Journal of Employee Assistance 2nd Quarter 2019 by Employee Assistance Professionals Association

2nd Quarter 2019 | VOL. 49 NO. 2

The magazine of the Employee Assistance Professionals Association

Where Do We Go From Here? |Page 10

Bonus! Read Cover Story for PDH!

PLUS:

Cannabis Issue Evolving Rapidly

Suicide Prevention in Korea

Page 14

Page 18

Going Digital: A Roadmap for EAPs Page 22

Plan to Attend EAPA 201 St. Louis

St. Louis Union Station Hotel, Curio Collection by Hilton St. Louis, Missouri, USA

Main Conference

Wednesday, September 25 â&#x20AC;&#x201C; Friday, September 27 Pre-Conference Sept 23-24 | EXPO Dates Sept 24-26

contents EAPA Mission Statement

2ND Quarter 2019 | VOL. 49 NO. 2

cover story

Where Do We Go From Here?

| By David A. Sharar, PhD

features

Going Digital: A Roadmap for EAPs

| By Navya Singh, PsyD;

Tom Shjerven, CEBS

Why don’t most workplace buyers choose higher cost and higher-value EAPs? … What is needed most is a way for providers of EAP to connect and quantify value for workplace customers and to measure and verify that customers actually received the value that was promised.

To differentiate themselves in today’s costconscious health landscape, EAPs need to know what to look for in an “enabling” technology that allows them to extend their expertise and deliver better results to more people…and for less money.

features

Attitudes, Laws Concerning Cannabis Evolving Rapidly

| By Tamara Cagney, EdD, CEAP

Not since the advent of managed care have employee assistance professionals seen a shift in public health and public opinion as far reaching as the rapidly evolving attitudes and laws concerning cannabis. Areas of concern for employee assistance professionals include: The potential for addiction to cannabis; and limited insurance coverage and access barriers to treatment for cannabis use disorders.

Special Report: Suicide Prevention in Korea

| By Jongmin Woo, MPH, PhD In 2017, the Korean government set up the goal of decreasing the nation’s suicide rate as one of four main national agendas, while increasing financial and human resource commitments 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.

Breastfeeding & Work in Latin America: Is There a Role for EAPs?

| By Andrea Lardani There is no doubt that women who work in an environment where their right to breastfeed is supported are more motivated and engaged. Absenteeism, requests for medical appointments, and medical leaves decrease …

departments 4 FRONT DESK 6 TECH TRENDS

8 LEGAL LINES

To promote the highest standards of practice and the continuing development of employee assistance professionals and programs. The Journal of Employee Assistance (ISSN 1544-0893) is published quarterly for $13 per year (from the annual membership fee) by the Employee Assistance Professionals Association, 4350 N. Fairfax Dr., Suite 740, Arlington, VA 22203. Phone: (703) 387-1000. Postage for periodicals is paid at Arlington, VA, and other offices. POSTMASTER: Send address changes to the Journal of Employee Assistance, EAPA, 4350 N. Fairfax Dr., Suite 740, Arlington, VA 22203. Persons interested in submitting articles should contact a member of the EAPA Communications Advisory Panel (see page 4) or the Editor, Mike Jacquart, by calling (715) 445-4386 or sending an e-mail to journal@eapassn.org. To advertise in the Journal of Employee Assistance, contact James B. Printup at development@eapassn.org. Send requests for reprints to Debbie Mori at d.mori@eapassn.org. ©2019 by The Employee Assistance Professionals Association, Inc. Reproduction without written permission is expressly prohibited. Publication of signed articles does not constitute endorsement of personal views of authors. Editor: Mike Jacquart Development & Donor Relations: Jim Printup Designer: Laura J. Miller, Write it Right LLC

Index of Advertisers ASAP ...................................................7 EAPA Plan to Attend ........................IFC

5, 21, EA ROUNDUP 31, 32 26 THE WORLD OF EAP 34 LETTERS 35 WEB WATCH

EAPA Unlimited Access Package ......BC Harting EAP .........................................5 KGA, Inc. ...........................................17 SAPlist.com ...................................9, 23 IFC: Inside Front Cover BC: Back Cover

frontdesk EA Services – The Price is NOT Right

Advice in Cover Story Vital to EA Profession | By Maria Lund, LEAP, CEAP

he cover story in this issue of the Journal of Employee Assistance is essential reading for EAP practitioners. Dave Sharar, an esteemed, longtime EA professional, presents a sometimes painful, but necessary reality check about the state of the EA profession. As Dave aptly puts it, “We need a better way to get paid – a method that rewards EA vendors for delivering superior value to employees (clients) and employers – in other words, for achieving outcomes at a reasonable rate.” Along similar lines, EAPA CEO Greg DeLapp explains in a foreword to Dave’s important article: “The missing link that can promote our field lies in measuring the outcomes of EA services. We concretely need to demonstrate the results of our efforts.” Later in his article, Dave describes detailed alternatives to capitated pricing. Whatever the payment method, the key lies in measuring and illustrating the positive results of EAP. This month’s cover story is important for another reason. Starting with this edition of the JEA, EAPA will offer one free PDH for reading the cover story of each issue and answering a 5-item multiple choice quiz. Read

Dave’s article, “Where Do We Go From Here?” and answer the multiple choice questions at bit.ly/PDH_Q2JEA2019 (URL is case-sensitive). Instructions are provided at the end of the quiz on how to get your free PDH. Since wellness is increasingly becoming part of our employee assistance services, Andrea Lardani makes a compelling case for how EA professionals can assist with issues around breastfeeding in the workplace. Marina London also presents a wellness angle for service in her Tech Trends column, “Screen Time for Children & Adults: An Opportunity for EAPs.” Elsewhere in this issue of the JEA, Jongmin Woo continues a three-part report on suicide around the world by examining suicide prevention efforts in Korea. Jodi Jacobson Frey will examine suicide in the US in the last installment of this series. Trends and legislation regarding medical and recreational marijuana are changing rapidly. Tamara Cagney discusses the current state of this issue in another important feature.

Shjerven present concrete examples of how EAPs can move core programs to a digital platform. Finally, we would love to hear your thoughts about the new, alldigital JEA. Comments are always welcome on EAPA’s LinkedIn page or via email at journal@ eapassn.org. As always, happy reading! v

EAPA Communications Advisory Panel Maria Lund, Chair – Columbia, SC maria.lund@firstsuneap.com

Mark Attridge – Minneapolis, MN mark@attridgeconsulting.com

Nancy R. Board – Seattle, WA nrboard@gmail.com

Daniel Boissonneault – Hamden, CT eap700@comcast.net

Mark Cohen – New York, NY mcohenintlcons@aol.com

Donald Jorgensen – Tucson, AZ donjorgensen@comcast.net

Andrea Lardani – Buenos Aires, ARG andreal@grupowellnesslatina.com

Peizhong Li – Beijing, China lipeizhong@eapchina.net

John Maynard – Boulder, CO johnbmaynard8@gmail.com

Bernie McCann – Waltham, MA

Technology is an increasingly important part of our practices, and Navya Singh and Tom

mccannbag@gmail.com

Igor Moll – Al Den Haag, the Netherlands l.moll@ascender.nl

earoundup Workplace Options Acquires Rehalto; Expands in India Workplace Options, the leading provider of integrated global employee well-being solutions, announced that it has acquired Rehalto, a European pioneer in the development of workplace wellbeing, from SCOR, the world’s 5thlargest reinsurance company. The acquisition further strengthens Workplace Options position in both France and Belgium. Workplace Options’ global reach, network, and integrated phone and case management systems provide enhanced solutions for multinational clients.

Workplace Options has also expanded its Bangalore, India, service center to include a second office location in a neighboring building. The India service center, which opened in 2013, includes a team of counselors and credentialed specialists that provide employee support, as well as teams responsible for sales, account management, implementation, and information technology (IT). Workplace Options is the world’s largest independent provider of employee wellbeing support solutions, serving employees in more than 200 countries and territories worldwide.

EAPA Sets Webinars Want to take the CEAP exam this year? EAPA will be offering a series of live webinars to prepare for the CEAP in June 2019. Online CEAP exam prep courses will be held June 4, 6, 11, and 13. The courses provide CEAP candidates with the knowledge and skills necessary to successfully evaluate questions on the CEAP exam. To learn more, contact Julia Barnes, EAPA Education Administrator, (703) 387-1000, extension 318, or email j.barnes@ eapassn.org Continued on page 21

techtrends Screen Time for Children & Adults An Opportunity for EAPs

| By Marina London, LCSW, CEAP

pregnancies, and puts children at a higher risk of being victims of sexual violence. It molds and shapes their values and attitudes towards themselves and how they view others around them. This can often lead to a distorted perception of reality, a devaluation towards human life in general, as well as trivializing violent behavior.

n October 2018, The New York Times published the article, “A Dark Consensus About Screens and Kids Begins to Emerge in Silicon Valley.”

Essentially, the article asked technologists in Silicon Valley about their struggle to limit the screen time of their children. Counterintuitively, the people who invented social media and apps are much stricter about screen time on average, than the rest of us. They believe, “the benefits of screens as a learning tool are overblown, and the risks for addiction and stunting development seem high.”

From a tech standpoint, I believe that too much screen time, and screen time that exposes children to toxic imagery is possibly the greatest issue facing the parents of the under-18 generation. And it’s not just children who are being damaged. Adults are also struggling with the lure of the screen.

How big of a problem is the misuse of screen time by children? The Novus Report is a nonprofit dedicated to preventing the relationally damaging effects of media misuse and explicit material by engaging students, families and schools through awareness, tools, and support.

Thus I think there is a golden opportunity for employee assistance professionals to inform themselves about current best practices related to screen time so they can advise employee clients on this issue and potentially create workplace presentations on these topics as well.

They cite studies showing that: 90% of young men age 18 have been exposed to pornography, much of which is hard-core (meaning it often involves violence and overtly explicit imagery); Of the 90%, the average age these young men were sexualized by pornography was between 8-11 years old; Similarly, 60% of young women by the age of 18 have been exposed to porn as well. Almost 80% of this exposure, which isn’t always voluntary, is happening in the perceived safety of their homes; 90% of the 8 to 16-year olds who have viewed online porn did so while doing homework; and 60% of families who give their children smartphones, do so between the ages of 10 and 11. (20% give their children phones between the ages of 8 and 9.)

Going back to the Times article, here are three different approaches to screen time: Parent number 1: Daughters, ages 5 and 3, have no screen time “budget,” no regular hours they are allowed to be on screens. The only time a screen can be used is during the travel portion of a long car ride or during a plane trip. Parent number 2: Children aren’t allowed to have cellphones until high school, are banned from phone use in the car and severely limited at home. Parent number 3 (The more comprehensive approach I liked best): “...no phones until the summer before high school, no screens in bedrooms, network-level content blocking, no social media until age 13, no

Novus argues that ongoing exposure to this material can lead to sexual addiction, unplanned 6

iPads at all and screen time schedules enforced by Google Wifi controlled from his phone. Bad behavior? The child goes offline for 24 hours.”

