in the UK Slow decrease in UK suicide rates since 1990s 75% of suicidal deaths are Male Sex split been same since 1991 – but may just reflect methods used 2006 5554 suicides in adults (15 or over) 2007 5377 suicides in adults (15 or over) 2008 5706 suicides in adults (15 or over)

34. Traumatic vs Non-Traumatic methods

35. Epidemiology of Suicide in the Midlands 1998-2004 Wolves 22.1 per 100,000 deaths 146 cases #101 Birmingham 19.3 per 100,000 deaths 541 cases #172 Dudley 18.0 per 100,000 deaths 147 cases #215 Coventry 17.3 per 100,000 deaths 146 cases #245 Sandwell 16.6 per 100,000 deaths 125 cases #268 Walsall 15.9 per 100,000 deaths 105 cases #294 Solihull 13.8 per 100,000 deaths 74 cases #363 Can we pin any of this to industry, ethnicity, decline, deprivation ????

36. Demographics of Suicide

37. Occupations & Region

38. Occupations & Region

39. Case – TC: Chronic Ill-health / Depression TC (male mechanic, 37) suicide in 2002 1996 right ear severed in accident at work IBC Vehicles Luton Prolonged tinnitus, headache, severe depression 2005 TCs widow at High Court for £750,000 IBC accepts liability for accident – not suicide. Awarded £82,520 Court of Appeal overturned award – Lord Justice Sedley claimed there to be no other cause. TC had previously been a “rational man. . . The suicide was proved to have been a function of the depression and so formed part of the damage for which IBC were liable. . . To treat TC as responsible for his own death was an unjustified exception to modern views on the links between accidents and their causes”.

40. Complexity • Emotive reporting of WRS suicides • Coroner’s & Inquests often too narrow in scope • Wrongly suggests WRS is “final remedy” for workplace problems e.g. stress • Suicide is complex final stage behaviour with many antecedents • Socio-demographics • Childhood experiences • Psychiatric morbidity / history • Recent stressful life events • Social interactions / supports

41. Complexity of Background • Beautrais (2001) • Following are all common to suicide & attempts: • current mood disorder • previous suicide attempts • prior outpatient psychiatric treatment • admission to psychiatric hospital within the previous year • low income • absence of educational qualifications • recent stressful interpersonal, legal & work-related life events. • Many suicidents do not fit this profile

42. Suicides and Recession – Japanese Data Suicides risen since 1989 and financial decline Climbed higher in 1997 recession Seems a natural end-point considering over-work and working hours Joins UN Financial boom Recession

43. Suicides and Recession Prof Natalie Jeremiienko – Bureau of Inverse Technology Engineering Created "Despondency Index" - correlating the Dow Jones Industrial Average with number of jumpers Detected by "Suicide Boxes" containing motion-detecting cameras, under the bridge. Boxes recorded 17 jumps in three months

44. High Risk Occupations US Data from 10,000 suicides and 135,000 deaths 15 occupations with higher / lower risk than the general pop. Reduced to 8 after adjustment for socio-demographics Dentists (X 5.4) Doctors (X 2.3) Scientists (X 1.5) Nurses (X 1.5) Social workers (X 1.5) Artists (X 1.2) Farm workers (X 0.69) Admin staff (X 0.85) UK picture different – suggests Farm workers & Veterinary have one of highest rates (Mellanby, 2005)

45. Predicting Occupational Risk • Stack (2001) Four stage model • Internal job stress • Job with Opportunity for suicide  dentists, vets, pharmacy, farming • Pre-existing psychiatric morbidity • Socio-demographics ???? • May explain differences in WS but not WRS • Psychosocial factors at work • stress leads increased • demands to risk of • control job ill • support strain health ?

46. Job Specific Factors • Vets and Farmers • Functional use of euthanasia • Facilitate a “Good death” • Long working hours • Rural isolation • Client dependence • Social isolation • Not adapting to change / flux • Attitudes to suicide and (non) help-seeing behaviour • This may serve to make suicide seem like a plausible solution to problems • Jobs with “Gallows Humour” Police, Nursing, Military, Fire, Ambulance ?

47. Suicide Space • Access to lethal means • Opportunity for solitude • Freedom of movement • Location away from assistance

48. Behavioural Yellow Flags • Observable in 75% of decedents in few weeks before death • Previous suicide attempts • History of suicide in family • Begin “tidying up” affairs • Person acting completely out of character • Symptoms of depression • Hopelessness about the future • Periods of difficulty and change – holiday periods, prior to disciplinary hearings

49. More Behavioural Yellow Flags • recent bereavement or other life-altering loss • recent break-up of a close relationship • major disappointment (failed exams or missed job promotion) • major change in circumstance (retirement, redundancy, children leaving) • physical illness • mental illness • substance misuse / addiction • deliberate self-harm, (particularly in women) • previous suicide attempts • loss of close friend / relative by suicidal means • loss of status • feelings of hopelessness, powerlessness and worthlessness • declining performance in work and other (sometimes this can be reversed) • declining interest in friends, sex, or previous activities • Neglect of personal welfare and hygiene • Alterations in sleeping habits (either direction) or eating habits

50. Background • Hunch #1 • Greatest risk of suicide in UK males = 16-44yrs (the working years) • Japan has greatest suicide rate in world • UK working becoming similar to Japan e.g long hours • unpaid overtime • schooling system • Hunch #2 • Jobs with greatest exposure to deaths / suffering • Jobs with death as a “practical solution” • Jobs with means of effective suicide • Jobs with “gallows humour” • Hunch #3 • Economic downturn • Recession • Redundancies Observable increase in suicides Comparable between jobs Adjust for sociodemographic factors Assess Occupational Risk