Advertise in

The reality is that opinions about best practices limiting screen time are all over the spectrum. Some parents believe that all children should learn to code at an early age. Others don’t believe in strict limits, they’ll argue they watched TV all the time as a child and still became successful.

Contact Jim Printup, Development & Donor Relations: (303) 242-2046, development@eapassn.org

There is a dearth of research on the subject, in part due to the lightning speed with which technology evolves. As soon as we establish best practices, we are faced with a new evolution. In our lifetimes, virtual reality environments will be increasingly perfected, and some of us will be able to drop out of the real world entirely. (Note: For an excellent illustration of how that might impact our children and grandchildren, read “Ready Player One” by Ernest Cline.) Of course, the difficulty is that regardless of the rules in your house, other children may have cell phones and tablets, and it is easy to go over to a friend’s house after school and use their devices. The Novus Project offers a range of resources for students, parents and educators. They favor a multi- pronged approach that includes using parental control software and talking to children as early as elementary school about the danger of pornography and explicit material. As stated earlier, EAPs have the opportunity to be on the front lines when it comes to developing education, and interventions for all of their clients. This is not a problem that is going to go away. v Marina London is the Director of Communications for EAPA and author of iWebU, (http://www.iwebu.info,) a weekly blog for mental health and EA professionals who are challenged by social media and Internet technologies. She previously served as an executive for several national EAP and managed mental health care firms. She can be reached at m.london@eapassn.org.

Resources A dark consensus about screens and kids begins to emerge in Silicon Valley (2018, October 26). Nellie Bowles. The New York Times. Retrieved from https://www.nytimes.com/2018/10/26/style/ phones-children-silicon-valley.html The Novus Project. Retrieved from http://thenovusproject.org/

legallines #MeToo on the Move

Sexual Harassment Laws Impacting Employers | By Robin Sheridan, JD, MILR

ver since the #MeToo and #TimesUp movements shined a national media spotlight on sexual harassment in the workplace, state legislatures have passed bills regarding various aspects of sexual harassment. The latest guidance may require employers to take additional action in developing policies and procedures related to sexual harassment, and training employees to respond to workplace issues and promote safe work environments. It is imperative that EA professionals are aware of these developments. Legal Updates In the past 30 months, elected officials in numerous states passed more than 260 laws directly addressing topics supported by anti-sexual harassment initiatives. Most of the proposals are related to the actions of legislators and government employees, but some are directed toward other employers – those in the private sector specifically. In summary: Twelve states (Arizona, California, Delaware, Illinois, Louisiana, Maryland, Nebraska, New York, Oregon, Tennessee, Vermont, and Washington) enacted laws that affect both private and public employers. Eight states (California, Delaware, Florida, Louisiana, Maine,

Maryland, New York, and Oregon) passed legislation that requires regular sexual harassment training for employees at various levels. Four (Maryland, New York, Vermont, and Washington) limited employers’ ability to enforce mandatory arbitration for workplace sexual harassment claims in employee contracts. The impact of these legislative moves may be blunted by the Supreme Court of the U.S.’s decision in Epic Systems Corporation v. Lewis. At the state and local levels, these laws have more variations, and the combination or types of laws indicate the direction or impact of certain industries, locales, and other factors. Hall Render attorneys surveyed a few states’ legislative developments as examples. California S.B. 1300 is a comprehensive bill that creates and amends state laws on sexual harassment in the workplace. It went into effect on January 1, 2019. The bill makes it unlawful for employers to require employees to sign non-disparagement or other agreements prohibiting employees from disclosing unlawful acts in the workplace, including sexual harassment, as conditions of employment or continued employment.

The law also expands sexual harassment liability for employers where the harassment is committed by a non-employee, such as a customer or vendor, and limits employers’ rights to fees as a prevailing defendant. The law permits employers to provide bystander training that encourages and enables an active response to assist victims rather than remaining silent. Finally, the law provides guidance for courts in applying the new harassment laws. As but one example, by 2020 employers with five or more employees must provide sexual harassment prevention training to both supervisory and non-supervisory employees at least once every two years. New York As of January 1, 2019, all state contractors must submit a declaration that they have a sexual harassment prevention policy that adheres to at least a minimum set of criteria and that they provide annual training to all employees. By October 9, 2019, all public and private employers in the state are required to adopt a sexual harassment policy meeting those same minimum criteria and provide copies and yearly training to employees. Beginning April 1, 2019, the Stop Sexual Harassment in NYC

Act signed by the mayor requires employers with 15 or more employees to conduct annual antisexual harassment training for all employees. The local law outlines required topics to be discussed during the training, including not only employer, state, and federal complaint processes but also bystander intervention, which may be required for certain managerial or supervisory employees. Since July 11, 2018, most new employment contracts cannot require employees to submit to mandatory arbitration for sexual harassment allegations and claims. Vermont As of July 1, 2018, HB 707 prohibited all employment agreements from containing provisions that restrict or waive an employee’s rights or remedies with respect to a claim of sexual harassment. The law also requires that settlement agreements resolving sexual harassment claims include a provision that the employee may report sexual harassment or cooperate with any investigation about the issue. Such settlement agreements must not restrict the employee’s ability to work for the employer in the future. The law further authorizes workplace audits by the Attorney General for compliance with the sexual harassment laws, such as the requirement that employers provide copies of their sexual harassment policies to new hires and other employees. Finally, because “employees” is defined so broadly in the statute, the law can be read to protect not only employees but also interns, volunteers, and independent contractors.

Court Developments Certain decisions may influence how employers choose to handle actual or potential sexual harassment claims. For instance, in Minarsky v. Susquehanna County, the Third Circuit Court of Appeals decided on July 3, 2018 that Sheri Minarsky’s four-year delay in notifying her employer, Susquehanna County, of sexual advances made by her supervisor was not per se unreasonable and vacated an order granting the defendant-employer summary judgment on the issue. In so holding, the court acknowledged several legitimate reasons for not reporting her supervisor’s behavior earlier, including her fear of job loss due to financial need in light of her daughter’s cancer treatments and the employer’s unfavorable handling of a previous employee’s complaint of misconduct. The U.S. Supreme Court in Epic Systems Corporation v. Lewis, decided May 21, 2018, questioned whether employment contracts requiring individualized arbitration for resolving disputes are enforceable if they are intended to prevent multiple employees from suing an employer jointly. The Supreme Court held that arbitration agreements providing for one-on-one or individualized proceedings must be enforced, and neither the Federal Arbitration Act’s saving clause nor the National Labor Relations Act suggests otherwise.

already, employers should check for updates to laws in their cities and states and ensure that their policies and procedures align with the current laws and court decisions. With the heightened awareness of sexual harassment brought about by #MeToo and #TimesUp, employers should expect additional legislation and court decisions to impact their workplaces. It behooves EA professionals to keep up with court and legislative actions. v Editor’s note: The recommendations provided in this article are for educational purposes only and are not to be construed as actual legal advice. Always consult with a local attorney. Robin M. Sheridan is an attorney with Hall, Render, Killian, Heath & Lyman, PC, the largest health care-focused law firm in the country. Robin may be reached at (414) 721-0469 or rsheridan@hallrender.com.

Practical Takeaways In just two years, states have adopted a number of laws and saw a number of court cases related to sexual harassment that impact both public and private sector employment. If they have not done so 9

coverstory Where Do We Go From Here? Improving Value and Pricing in EAP

| By David A. Sharar, PhD

Foreword

One of the key expectations of purchasers and providers of EA services is that those services will be high quality in design and implementation, comprehensive in delivery, and performed at a reasonable cost. Moreover, purchasers and providers expect that these services will be easily accessed by the user, and there are both stated and implied benefits for all parties involved.

marketplace, and the latest cost pressures from benefits consultants. We cede control of the EA narrative to others when we fail to measure our own effectiveness. We have a fundamental challenge in the EA business: pricing for EA service delivery is low (for many reasons); yet we have a tough sell because we don’t establish the value of our services in ways that are tangible. The value of EA services (and our future) is absolutely linked to the ability to measure the outcomes of our activity.

Most of the field has been working without common definitions of what constitutes quality, comprehensive services, easy accessibility, or reasonable cost.

The following article by longtime EA colleague David A. Sharar, PhD, is simultaneously infuriating (how did we get to this point?) and invigorating (there is a path forward). Let’s collectively read, absorb, react, discuss, and do what we do so well in the EA profession: intervene, assess, and move to resolve problems. In this case –our own.

The missing link that can promote our field lies in measuring the outcomes of EA services. We concretely need to demonstrate the results of our efforts. If results are not measured, they are merely impressions or opinions. If impressions or opinions are the basis for EA business, then we subject ourselves to the whims of the

Gregory P. DeLapp. MHS, CEAP CEO – EAPA

hy are many EAP practitioners reluctant to change when change is crucial to the survival of our profession? But my intent in writing this article is not to be negative or overly critical, but rather to realistically and truthfully confront the current state of the employee assistance profession. Rather than just addressing our problems, I will also propose solutions later in this article.

decreased over the past three decades. The once standard internal EAP – where EA staff are full or part-time employees of the employer sponsoring the EAP service – has largely been replaced by external programs or outsourced vendors (Frey, Pompe, Sharar, Imboden, and Bloom, 2018). Many longstanding internal programs have been downsized or eliminated in favor of cheaper external providers. The continued push for vendor consolidation (acquisitions & mergers) has moved the field towards “product parity”. In other words, external EA vendors tend to look similar in terms of program features and services.

PEPM Rates Per-employee-per-month (PEPM) rates for Employee Assistance and Work-Life have significantly 10

This makes it difficult for EA service providers to differentiate their services from the features and offerings of competitors. Price increases are generally viewed by EA vendors as significant threats to contract retention and by employer customers as expenses to be suppressed or avoided. Marginal service providers typically receive about the same rate as “optimal” ones due to the “invisible” nature of the way EAP cases are handled and managed. Service quality is highly variable and some EAP clients receive optimal care but many do not. We lack common definitions and agreed upon markers of success so that buyers can accurately compare vendors and program models using the same “yardstick”. As a field, our approach to metrics and measurement tends to be blunt, simplistic, and even at times exaggerated or distorted. Many employers don’t know a good performance measure from a bad one. Unlike the early days of EAP, there now seems to be a high degree of apathy and lack of senior management engagement in selecting and supporting EA vendors. Decision-making around EA purchases, particularly for large employers, has migrated to purchasing departments and benefit consultants who frequently consider buying decisions from the myopic perspective of low cost. Trying to penetrate a different center of buying influence in today’s workplace benefits labyrinth is filled with constraints.

ing a kind of “managed care” type of EAP. How as a field do we compete on who is actually best at resolving employee (client) personal and work problems rather than on marketing pizzazz, under-utilized features, and the albatross of the field – the lowest possible price? Sad State of Pricing A proprietary, fee-based procurement website that summarizes benchmark pricing for purchasing agents revealed that the PEPM fee for comprehensive EAP services in 2018 was $1.08. A phone-only model showed a $0.60 PEPM; a three-session model, 0.77, and a six -session model was paying $1.71 PEPM. An employer with 2,000 + employees was paying around $0.96 PEPM – a smaller employer with roughly employees around $1.58 PEPM. Adding on “work-life” referral and resource services increases the PEPM by only about $0.08. During the 1990s that same three-session model averaged $1.58 PEPM or $19.00 per-employee-per-year (PEPY) while a six-session model averaged $2.08 PEPM or about $25.00 PEPY (Sharar and Hertenstein, 2006). Figure 1: Per-employee-per-month rates: 1990s compared to 2018 Model 1 – 3 sessions 1 – 6 sessions Benchmark

“Free” EAPs Buyers of workplace services are generally incentivized to drive down price and reduce higher level value propositions to the lowest common denominator. There is even a clear trend for certain insurance and disability carriers to bundle EAP into their core insurance products and offer it for “free” (Sharar and Burke, 2009). Of course the so-called “free” EAP is not really free, but the buried low price of the program allows the insurer to easily absorb the EAP expense into their overall plan fees. Put another way, the EAP is sold at or below cost to attract attention to a higher margin product. This overall state of affairs in EA has hobbled true innovation and allowed pseudo-innovation and marginal quality, with no meaningful way to neither measure and compare value, nor thrive in EA work. Sadly – in spite of this state of affairs – some EA providers eke out a profit by insidiously implement-

1990s $1.58 PEPM $2.08 PEPM $1.83 PEPM

2018 $0.77 PEPM $1.71 PEPM $1.08 PEPM

Consider the low-cost nature of EAP pricing by comparing outpatient mental health counseling or psychotherapy services with a typical employer-sponsored health plan to an EAP. When psychiatry (medical) and pharmacy are excluded and average, proportionate administrative loads (for outpatient mental health only) are factored in, what remains in the health plan is outpatient counseling or psychotherapy with a licensed “helping” professional (e.g. psychologist, social worker, counselor, or family therapist). After deducting typical employee co-payments, a converted PEPM rate for the outpatient mental health portion of a health plan is $11.00 or a PEPY of $132.00 (S. Melek, personal communication, January 25, 2017). In contrast, the current benchmark price for an EAP is $1.08 PEPM or about $13.00 PEPY. 11

coverstory Figure 2: Per-employee-per-year conversion: Outpatient mental health compared to EAP Self-funded outpatient mental health Benchmark EAP

Much like Walmart, the largest vendors have reduced their costs and prices over time and pursued high volume in order to try to make money on thin margins and managed or low-service utilization. These types of commodity sales exist because some EAP providers – particularly the largest ones – have deliberately selected and pursued this type of sales strategy. Commodity-type sales encourage buyers to ignore a real value proposition in the quest for the lowest price Buyers of EAPs think they are making solid decisions with low-price proposals but in reality the decision is frequently flawed. This is because buyers are shielded from the actual cost to deliver an EAP – costs that are usually invisible or hidden by what appears to be a byzantine system of deflecting or reducing the type and amount of service utilization.

$132.00 PEPY $13.00 PEPY

The average number of counseling sessions per case in a typical employer-sponsored health plan is about 8, with a utilization rate of 7.6% for a typical employer (S. Melek, personal communication, January 25, 2017). The average number of counseling sessions per case in EAP is 2.47 with a utilization rate of 4.5% (Granberry et al, 2013). It is not empirically known what percent of cases overlap or use both EAP and outpatient mental health in the employer’s health plan. Keep in mind the global prevalence of common mental health issues in a workforce is 17.6% (12-month estimate). With an average EAP utilization rate of 4.5%, consider that a portion of that 4.5 % is “sub-clinical”, meaning the employee has emerging symptoms or “life” issues but does not necessarily meet the diagnostic criteria for a “disorder”. There is a clear need for EAPs to significantly increase utilization, create a cost “off-set” in the employer’s health plan, and of course get paid more for doing so. A self-funded employer spends a combined total of $145.00 PEPY for outpatient counseling/therapy + EAP, but only about 11% of that amount is allocated for EAP. EA providers can and should find a way to take a much larger share of the $145.00 rate.

Examples of Care “Invisible” to Purchaser The following are examples of how this byzantine system of deflection makes substandard care largely invisible to the employer purchaser. It is important to note that the pervasiveness of these illustrations is unknown, and the sources include ex-employees from large EA vendors who confidentiality stated these were deliberate strategies to manage the cost and utilization in order to squeeze a profit margin out of a low bid. After an initial telephone intake consultation, the employee is carefully “steered” towards (a) receiving self-care instructions, (b) a referral to a website or online program, or (c) a direct specialist referral covered under the employee’s health benefit plan with co-pays and deductibles (not “free” EAP counseling for up to six sessions). The employee’s situation is addressed at the EAP call center with a single phone call and no actual intervention or brief counseling with a qualified professional working for the EA vendor. With this approach, the EA vendor avoids payments to an “affiliate” clinician at an average rate of roughly $70.00 per session.

Commodity Sales and Reduced Profits A common but tragic strategy in EAP sales is to use an approach that, “we can give you the same (or better) program as the higher cost bidder for 40% (or more) less”. Some vendors make their pitch even better by adding new, shiny, “technology” features to their package of EAP solutions, even when it’s not clear when these features actually add incremental value or contribute to a measurable outcome. It seems these features frequently end up being more of a “sales strategy” than a genuine utilized tool for ongoing employee or user engagement and ultimate behavioral or lifestyle change. This feeble but highly successful sales argument works because the buyer cannot discern how the various bidders differ from one another and the more expensive bidders cannot clarify the value underlying their higher cost.

Definitions of “utilization” vary significantly by vendor, and some providers use inconsistent definitions to inflate or distort actual utilization rates and services. This gives the employer (customer) an impression of good or acceptable vendor performance 12

without knowing how the utilization metric was determined and calculated – or exactly what modality was used to serve employees (e.g. telephone, online, or face-to-face).

as sellers overestimate the actual value of our value proposition OR we overestimate the buyer’s ability to understand and comprehend our value proposition. What is needed most is a way for providers of EAP to connect and quantify value for workplace customers and to measure and verify that customers actually received the value that was promised. This solution must include the credible and rigorous measurement of outcomes. It must also include common and agreed-upon standards for defining a “case”, calculating “utilization”, and describing service modalities at the individual employee or “user” level. Without these standard definitions, variations in utilization rates and performance metrics are an illusion created by differences in methodologies and calculations rather than in vendor practices. We need to bring greater objectivity to this predominant theme of measuring value in EA services, which is now mostly subjective, anecdotal, and intuitive.

Capitation Does Not Lead to Better Value or Rate Increases We need a better way to get paid – a method that rewards EA vendors for delivering superior value to employees (clients) and employers – in other words, for achieving outcomes at a reasonable rate. Our dominant payment model – capitation or “per-employeeper-month” (PEPM) – is arguably one of the biggest obstacles to improving our place in the employer’s portfolio of benefit offerings. Redefining and carefully measuring value is absolutely essential to (1) understanding our actual performance, and (2) increasing our rates. Under the prevailing method of capitated pricing – where employers make a single PEPM payment for each covered employee regardless of service utilization – EA vendors with superior utilization and outcomes have no way to bill their superior services or higher utilization. Capitation fosters misaligned motives by having vendors assume financial risk against program use. It puts the focus on limiting the overall amount of services delivered without tying outcomes back to the individual employee. As a field, EA has struggled and largely failed to relate costs to the actual outcomes produced – and capitation has exacerbated if not largely caused this problem. Capitated pricing has also contributed to consolidation of EA vendors as vendors bear greater actuarial risk – and there is an incentive to amass as large a population of covered employees as possible to spread risk and “make it up with volume”. The end result has been the emergence of a few dominant national and global EA vendors, which ultimately reduces competition. Capitation not is the right solution to fundamentally change the trajectory of a stagnant field and will fail to drive the need for true accountability for outcomes. Employers, and their purchasing representatives need to move to value-based reimbursement models that tie payments to achieving outcomes that matter to employees and employers. Why don’t most workplace buyers choose higher cost and higher-value EAPs? One of two reasons: we

Value Should be about Outcomes Michael Porter defines value as, “outcomes achieved relative to costs incurred” (Porter and Kaplan, 2018). Using this definition of value, the success of EA work exclusively depends on measuring employee outcomes or the actual results of services, not just the volume or process of service delivery. An EA vendor cannot really have a true value proposition unless that proposition includes the measurement of results – outcomes that occur after the EAP intervention is complete (which does not mean a post-EAP-use measure at the last session), are the end result of the intervention, and are directly linked to the intervention. It’s really only about what degree the EAP intervention correlates with improved work effectiveness, life functioning, or symptom reduction. In the world of EA work, what else matters? We can no longer afford to obscure the link between EAP processes and outcomes. Access is a basic requirement to achieving an outcome, but access per se does not constitute value. Client satisfaction with the process of EAP can be a contributor to outcomes but is not a true outcome. An EAP client can be pleased with the access experience, appreciate the EA vendor’s website, and even “like” his or her EAP counselor but have no improvement clinically or in the work setting. Continued on page 33 13

featurearticle Attitudes, Laws Concerning Cannabis Evolving Rapidly | By Tamara Cagney, EdD, CEAP

ot since the advent of managed care have employee assistance professionals seen a shift in public health and public opinion as far reaching as the rapidly evolving attitudes and laws concerning cannabis. Although cannabis is an illegal drug under US federal law and the Americans with Disabilities Act does not protect its use, even for medicinal purposes, a majority of states have now legalized its use in one form or another. Ten states have now legalized cannabis for adult recreational use, while 33 states including the District of Columbia, Guam, and Puerto Rico allow medical use. In 2018 Canada legalized adult recreational use of cannabis nationwide. Proposals for loosening America’s federal prohibition abound in Congress and cannabis seems to be on an unstoppable roll to legalization in the United States. Some 65 percent of Americans favor legalization, and several potential candidates for US president support ending federal prohibitions on cannabis. Here are the states that are most likely to legalize cannabis for adult recreational use in 2019, in alphabetical order: Connecticut - Gov. Edward Lamont calls “legalization an idea whose time has come.”

Illinois - Gov. J.B. Pritzker says “legalizing marijuana would create 24,000 jobs.” Minnesota - Gov. Tim Walz “trusts adults to make personal decisions based on their personal freedoms.” New Hampshire - The Granite State is one place that could legalize cannabis in 2019 even with strong gubernatorial opposition. New Jersey - Garden State Gov. Phil Murphy has continued to push for an end to prohibition. New Mexico - Gov. Michelle Lujan Grisham states “marijuana will bring hundreds of millions of dollars to New Mexico’s economy.” New York - Gov. Andrew Cuomo says that ending cannabis prohibition is one of his top priorities for 2019. Rhode Island - Gov. Gina Raimondo says that her state might be effectively pressured into ending cannabis prohibition by neighboring states. Shift Toward Employee Protection Courts in Rhode Island, Massachusetts, and Connecticut have offered workplace protections for employees utilizing medical cannabis off duty and there are no signs that this trend will end. But EA professionals should be aware that these laws

are far from uniform, and the courts have taken different views on the enforceability of zerotolerance policies. Two recent cases illustrate this conundrum: The U.S. Court of Appeals for the Ninth Circuit held that Montana law permitted an employer to discharge an employee for testing positive for cannabis use. The U.S. District Court for the District of Connecticut held that Connecticut law prohibited an employer from rescinding an offer of employment to an applicant who used medical cannabis. In a significant shift away from decisions in favor of employers, both courts agreed that the federal Drug Free Workplace Act does not preempt state legalization laws, and every employer must be cognizant of applicable state requirements to accommodate or not to discriminate against cannabis users. Public Attitude Continues to Evolve The huge shift in public attitudes to cannabis is fed by a decreased sense of risk and increased access to the drug. The US moves towards legalization even though most Americans do not use the drug. Only 15 percent

of people over 12 used it even once in 2017, according to a large federal survey. That year, only three million people tried it for the first time. Unfortunately, there has not been a loud and clear message that the cannabis of today is not the same as the pot of the 1970s. Many Americans remember cannabis as a relatively weak drug that they used casually in social settings like rock concerts. In the 1970s and 1980s, cannabis generally contained less than 5% THC. Today, the cannabis sold at legal dispensaries often contains a minimum of 25% THC. In fact, many people use extracts that are 80% THC or higher. In other words, there has been a dramatic change in the drug’s potency even though the general public does not perceive cannabis as being any more dangerous than it was decades ago. In fact, we do not know the impact of prolonged use of high potency cannabis, especially on developing addiction. And although legalization hasn’t led to a big increase in Americans trying the drug, it has meant that those people who already use it do so far more frequently. In 2005, about three million Americans used cannabis every day. Today, the figure is eight million. Put another way, about one cannabis user in five uses it daily. By contrast, only one in every 15 drinkers, about 12 million Americans, consumes alcohol every day. Not long before Canada legalized nationwide adult recreational use of cannabis, Beau Kilmer, a drug-policy expert with the RAND Corporation, testified before the Canadian Parliament. He warned that the fastest-growing segment of the legal market in Washington State was extracts for inhalation, and that the mean THC concentration for those products was more than 65%. “We know little about the health consequences— risks and benefits—of many of the cannabis products likely to be sold in nonmedical markets,” he said. Nor do we know how higher-potency products would affect THC consumption.

Tips for Increasing Use of EAP

ost organizations are not reaping the full financial benefits of having an EAP. Business Management Daily offers the following suggestions for boosting use of the EAP: Make it convenient. Employees are more likely to use the EAP if counselors are a short drive from work, or they can access them 24/7 by phone or online. Emphasize confidentiality. Employees are more likely to use EAP services if they are not concerned about co-workers knowing about it. Host wellness seminars. For instance, free lunchtime “brown bag” sessions on topics like stress management or time management. Inform families. Let employees’ families know they can contact you. Offer information about your services, hours, and phone numbers. Publicize, publicize, publicize. Promote your EAP regularly through emails, website updates, and free posters and refrigerator magnets that list hours and phone numbers. Remind employees there’s more to EAP than they might think. Stress that the EAP is available for personal reasons such as financial concerns, relationship counseling, and others. Encourage staff to bookmark the EAP. Add a link on a company intranet to the EAP site.

Health Impact and Implications Several years ago, the National Academy of Medicine convened a panel of 16 leading medical experts to analyze the scientific literature on cannabis. The report they prepared, issued in January 2017,

Train supervisors. Teach them how to recognize work problems and to recommend using the EAP as an option for improving work performance. v 15

featurearticle runs 468 pages. It contains no surprises, which perhaps explains why it went largely unnoticed. It simply stated, repeatedly, that cannabis, the drug North Americans have become enthusiastic about, remains a mystery. For example, smoking pot is widely supposed to diminish the nausea associated with chemotherapy. But, the panel pointed out, “there are no good-quality randomized trials investigating this option.” We have evidence for cannabis as a treatment for pain, but “very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.” Is it good for epilepsy? “Insufficient evidence.” Tourette’s syndrome? Limited evidence. A.L.S., Huntington’s, and Parkinson’s? Insufficient evidence. Irritable-bowel syndrome? Insufficient evidence. Dementia and glaucoma? Probably not. Anxiety? Maybe. Depression? Probably not. Proponents of legalization have postulated that the use of cannabis will decrease opioid overdoses. This analysis is complicated by the fact that the first wave of cannabis legalization took place on the West Coast, while the first serious wave of opioid addiction took place in the middle of the country. So, if all you do is eyeball the numbers, it looks as if opioid overdoses are lowest in cannabis states and highest in non-cannabis states. Areas of Concern Areas of concern for employee assistance professionals include:

• The potential for addiction to cannabis; • Limited insurance coverage and access barriers to treatment for cannabis use disorders; • The correlation with mental illness; • The dangers of someone who is high getting behind the wheel or performing safety sensitive work; • The long-term respiratory health impact of smoking (or second-hand exposure to) cannabis; and • Underage use of cannabis by youth. Judith Grisel, a professor of psychology and a practicing neuroscientist stated, “In our rush to throw open the gate, we might want to pause to consider how well the political movement matches up with the science, which is producing inconveniently alarming studies about what pot does to the adolescent brain.” With large studies in peerreviewed journals showing that cannabis increases the risk of psychosis and schizophrenia, the scientific literature around the drug is far more negative than it was 20 years ago. Substance Abuse and Mental Health Services Administration (SAMSHA) surveys also show that rates of serious mental illness are rising nationally, with the sharpest increase among people 18 to 25, the ones who are also the most likely to use cannabis. Surveys and hospital data cannot prove that cannabis has caused a population-wide increase in psychosis, but they do offer intriguing evidence.

Developments to Come In December 2018 one thing many people missed was the authorization of an unprecedented bill that ended federal prohibition for one strain of cannabis. The 2018 Farm Bill modified the Controlled Substances Act to exempt hemp from its definition of cannabis. Hemp preparations contain CBD, which is a chemical component of the cannabis sativa plant, more commonly known as marijuana. However, CBD does not cause intoxication or euphoria (the “high”) that comes from tetrahydrocannabinol (THC). What this means is that a category of cannabis called hemp, which contains less than 0.3% of the psychoactive ingredient THC, will be removed from its Schedule 1 classification under the Controlled Substance Act of 1970. The FDA is still developing regulations regarding CBD products sold as food, supplements or medication. Also in 2018 the U.S. Food and Drug Administration approved Epidiolex (cannabidiol) (CBD) oral solution for the treatment of seizures associated with two rare and severe forms of epilepsy. This is the first FDAapproved drug that contains a purified drug substance derived from cannabis. Next year will see still more movement in state legalization regardless of US federal classification of cannabis as a schedule I drug. Looking ahead to the 2020 presidential election, states like Arizona, Florida, Ohio, and North Dakota could consider ballots to fully legalize cannabis, while Mississippi,

Nebraska, and South Dakota could see medical cannabis questions.

Several firms are actively working to develop and bring to market a portable breathalyzer that would indicated recent use within 60 to 90 minutes. With today’s high potency cannabis that could be the gage for impairment. Expect to see more legislation that makes it unlawful for a business to take adverse action against an employee for off-premises conduct that is lawful or for a positive drug test for cannabis – unless the employer can show “by a preponderance of evidence that an employee’s lawful use of cannabis has impaired the ability to perform the employee’s job.” v

In Kansas, for example, Gov. Laura Kelly supports legalizing medical cannabis, setting the state up to join its neighbors, Missouri and Oklahoma, in allowing patients to use the drug with their doctor’s recommendation. Wisconsin Gov. Tony Evers says he wants to decriminalize cannabis and allow medical cannabis and supports letting voters decide on a referendum to fully legalize cannabis. In Pennsylvania, Gov. Tom Wolf, who until recently said that the state is not ready for legalization, now says that he’s ready to take a serious look at the issue. He also supports moving ahead immediately to decriminalize cannabis possession. In Texas, Gov. Greg Abbott indicated during a debate that he is open to some form of cannabis decriminalization and advocates will also push lawmakers to legalize medical cannabis. Finally, advocates are making it a priority to encourage South Carolina lawmakers to legalize medical cannabis.

Employee assistance professionals are in a unique position to consult with employers regarding cannabis policies, treatment benefits and disciplinary procedures. Check out “Cannbis@Work: Employee Assistance Professionals Toolkit”, at http://www.eapassn. org/CannabisatWork for additional information. Tamara Cagney, EdD, MA, BSN, CEAP, is an internal EAP at Sandia National Laboratories in Livermore, Calif. She is also Immediate Past President of EAPA. She may be reached at tcagney@sandia.gov.

Though cannabis legalization continues state by state, federal laws still prohibit its use, cultivation, and sale. With federal policy often at odds with states that have gone through with legalization and decriminalization of both recreational and medical cannabis, employers and businesses are put in a difficult position. Employers must balance complying with often divergent federal and state laws, maintaining a safe work environment, and protecting employees’ rights. Many experts have hypothesized that cannabis will not be rescheduled until a reliable test for actual impairment is available to employers and law enforcement. The fact that there is no scientific way to determine impairment, and that drug tests just indicate the presence of the cannabis metabolite that could be from ingestion days before, has employers reexamining their drug testing programs. So far only seven states, including Washington and Montana, have set legal guidelines as to how much THC in the system makes you dangerous behind the wheel. Yet some scientists are skeptical, saying those limits aren’t really backed by hard science.

KGA Life Services Because when it comes to work-life, experience matters most. Ask us how we can help enhance your EAP with KGA’s work-life fulfillment services. 800.648.9557 info@kgreer.com kgreer.com

featurearticle Special Report: Suicide Prevention in Korea | By Jongmin Woo, MD, MPH, PhD

he 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 mostcommon 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 halftimes 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 the nation’s suicide rate as one of four main national agendas, while increasing financial and human resource commitments 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.

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 https://www.mindtools.com/pages/article/ newTED_05.htm. An additional link explains the decision-making process https://leandecisions. com/2012/09/how-to-create-an-effective-weightedpro-con-list.html v

Three Categories of Suicide Prevention KEAPA uses a comprehensive model of suicide prevention using three categories: primary, secondary and tertiary (see Table 1 on page 20). 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. With respect to gatekeeper training, in 2012, KASP (Korea Association for Suicide Prevention) developed a three-hour gatekeeper program including video 19

featurearticle 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

Before meeting an attempter

Urgent psychological support

• Reducing bullying and harassment • Intake: managerial or selfreferral • Raising awareness of mental

• Witnesses to the self-inflicted violence and suicide

• Assigning and dispatching a counselor (within 24 hours)

• Managers and colleagues of the same team/department

• Anti-stigma campaign

• Telephone call by the assigned counselor with direct manager or related peer (and HR if needed)

• Bereavement counseling: usually 1~4 sessions / month

Education

On-site intervention

Suicide attempter

• “Observe-Listen-Tell” program

• Interview with a manager/peer/HR • Fitness for duty evaluation

• 1-hour suicide prevention education as an on-the-job training for newcomers and middle managers

• Helping peer supporter

disorders and stress at work

• Improving access to mental health and substance use treatment

• Life respect education Gatekeeper training • Training peer supporter and in-house instructors to detect risk groups early and help them effectively

• Interview with attempter: Assessing imminent suicide risk, general check-up, comprehensive psychological assessment if needed, psychiatric consultation Referral to external professional facilities

• Monthly follow up by the assigned counsellor • Discussion with HR regarding job position, relocation, and return to work program Counseling service for the bereaved family • Extended number of sessions as needed

• Training for counselors and occupational health nurses 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 on page 19 for a case example.) v 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 Jongmin.woo@gmail.com.

References

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

earoundup Chatbots Here Just in Nick of Time? A growing number of chatbots and voice analysis apps are geared toward improving how we feel. Fast Company reports that chatbots like Woebot and Tess claim to be able to identify the mood or condition of the user, and in many cases can offer advice or suggest therapeutic exercises. Technological advances like these seem to have arrived just in the nick of time. According to a Chronicle of Higher Education report, suicide is now the second leading killer of college students, after traffic accidents. Since 1999, the overall suicide rate in the U.S. has surged by about 25%. In 2017, a study of 73 participants who reported at least one symptom of PTSD or depression completed a 12-week field trial with Companion MX, which makes an app that detects changes in moods by analyzing users’ voice patterns and levels of activity. Participants were asked to record an audio diary at least once a week. Their social and physical activity was also tracked via their smartphone. Companion converts voice and activity data into predictions about behavior symptom measures like mood, fatigue, physical isolation, and social isolation. Not everyone, however, is sold on technological marvels like these for treating issues like depression and addiction. While more research is needed, a review by the American Psychological

Continued from page 5

Association of published studies on a number of therapy apps found that while they had a small effect on reducing depression, they have not contributed to reducing suicide rates. Read more here https://www. fastcompany.com/90299135/ mental-health-crisis-robotschatbots-listeners.

Achieving a More Inclusive Workplace Research shows that inclusive workplaces are six times more likely to be innovative and twice as likely to meet or surpass financial goals, reports Limeade, an employee engagement company. In addition, employees who feel able to bring their whole selves to work are 42% less likely to plan on leaving for another position within a year. According to the Forbes Human Resources Council, the following are among important factors that impact inclusion. Offer access to resources: Encourage employees to send agendas and materials in advance so everyone feels prepared. Protect time by setting up technology properly, and be sure to involve all members. Be sure employees have a voice: Employees need to feel they have a say in decisions that impact their work. Hold focus groups or have weekly surveys that measure or address inclusion. Accept and value people for who they are: Have intentional conversations with your employees that not only recognize great work, but explain why

you value them and their work. Acknowledge specific achievements or even small “wins” to show you care and take part in their successes. Provide learning and development: Offer employees the opportunity to expand professional and personal goals by supporting further education, learning a new skill or developing a hobby or passion. Promote a collaborative environment: Pause to ask what others think in a meeting. Make sure to give credit where credit is due, even if the person who came up with the idea isn’t in the room.

EAPA Issues 2nd Cannabis Toolkit Marijuana is no longer just an issue for employers in a few states. As marijuana use, both medicinal and recreational, continues to become legally accepted in the U.S., it may ultimately be removed as a Schedule I drug under the Controlled Substances Act. This would change how employers approach cannabis at work. Several major societal trends are converging to make cannabis in the workplace one of the biggest challenges facing employers and employee assistance professionals. The toolkits are intended to give EA professionals information to assist their companies and clients. Both kits can be downloaded here: https://eapassn.org/ CannabisAtWork. Continued on page 31

featurearticle Going Digital: A Roadmap for EAPs | By Navya Singh, PsyD; Tom Shjerven, CEBS

ecent innovations in technology and predictive analytics are profoundly changing the world around us. Smart phones and mobile apps, big data, and artificial intelligence are all affecting how we live and work. These developments are changing how EAPs are providing services and will have significant impact on how workplace behavioral health is practiced and delivered in the coming years. Some EAPs are beginning to incorporate evidence-based mobile apps into their practice: self-management tools to help employees track and manage chronic health conditions such as depression, anxiety, substance abuse, and/or diabetes; apps to add support to the care provided by a counselor or doctor to help build the skills and confidence needed to sustain healthy habits; and as an early intervention for employees not yet meeting the criteria for a formal diagnosis, but who can benefit from education on risk factors and appropriate prevention strategies. Still, most EAPs have barely scratched the surface in leveraging these technologies to fundamentally change and improve service delivery (the ability to effectively scale their

expertise), user engagement and outcomes (lower stress, depression; better sleep, more productivity, etc.). To differentiate themselves in today’s cost-conscious health landscape, EAPs need to know what to look for in an “enabling” technology that allows them to extend their expertise and deliver better results to more people…and for less money. Equally important, they need to have a clear and realistic understanding of the challenges and know what to look for in a technology partner to drive the process – from needs assessment, to planning, through implementation and follow-up. The Central Challenges Many digital health products fall short because they apply a strategy to healthcare that was developed and refined in the tech sector, versus taking a “needdriven” approach that starts by deeply understanding an important problem in workplace behavioral health and then designing a technology that is uniquely suited to solve it. For instance, CRM (customer relationship management) and ERP (enterprise resource planning) technology are often sold on the breadth of features that looked good during the presenta-

tion, but are seldom used when actually implemented. You see this in mHealth apps, where the “fun” component – say, a leaderboard for health-related achievements (more miles run, etc.) – loses its novelty and the app is abandoned. New technology takes time to integrate into practice. The section below shows how this can be done with online exercises based on CBT (Cognitive Behavioral Therapy) and/or mindfulness techniques. It’s also important that the technology offer users an easy way to reach and engage a counselor when needed. Mobile health apps and games may be user-friendly and fun, but many are flawed in that they’re entirely self-administered and produce numbers – heart rate, number of steps, etc. - without having the appropriate expertise available to interpret these numbers and provide support for real, lasting change. For instance, many focus on tracking stress without providing any clue as to how to develop resilience strategies. Toward a Hybrid “High-Tech, High-Touch” Solution Digital technology supports connection and collaboration by giving both the patient and population the ability to share information needed to make

better decisions. The digital “migration path” can be as long and winding – or as short and brief – as you make it, and no two EAPs will necessarily follow the same route. That said, here are several core elements that all EAPs ought to consider as they evaluate technologies that improve service delivery, access, engagement and, ultimately outcomes. The platform or app should: Provide EAP clients with the ability to navigate the platform or application on their own. They should have easy access to customized interventions, with psycho educational content that people can work through actively. Be aligned with core principles and approaches. For instance, EAPs that focus on CBT, Mindfulness and Positive Psychology should use technology that facilitates interventions that are based on these techniques and methodologies. Connect users back to the EAP for more personal counseling. The platform or app should make it easy for employees to seek out clinical experts for personal guidance, and to augment and guide additional interventions and solutions. Offer Artificial Intelligence based assistance to clinicians (it’s not a bot trying to replace experts; it’s AI to enable experts to reach more people faster). Provide analytics that enable clinicians to assess the success of the program from start to finish. For instance, has completion of the sleep module resulted in users selfreporting heighted alertness, less irritability, etc.

Generate ongoing promotional messages to promote EAP engagement and utilization. These messages ought to be measured based on how they resonate with platform users and should help create steps to action. Integrate with other programs through screenings, tools and content to guide the right level of access to care at the right time for employees. How it Works Here are several concrete examples of how EAPs can move their core programs to a digital platform. Each component or module includes an online assessment and a guided, user-driven program, each with a specified number of sessions. The assessments can screen and identify employees struggling with anxiety, depression, anger, relationship concerns, post-traumatic stress, substance use, work engagement and sleep issues and others, in order to provide appropriate referral to clinical care, self-use programs or coaching (as determined by the EAP partner). The self-assessment programs outlined below are based on Cognitive Behavioral Therapy (CBT), mindfulness and positive psychology. These programs can include animated videos and interactive sessions that are delivered via an app and the web. The program teaches coping skills and uses science-based techniques to manage emotional problems, foster resilience and positive thinking, as well as mindfulness based relaxation exercises – and at all times, a counselor is always a mouse click away.

a. Work-Life Balance Goal Description: Life can throw a lot of stressful scenarios our way – from work stressors, to managing relationships and handling finances – as well as the pressure we put on ourselves to perform or achieve goals. These stressors can impact our productivity and work engagement; in turn, lowered productivity can lead to even more stress and feelings of sadness. This track is designed to help your employees on a path to a happier, more productive life. # of sessions: 30 Estimated time per session: 6 min each Skills: Mind-body connection; identifying stress patterns; challenging negative thoughts; positive thinking, and activity planning

featurearticle b. Work Stress Goal Description: Taking time out for self-care while managing a busy work schedule, can be very difficult. Stress and burnout can negatively impact your mind and body, leaving you sad and affecting your productivity. This track is designed to help your employees on their path towards lower-stress and a happier life. # of sessions: 30 Estimated time per session: 6-8 mins Skills: Identifying triggers, patterns and thoughts; challenging and replacing negative thoughts with positive thoughts; coping skills like progressive muscle relaxation and mindfulnessbased exercises. c. Sleep Goal Description: Different people naturally have distinct patterns for basic needs-- how much we eat, sleep, and even work varies

from person to person. Sleep is one area in which complications may arise if you do not get the amount required for your unique body and its unique demands. The impact of sleep deprivation can be seen on work performance, interpersonal relationships, mood, concentration, decision-making or problem-solving abilities. This track is designed to help employees foster behaviors that will help them sleep better. # of sessions: 8 Estimated time per session: 25-40 min, 1x/weekly Skills: Basic principles of CBT; daily tracking using sleep diary; basic sleep hygiene skills and checklist; stimulus control and sleep restriction; relaxation techniques and mindfulness d. Relationship Conflict Goal Description: Managing interpersonal relationships can be stressful at times. Despite being

rewarding, it takes time and commitment to make them work. The stress of a difficult relationship can leave you sad and impact your productivity. This track is designed to help your employees manage their relationships better and guide them toward a happier life. # of sessions: 30 Estimated time per session: 6 min Skills: Perspective-taking; role-play; cognitive distortions and assertive communication skills vs. passive/aggressive communication. The following screen shots take you through the process: it begins by setting a goal (for instance, stress reduction), which moves the user to concise videos that provide context pertinent to the goal (understanding stress), interactive sessions to get a better handle on how it affects them, and tools to manage stress and build resilience.

At any point the user can seek out a counselor and schedule a live session. The EAP and employer can monitor progress via a reporting screen (below) that shows the number of people using the system, the goals set, the number of sessions completed, and the number of people accessing coaches or counselors.

ease-of-use, etc.), but also how their partner is going to help them launch and sustain it over time: Together, the EAP and technology partner must establish the implementation team and set project goals. This includes: Customizing the platform or app, planning integration; and establishing the account interface over the length of the project; Training the EAP’s internal staff on the solution – not only how it operates and the features, but also how to market/sell it to the clients; Training/orienting end user clients, whether that is the employer purchaser or the actual individual users. Developing communica-

tion plans and materials for sales promotion, program launch and ongoing engagement of users. The technology partner ought to control and handle most of this so it’s not up to time-constrained EAP partners and employers to drive the success of the program. Providing analytics related to user engagement and helping partners understand the significance of that data so they can convey that to their clients. As with any technology partnership, careful project planning – and management – is key to a successful implementation. An implementation schedule begins with a clear continued on page 31

Digital EAP by the Numbers

Practical Steps in a Successful Rollout In order for EAPs to successfully implement a given technology they need to find partners who will shoulder most of the implementation – from a needs analysis, to customization, promotion, deployment, to testing, training and follow-up. The reality is that most EAPs don’t have the extra “hands on deck,” let alone the specific expertise, to take this on. In evaluating a new technology solution, EAPs need to assess the solution itself (functionality,

A national EAP that provides holistic, evidence based, “high-touch, high-tech” services, wanted to use technology to improve their ability to serve more organizations and their employees more efficiently and deliver improved health outcomes. The EAP worked with a leading technology vendor to roll out a selfuse app that would enable employees to take structured assessments on how to self-identify problem areas such as stress, generalized anxiety, depression, relationship conflicts, work engagement, anger, substance abuse, and quality of sleep. Employees who wished to use the app were provided with information on how to access and use the app. If users needed help in navigating the app, coaching was provided by the technology vendor and/or EAP staff. Working with the technology vendor, the EAP established when to schedule email reminders to keep users motivated or otherwise on track. Thirty-seven percent of employees registered to use the app within the first three months of its roll-out. Results after three months break out as follows: • Over 30% of employees completed the full screening process. • 15% of population utilized the self-use app versus 4.5% average EAP utilization. • Over 59% saw a symptom reduction in depression. • Over 48% saw a symptom reduction in anxiety. • Over 32% saw a symptom reduction in avoidance. • Over 27% saw a symptom reduction in fear v 25

theworldofeap Tradition of Workplace Services Leads to EAP Diversity in Germany | By John Maynard, PhD, CEAP

ermany is an economic powerhouse. Despite being well down the list of the world’s most populous countries (ranking 16th, behind Vietnam and Egypt), Germany has the world’s 4th largest economy and ranks 3rd in terms of exports. Germany’s EAP marketplace is among the most diverse anywhere, in large part because of its long tradition of workplace-based human services and its well-developed national health system. I had the opportunity to talk with many of the country’s leading EAP providers while I was in Germany to attend the 2018 Employee Assistance European Forum (EAEF) conference in Hamburg. Long History of Workplace Health and Social Services The evolution of the German health insurance system can be traced back to the Middle Ages, when craftsmen were members of guilds. All guild members were required to pay into a fund, which was available to help individual members who experienced financial difficulties because of accidents or illness. With the advent of the industrial revolution, similar insurance funds were organized for factory workers. In 1883, Otto von Bismarck’s social legislation standardized health insurance for workers involved in both industrial and non-industrial

production. He set out the principles that have been at the core of Germany’s healthcare and insurance delivery systems to this day. Health insurance is compulsory and available to everyone. Funding is generated primarily by mandatory insurance premiums paid by employees and their employers, supplemented by tax revenues when necessary, such as for social welfare recipients. (This system is in contrast to publicly funded national health systems, such as those in the UK and Canada, which draw primarily on tax revenue.) Funds are administered by private self-governing bodies, made up of members representing doctors, dentists, psychotherapists, hospitals, insurers, and the insured. Premiums are based on income, not health status or actuarial calculation. In addition to universal health insurance, Germany has been providing workplace-based social and human services since the early 20th century. German workplaces lost much of their male workforce when the army needed men during World War I. Women – many with children and other family obligations – were brought into the workforce to keep factories running. Most large companies recruited and employed nurses and social workers to support and assist these women. Even after the war, these services continued, gradually evolving into what

became known as occupational social work. With universal healthcare (including behavioral healthcare) eliminating any healthcare cost containment incentives, and occupational social work services already available onsite at most major employers, EAPs in Germany struggled to gain a foothold. Only in the last ten years have EAPs begun to proliferate and develop a substantial presence. EAPs Appear The earliest EAP-like external service in Germany began operations in 1989, offering face-toface counseling for employees and families, education and team building services, and special services for executives. In the early 2000s, a few other EAPs appeared, driven primarily by multinational companies based elsewhere wanting services for their employees in Germany. By about 2009, the demand for behavioral health counseling, therapy, and treatment began seriously outstripping the capacity of services offered under the national healthcare system. Waiting times to access behavioral care grew longer, often stretching to several months. Associated with this unmet demand were rising numbers of people away from work for extended sick leaves and increased levels of employee turnover.

In this environment, EAPs began to flourish. Not only did they offer short-term counseling without long waiting periods, but they also provided education and prevention activities, as well as hands-on guidance to help employees and families navigate the quickest possible access to care within the health system. In 2013, Germany adopted the Occupational Health and Safety Act requiring all employers to identify and assess work-related psychosocial risk factors, and to develop and implement measures to respond. Both assessments and responses can be conducted by the employers themselves or by outside contractors. This act provided a huge boost for EAP services. Some EAP firms began conducting or participating in the assessment process, and virtually all have benefitted by being part of the required response actions.

A prime motivation for companies to engage EAP services often is to comply with health and safety requirements related to psychosocial assessments and interventions. As a result, EAPs in Germany tend to focus more on employer services, such as training, consultation, and education, and they are often connected quite closely with occupational health departments or services. The broad focus on psychosocial issues also leads to a strong emphasis on work-life concerns, in addition to psychological, addiction, and relationship difficulties. Given these differences, German EAPs appear to have higher levels of staffing and the luxury of charging higher prices than the market will allow in many other countries. Whether this will last as EA markets everywhere continue to mature will be interesting to observe.

Finding Their Niche Widespread onsite occupational social work services and universal healthcare have led EAPs in Germany to look to niches and gaps in other services for growth. In this environment, EAPs have evolved in unique and interesting ways. In contrast to many countries, where expansion of EAPs within foreign-based multinational corporations has led the way, EAP firms in Germany do most, if not all, of their work with German-owned corporate clients. Perhaps because a significant selling point for EAPs is helping employees efficiently access services available from the national health system, German EAPs tend to do more face-to-face and onsite counseling with fewer session limits than those in most other countries.

Challenges and Opportunities The existence and strength of “Works Councils” in German companies presents both challenges and opportunities for EAPs. Although Works Councils exist in a number of countries, especially in Europe, they are most developed and have the longest history in Germany. In German workplaces with more than 500 employees, nearly 90% have Works Councils. Members are elected by workers for fouryear terms. If a union is present, members don’t have to be union members, but they can be. Works Councils exist primarily to provide systematized communication channels between workers and management. They do not participate in collective bargaining or organized work actions, such as strikes, but

they must be consulted on specific issues, including in most cases, the establishment of an EAP. Of course, the challenge is to convince the Works Council to recommend the EAP; without their endorsement, the EAP is unlikely to be established or to succeed. On the other hand, they can become significant EAP allies within the workplace when they do support it. Probably the greatest opportunity for EAPs in Germany is the sheer size of the market that remains untouched. With that market ahead of them, German EAPs for the most part seem confident in their future, less focused on what others are doing globally, and more centered on meeting the unique needs in German workplaces. Their success so far is a testament to the strength and flexibility of the EA concept. v Acknowledgments My thanks to the following individuals for taking the time to meet with me in Germany as I was preparing this column: Beate and Manuela Görcke of OTHEB GmbH; Juliane Barth of Corrente AG; Dr. Amina Özelsel, CEAP, of Hanza Resources GmbH; Reinhild Fürstenberg of Fürstenberg Institut GmbH; and Dr. Hansjörg Becker of Insite-Interventions GmbH. Dr. John Maynard served as CEO of EAPA from 2004 through 2015. Prior to that, he was President of SPIRE Health Consultants, Inc., a global consulting firm specializing in EA strategic planning, program design, and quality improvement. In both roles, he had the opportunity to meet and exchange ideas with EA professionals in countries around the world. He currently accepts consulting projects and speaking engagements where he believes he can make a positive difference. He can be reached at johnbmaynard8@gmail.com.

featurearticle Breastfeeding & Work in Latin America Is There a Role for EAPs?

| By Andrea Lardani

reastfeeding is beneficial to the health of both women and infants. According to the World Health Organization (WHO), women who breastfeed have longer intervals between births and, as a result, a lower risk of maternal morbidity and mortality, as well as lower rates of breast cancer before menopause and potentially lower risks of ovarian cancer, osteoporosis, and coronary heart disease. Because of this data, WHO recommends exclusively breastfeeding for at least the first 6 months of life. In 2012, the World Health Assembly (WHA) endorsed breastfeeding as one of the key global nutrition targets to foster a healthy, equitable, and sustainable future for individuals and nations. Nevertheless, little progress has been made. Women may avoid or stop breastfeeding for a number of medical, cultural, and psychological reasons. But most commonly, women stop breastfeeding because of lack of support in the workplace. This article describes a public health problem and describes an important and appropriate role for EAPs to play in supporting breastfeeding at work. Breastfeeding is significantly reduced in the workplace when breastfeeding breaks are unavailable, if infant care near the workplace is

inaccessible or unaffordable, and if no facilities are available for expressing or storing milk. Legislation guaranteeing breastfeeding breaks could improve a working mother’s ability to continue to breastfeed. However, it might not be enough if organizations do not incorporate a culture of breastfeeding with policies and procedures that support it. What Happens in Latin America? In Latin America and the Caribbean, it is estimated that 66% of infant deaths due to diarrheal disease and acute respiratory infection occurring between birth and 3 months of age could be prevented by exclusive breastfeeding, Nevertheless, according to the Pan American Health Organization (PHO) only 38% of infants receive breastmilk exclusively during their first 6 months of age. There are variations between countries. Breastfeeding rates in the Dominican Republic remain at 8%. In Mexico they dropped from 20% to 14.5%. Still other countries have shown progress, such as Colombia where it increased from 15 to 43%. In Brazil they increased between 1986 and 2006, going from 2.9% to 37.1%. There is strong evidence that returning to work is one of the

principal barriers to breastfeeding. In Guatemala, for example, although there is a culture that supports breastfeeding, mothers who work outside the home are significantly less likely than mothers who do not work to exclusively breastfeed (9% vs. 25%, respectively). In Mexico, a study of mothers from Veracruz, concluded that one of the principal factors of early abandonment of breastfeeding is working outside the home. In Argentina, a 2018 study of 1,883 employed women who returned to work with a child below the age of 1 revealed that: Eight out of 10 women said that combining breastfeeding and work is difficult. Women working in factories find it more difficult as well as those who work only for economic reasons. There is a significant belief that employers do not support breastfeeding. One of the employees said: “My boss did not give me time to go to the breastfeeding facilities nor to breastfeed my baby. He claimed to be supportive, but with the daily pressures he imposed on me it was not possible.” There is lack of role models: Only 2 out 10 women believed that female leaders in their work-

place breastfed and/or expressed milk at work. One third said that career opportunities were negatively impacted by breastfeeding or expressing milk at work. One woman stated: “My boss did not support me, and scheduled meetings during the time I was in the breastfeeding room.” Two out of 10 women felt, that in some way, their jobs were at risk if they continued breastfeeding or expressing milk at work. One of the study participants said: “Although it is said that expressing milk at work is permitted, it is badly seen if you leave your position more than once a day.” Seventy-three percent felt uncomfortable asking where to breastfeed or express milk – 63% felt uncomfortable talking about the issue with their direct boss, while 43% felt uncomfortable talking with colleagues. One of the participants said: “There was no understanding either from management or Human Resources.” “Companies are not prepared to have a woman use a breast pump, not even their colleagues.” Eighty-eight percent said there is a lack of information from their employer, and they do not know who to ask when returning to work. “Nobody explained to me how to combine breastfeeding and work so that my milk production would not be interrupted.” Six out of 10 could not organize regular and long enough breaks to express milk at work. Four out of 10 considered that the assigned room was not clean.

Five out of 10 stated the room was not private. Eight out of 10 said comfortable seating was not provided... How could EAPs Intervene to Reduce Workplace-related Barriers to Breastfeeding? The Employee Assistance Professional Association states: “Employee Assistance Programs (EAPs) serve organizations and their employees in multiple ways, ranging from consultation at the

“For this reason, as EA professionals committed to promoting well-being and health in the workplace, we should pay particular attention to specific issues impacting women such as breastfeeding.” strategic level about issues with organization-wide implications to individual assistance to employees and family members experiencing personal difficulties”. Taking this definition into account, how could EAPs serve organizations to support both returning to work and breastfeeding? We suggest the following three levels of interventions: 1) At the organizational level • Collaboration in designing

breastfeeding policies and procedures adapted specifically to the company client and its culture. • Collaboration in creating procedures and guidelines for managers and breastfeeding employees • Providing specialized recommendations regarding adequate maternity and paternity leaves as well as how to support mothers who return to work. • Specialized professional recommendations about how to incorporate breastfeeding, pumping and storing facilities and promoting their proper use. • Suggesting and designing communications to promote a breastfeeding culture. 2) At the management level • Providing face-to-face and/or online trainings for managers, supervisors and Human Resources offering information about the benefits of breastfeeding, how to support mothers who are returning to work after maternity leave, and how breastfeeding/pumping facilities can be used by employees with management support. • Offering telephonic management consultations about issues related to employees who are breastfeeding. • Encouraging managers who breastfeed in the workplace to become mentors, sharing their personal experience with employees who will be in the same situation. These mentors may also become intermediaries between the

featurearticle employee and the company, helping them obtain information and present their needs related to breastfeeding. 3) At the employee and family level • Provide telephonic and faceto-face breastfeeding counseling by specialized professionals both during and after maternity leave. • Offer a 24/7/365 support line for breastfeeding employees during and after maternity leave. • Present telephonic, faceto-face counseling and workshops for family members on how to support the mother who returns to work and wants to continue breastfeeding and/or expressing milk. • Offer online workshops for breastfeeding employees providing specialized information on how to manage lactation and return to work and resources such as books and targeted reading materials. Summary Overall female participation in the global workforce has fallen 2% since 1990. But this is not the case for Latin America and the Caribbean where it has increased by 14%. This region had women joining the workforce at a faster pace than anywhere else in the world, adding up to 80 million more working women since the 1960s. For this reason, as EA professionals committed to promoting well-being and health in the workplace, we should pay particular attention to specific issues

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impacting women such as breastfeeding. This of course benefits the work organization as a whole, and not just the women. There is no doubt that women who work in an environment where their right to breastfeed is supported are more motivated and engaged. Absenteeism, requests for medical appointments, and medical leaves decrease, as breastfeeding benefits both the mother and the child´s health. Work abandonment by new mothers, with the related costs of staff turnover, should also decrease. Further research should focus on how breastfeeding impacts work performance and engagement. v Andrea Lardani is the Director at Grupo Wellness Latina. She has extensive experience in developing and managing EAPs and well-being programs for multinational companies, as well as in training and leading affiliate networks and teams in Latin America. Andrea is a psychologist with post-graduate studies and complementary training, including a solid background in clinical organizational contexts. She may be reached at andreal@grupowellnesslatina.com.

References Employee Assistance Professionals Association. (2001). Definitions of an Employee Assistance Program (EAP) and EAP core technology. Arlington, VA: Author. Retrieved from: http:// www.eapassn.org/About/AboutEmployee-Assistance/EAP-Definitionsand-Core-Technology Pan American Health Organization & World Health Organization. (2013). Situación actual y tendencias de la lactancia materna en América Latina y el Caribe: Implicaciones políticas programáticas. Washington, DC: Author. Voices Research & Consultancy. (2018). Encuesta Nacional de Lactancia y Trabajo preparado para la Liga de la Leche Argentina. Retrieved from: http:// www.ligadelaleche.org.ar

World Health Organization. (2013). Breastfeeding policy: A globally comparative analysis. Bulletin of the World Health Organization, 91, 398406. doi:http://dx.doi.org/10.2471/ BLT.12.109363

Further Reading Betrán, A.P., de Onis, M., Lauer, J.A., & Villar, J. (2001). Ecological study of effect of breast feeding on infant mortality in Latin America. British Medical Journal, 323(7308), 303-306. Boccolini, C.S., Boccolini, P.D.M.M., Monteiro, F.R., Venâncio, S.I., & Giugliani, E.R.J. (2017). Breastfeeding indicators trends in Brazil for three decades. Revista de saude publica, 51,108. doi:10.11606/S15188787.2017051000029 Buccini, G., Pérez-Escamilla, R., Giugliani, E.R.J., Benicio, M.H., & Venancio, S.I. (December, 2018). Exclusive breastfeeding changes in Brazil attributable to pacifier use. PLoS ONE. Retrieved from: https://www.researchgate.net/ publication/329787663_Exclusive_ breastfeeding_changes_in_Brazil_ attributable_to_pacifier_use Chioda, L. (2016). Work and family: Latin American and Caribbean women in search of a new balance. Washington, DC: International Bank for Reconstruction and Development / The World Bank. ISBN (electronic): 978-08213-9962-0. Retrieved from: https://open knowledge.worldbank.org/bitstream/ handle/10986/23748/9780821384855. pdf?sequence=3&i Dearden, K., Altaye, M., Maza, I. D., Oliva, M. D., Stone-Jimenez, M., Morrow, A. L., & Burkhalte, B. R. (2002). Determinants of optimal breastfeeding in peri-urban Guatemala City, Guatemala. Revista Panamericana de Salud Pública, 12(3), 185-192. doi:10.1590/S1020-49892002000900007 Flores-Díaz, A.L., Bustos-Valdés, M.V., González-Solís, R., & MendozaSánchez, H.F. (2006). Maternal breastfeeding-related factors in a group of Mexican children. Archivos en Medicina Familiar, 8(1), 33-39 Gonzalez, E. (2017). Weekly chart: Women in the workforce in Latin America and the Caribbean. Retrieved from: https:// www.as-coa.org/articles/weekly-chartwomen-workforce-latin-america-andcaribbean

featurearticle articulation of all stakeholders and their roles, and defines time frames and targets, from customization to workflow to training, testing official launch, and follow-up. When the technology partner supports the EAP in planning, execution and promotion, the implementation and roll-out will go more smoothly, the EAP will be ready to provide the necessary support to stakeholders, the communications plan will maximize reach and engagement, and the technology partner will be in optimal position to evolve with the EAP to make continual improvements and enhancements to the program. Summary: The Digital Future Since their inception, EAPs have been grappling with the same chal-

earoundup Bosses can Reduce Mental Health Stigma Experts tell us that one in four adults will struggle with a mental health issue during his or her lifetime. At work, those suffering from clinical conditions, or minor ones, often hide it for fear that they may face discrimination from peers or bosses. These stigmas can be overcome, but it takes more than policies, it also requires empathetic action from managers. As reported in the Harvard Business Review, the following are some ways managers can help drive a more empathetic culture:

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lenge: making mental and behavioral healthcare more accessible by bridging the barriers to access, awareness, and affordability in screening and treatment. As this article illustrates, the challenges today are even steeper as increasing price pressure forces EAPs to make hard decisions in their business models in order to remain competitive. Digital health solutions can help shift purchasing focus from costs to return on investment by supporting collaboration between clinicians and patients, providing efficient resource allocation, making patient data available at the point of care, and leveraging AI and “prescriptive” analytics to turn information into insights that inform decisions for patients, providers, and organizations.

As EAPs contemplate a digital future – their digital future – the age-old cautionary advice applies: look before you leap. The EAP needs a clear grasp of the challenges (and typical pitfalls), a rigorous evaluation of the technology and how it advances work and goals, and, perhaps most importantly, a technology partner that will support you on your journey, and assure a smooth and successful transition. v Navya Singh, PsyD, is a psychologist and founder of PsyInnovations Inc. She may be contacted at navya@wayforward.io. Tom Shjerven, CEBS, joined wayForward (PsyInnovations, Inc) in 2018 as Director, EAP Business, to lead the organization’s sales and business development efforts with EAP and wellness company partners. Tom may be reached at tom.s@wayforward.io.

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Rethink “sick days.” If you have cancer, no one says, “Let’s just push through.” They recognize that it’s an illness and you’ll need to take time off to treat it. But few people in business would react in the same way to signs of stress, anxiety, or manic behavior. Managers need to be more comfortable with the idea of suggesting and requesting days to focus on improving mental as well as physical health. Encourage open and honest conversations. It’s important to create safe spaces for people to talk about their own challenges, past and present, without fear of being called “unstable” or passed

up for the next big project or promotion. Employees shouldn’t fear that they will be judged or excluded if they open up in this way. Leaders should also encourage everyone to speak up when feeling overwhelmed or in need. Be proactive. In a Harvard Business Review survey on employee burnout, nearly 70 percent of respondents said that employers were not doing enough to prevent or alleviate burnout. Bosses need to do a better job helping their employees connect to resources – like an EAP – before stress leads to more serious problems. continued on page 32

earoundup

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Remote work is becoming more common than ever. In fact, in a recent survey conducted by Indeed, out of the 500 employees surveyed, 55% percent said they were allowed to work remotely, and among those, 75% said this perk improved work-life balance. The following are some recommendations on successfully working off site. Join weekly meetings — Make sure a 1:1 meeting is set up with the manager and the individual starts joining regular team meetings to get a sense of how things work in the company. Identify roadblocks — The manager may not have insight into the struggles the employee is dealing with since he/she is not physically in the same office. Encourage the individual to speak up and start an open conversation. Understand communication styles — How does the individual communicate best? (instant message, video chat, email?) If unclear, be sure to ask before kicking off any projects. It will make collaboration go much smoother. Schedule virtual meetings — Regular interactions with colleagues are vital even if it is just for a casual 10-minute chat.

one thing, according to Littler Mendelson PC, it’s vital to stress that the legalization of recreational marijuana does not provide Canadian employees with the right to use marijuana in the workplace. The law firm adds that employers have the right to set policies pertaining to the use and possession of marijuana at work, which is similar to use of alcohol and illegal drugs. This is crucial when the workplace environment is safety-sensitive, because employers are requited under occupational health and safety laws to protect the health and safety of their workers and the public. Since many employers already have existing drug and alcohol policies in place, the legalization of recreational marijuana will require employers to update these policies. Littler Mendelson notes that a comprehensive drug and alcohol policy is an important means of establishing what is and is not acceptable with regard to marijuana use and possession in the workplace. Finally, unlike the U.S., preemployment testing is generally not permitted in Canada except in limited circumstances. However, there appears to be a trend in favor of the implementation of random drug and alcohol testing for employees who are in safety-sensitive positions (for health and safety reasons).

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Read JEA Cover Story, Earn Free PDH! EAPA will offer a free PDH for reading the cover story of each issue of the JEA and answering a 5-item multiple choice quiz. Read “Where Do We Go From Here?” by David Sharar in this issue and answer the multiple choice questions here https://elearning. easygenerator.com/345a4851-a0554afc-a155-fec721b158b0. Instructions are provided at the end of the quiz on how to get your free PDH. v

coverstory

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Conversely, and while rare, a client can dislike his or her EAP counselor and have improved work performance as a result of the EAP intervention. While access and service experience are usually very important ingredients for positive outcomes to occur, the risk of focusing solely on measuring friendliness, convenience, ease of appointments, website features, phone apps – rather than outcomes – is a distraction from true value-based improvement. Simply put, measuring true value as a way of increasing rates requires the credible measurement of outcomes.

sent an invoice. If utilization is below the “floor”, the employer receives a “credit”. This reconcilable option offers a structure that adjusts during each program year to reflect actual usage. Another variation on this model is a hybrid of capitation and fee-for-service, so the employer only pays for services received. This hybrid typically includes a PEPM that only covers administrative costs such as access, reporting, account management, promotional support, and online features. The employer then pays a fee – something like $75.00 – for each counseling visit actually received. The budgeted utilization or hybrid model can also have elements of value-based reimbursement tied in.

Options to Capitated Pricing Value-based reimbursement. This term describes an arrangement where service providers are paid based on the attainment of specific outcomes or quality indicators that are valued by the funder (or employer). Payment can be in the form of bonuses (up-side risk) or penalties (down-side risk). Examples in EAP include: • Employee self-report of decreased absenteeism or presenteeism at case opening and then at a 90day follow-up. • Supervisor report of improved employee work performance following a supervisor referral. • Percent of supervisor or manager consultations that result in a formal referral to EAP. • Employee self-report of symptom reduction or clinical outcome at case opening and then at a 90-day follow-up. • Percent of substance use cases that followed through with a treatment referral and completed continuing care.

Bundled payments are a variation on what used to be called a “case rate”. The total amount of a bundled payment should be lower than the sum of fee-forservice elements that make up the bundled payment. For example, if the case is short-term counseling within a six-session EAP model, the bundled payment should be significantly less than six visits x $75.00 a visit. The payment should account for variations in service modality (e.g. face-to-face, telephone, online) and average numbers of visits. The determination of a bundled payment rate should be based on historical utilization data (such as an average number of visits in short-term counseling, which could be three). Any bonuses should include aggregated evidence that the client’s presenting problem was resolved within the EAP, thereby preventing use of the more expensive health plan. Unlike capitation, this approach has built-in accountability for outcomes with incentives that don’t involve denial, delay, or deflection of the intervention itself. The idea is for the payment to cover the full cost for handling the employee’s case, and the bundled payment can be tied to achieving outcomes that matter to the employer.

When proposing value-based reimbursement as an alternative pricing model, consider this new mock sales pitch: “Please be aware of something right from the start. When it comes time to propose a price for your EAP, I can guarantee you we will not be the lowest price. I intend to demonstrate to you why that does not matter. I will help you evaluate how my program will reduce your costs in areas other than the low price of an EAP, so your total cost picture will be more attractive, even with my higher price or the chance to receive a bonus”.

Summary Combining the proper and credible measurement of outcomes with a new pricing model is the single most powerful lever for improving rates and value in EAP. Current measurement efforts in an applied setting such as EAP are never perfect, but the process of measurement has begun with a standardized tool known as the Workplace Outcome Suite.

Budgeted utilization model. This model involves the employer paying a fee based on a budgeted or expected utilization rate. At the end of a year, if utilization exceeds the “ceiling” the employer is

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If employers, EA vendors, benefit consultants, and other stakeholders were to embrace outcome measurement as a central goal, our field could move beyond sustainability as a goal and as a result, thrive instead of merely survive. Much remains to be done but we have to start somewhere. v

program managers: Factors associated with successful, at-risk, and eliminated programs. Journal of Workplace Behavioral Health 33, 1-23. Retrieved from https://doi.org/10.1080/155552 40.2017.1416293 National Behavioral Consortium. (2013). [PowerPoint presentation of EAP vendors]. National Behavioral Consortium Industry Profile of External EAP Vendors. Retrieved from www.nbcgroup.org

David Sharar is the CEO of Chestnut Health Systems. He co-developed the Workplace Outcome Suite, a free and scientifically validated tool designed so EA providers can accurately measure the workplace effects of EA services. He can be reached at dsharar@chestnut.org.

Porter, M.E., & Kaplan, R.S. (2018). How to Pay for Health Care. In HBR’s 10 Must Reads 2018 (pp. 69-91). Boston, MA: Harvard Business Review Press.

Editor’s note: Earn a FREE PDH for reading this article at https://elearning.easygenerator.com/345a4851-a055-4afc-a155fec721b158b0/#/login.

Sharar, D.A., & Burke, J. (2009). The Perceived Value of ‘Free’ Versus Fee-Based Employee Assistance Programs. World at Work Journal, 4. 21-31.

References

Sharar, D.A., & Hertenstein, E. (2006). Perspectives on Commodity Pricing in Employee Assistance Programs (EAPs): A Survey of the EAP Field. World at Work Journal. 32-40.

Jacobson Frey, J., Pompe, J., Sharar, D., Imboden, R., & Bloom, L. (2018). Experiences of internal and hybrid employee assistance

letters Advocacy is Key

ince entering the Employee Assistance profession in 2014, I have noticed an increased effort by EAPA to bring attention to issues that seemingly went unacknowledged for decades. For this reason, I believe our profession’s success will depend on our willingness to be active advocates for EAPs as we adjust to changing demographics and an evolving economy. Being an active advocate means unwavering support for the efficacy of our respective programs to the companies, organizations, governments, and unions that benefit from our services. It also means asking difficult questions. Does our professional membership reflect the diverse populations we serve? Do we have an ethical obligation to diversify our membership? Do external EAP vendors hurt the profession? These ques-

tions need to be discussed through constructive dialogue, and we should expect disagreement. Active advocacy doesn’t stop after difficult questions have been raised. There must be action as well. Fortunately, our profession has opportunities to get involved. We can look at the recent accomplishments of EAPA’s Next Generation Taskforce. Since 2016, the taskforce has brought together professionals from Canada and the United States. One of the major accomplishments of the taskforce was creating a foundation in which to recruit and train the next generation of EA professionals. Additional accomplishments include filming promotional videos and submitting various internship and website recommendations to be considered for future development.

At the local level, the Northern Illinois Employee Assistance Professionals Association recently provided a free event for students and current professionals to attend a moderated presentation and panel discussion to learn about the Employee Assistance profession. But not every employee is given the chance to get involved in EAPA. For managers with early career professionals, it is crucial to the future success of the profession to allow employees to join committees and attend local chapter meetings and events. It’s vital to encourage employees to become active advocates. I believe, in so doing, we will create the conditions necessary for the EA profession to succeed well into the future. v – Mike Laird, LCSW, CEAP

webwatch Disability Management Disability Management Employer Coalition http://dmec.org/ The Disability Management Employer Coalition (DMEC) offers strategies, tools, and resources to minimize lost work time, improve workforce productivity, and maintain legally compliant absence and disability programs. Evidence-Based Services Workplace Outcome Suite http://eapassn.org/WOS The Workplace Outcome Suite (WOS) is an EAPA-endorsed tool. It demonstrates the effectiveness of EAPs in quantifiable business terms through the use of only five questions in both pre- and postEAP counseling. Inclusion Human Rights Campaign Foundation https://www.hrc.org/campaigns/ corporate-equality-index The Human Rights Campaign (HRC) invites US-based companies to participate in an annual Corporate Equality Index (CEI). The CEI is a benchmarking tool on policies and practices pertinent to LGBT+ employees. In the 2018 CEI report, 609 major businesses earned a top score of 100 percent. Mental Health Crisis Centre: FAQs About Suicide https://crisiscentre.bc.ca/ frequently-asked-questions-aboutsuicide/ What are some of the warning signs that someone is ready to take their life? What can we do if we think someone is suicidal? This site addresses many of the tough questions.

Mental Health Getting Started with Mindfulness www.mindful.org/meditation/ mindfulness-getting-started You want to try mindfulness techniques but don’t know where to start. This site shows you how. Mental Health Suicide Rate by Country 2019 http://worldpopulationreview.com/ countries/suicide-rate-by-country/ Suicide occurs throughout the world, affecting individuals of all nations, cultures, religions, genders, and classes. In what countries are suicide rates the highest? Lowest? This site offers a comprehensive list and useful data. Sexual Harassment Workplaces Respond to Domestic & Sexual Violence https://www.workplacesrespond. org/blog/top-10-things-victimsworkplace-sexual-harassmentviolence-can/ This blog presents information on the top 10 things that victims of workplace sexual harassment and violence need to know. The “how-to” list for victims also includes links to the Equal Employment Opportunity Commission (EEOC), sexual assault coalitions, and an example of a model workplace policy on sexual harassment. Substance Use & Addiction Is Marijuana Addictive? – American Addiction Centers https://americanaddictioncenters. org/marijuana-rehab/is-it-addictive What are the long-term effects of marijuana on the brain and body? What can it be laced with? How can someone quit smoking weed? What are the signs of use, abuse, and addiction? Those links and more can be found on this informative site.

Technology Camp Tech https://camptech.ca/ Their main page states: “Go from newbie to nerd at Camp Tech, and show the web who’s boss.” Resources include workshops, a certificate program, and more. Technology Novus Project http://thenovusproject.org/ The Novus Project is a community dedicated to preventing the relationally damaging effects of media misuse and explicit material by engaging students, families, and schools through awareness, tools, and support. Travel Safety WanderSafe https://www.wandersafe.com/ Whether your journey is a meander in Manhattan, a yoga trip to India, or a business trip to Bangkok, WanderSafe’s mission is to make travel safer wherever you are going. Workplace Bullying Civility Partners https://www.civilitypartners.com/ Civility Partners offers a variety of civility consulting services in order to effectively eradicate workplace bullying and create a positive workplace. Workplace Wellness CancerCareers.org https://www.cancercareers.org/ Who isn’t affected by cancer today? This site, formerly known as Cancer and Careers, helps patients, survivors, healthcare professionals, and employers navigate the practical and legal issues common after a cancer diagnosis. v

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