EAPA Annual Institute and Expo

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Mental Health Toolbox Growing for EAPs

| By Ivan Steenstra, PhD, MS & Barb Veder, MSW, RSW

You might have heard this story before: An inquisitive man comes out of a pub and finds another man leaning against a lamp post, staring at the sidewalk. Slightly inebriated, the inquisitive man pauses for a while to look over for whatever the man leaning against the lamp post is looking for, but there is nothing there. Curiosity piqued, he asks the leaning man, “What are you looking for?”

“My gold watch,” the leaning guy answers. “I lost it coming out of the pub”

The other man then responds, “Oh, please let me help you find your watch!”

Shortly after, another man leaves the pub and sees the two men searching, and he too asks, “What are you looking for?”

“He lost his watch,” the inquisitive man responds.

A woman gets out of the pub, asks the same question and then she too decides to help. After 15 minutes, a group of 5 is on the sidewalk (all a bit drunk) looking for the watch. After a while of searching, the woman asks, “So where did you lose the watch?

“Oh, I lost it a hundred meters to the right of here,” the man replies.

The lady is perplexed and decides to go home, but not before asking: “Why are you looking over here then?”

“Well,” the man says, “there’s light over here and the lamp post provides me support from falling over because I had a few too many.”

What is the “gold watch” for EAP providers? What are the outcomes we are trying to achieve and measure? Traditionally EAPs report on utilization, (time to) access to care, and customer satisfaction, while providing evidencebased interventions.

However, our clients come to us with a variety of issues that prevent them from functioning at an optimal level at work - clinical issues such as depression and anxiety, as well as many generalized issues beyond mental health concerns.

Which tools are valid to capture these outcomes adequately? Is there a tool developed for our specific population? Does the tool have the validity required to capture the state of the individual and does it have the properties to detect change over time?

Ultimately, we all agree on the importance of measuring outcomes in EAPs to:

• Demonstrate the effectiveness of services; • Show our value to customers; • Be accountable to customers and clients; and • Guide our choice of intervention.

What does our golden watch/population look like? From the Workplace Outcome Suite annual report 2021 (LifeWorks, 2021), we know that mental health issues (30%) were the most defining issue of EAP use. Specific issues within the mental health category included depression (8% of all cases), anxiety (7%), general emotional health (7%), behavioral conduct/anger (3%), grief (3%), and violence or trauma (2%).

Next was the issue of personal stress (24%), which included a small subset of cases (n = 191; < 1%) who specified having issues related to the COVID-19 pandemic.

About 1 in every 5 cases (20%) used the EAP for difficulties with a personal relationship (i.e., marriage; 14%) or family and work/life issues (6%). About 1 in every 5 EAP cases (20%) seek counseling for work-related issues, either occupational focused problems (14%) or work stress (6%). Alcohol misuse and drug problems accounted for less than 3% of cases. Other personal life issues (legal, financial, medical) accounted for the final 3% of cases.

In LifeWorks’ North American trend data, 60% of clients present as struggling with issues such as anxiety, depression, grief, personal and workplace stress, and so forth. 40% of clients need support managing decisions around life changes like job, relationship, parenting, and interpersonal conflicts. In short, EAPs support clients with a wide variety of presenting issues. The choice of measures to monitor progress and evaluate effects depends on the outcomes we aim to achieve. The bias of clinicians is to define improvement in terms of decrease of clinical signs and symptoms.

This is a good fit for only about half of all EAP cases; there is less relevance to measuring clinical improvement for those who, upon completion of a mental health screening, do not present with clinical distress. However, we

can define improvement in the primary objective of EAPs to support optimal functioning of employees in their ability to be productive at work.

The Right Outcome Tool for the Right Issue

The two most common presenting mental health issues in the general population are depression and anxiety (Kroenke et al., 2016). Generalized anxiety disorder (GAD) is a prevalent and disabling disorder distinguished by persistent worrying, anxiety symptoms, and tension. The natural course of GAD can be characterized as chronic with few complete remissions, a waxing and waning course of GAD symptoms, and the occurrence of substantial comorbidity, particularly with depression (Wittchen, 2002).

Two important tools, the PHQ-9 for depression and GAD-7 for anxiety, have been widely adopted for measuring clinical symptoms. These brief scales are simple to use and administer and they measure results and help us shape a support pathway that provides a solid clinical direction to follow.

However, the other half of our clients require support for a variety of issues like interpersonal struggles, life changes, family problems, workplace issues, and so forth, factors that are less relevant to clinical condition-based assessments like the PHQ-9 or GAD-7. Instead, these cases are better measured with the Workplace Outcome Suite (WOS).

Since the aim of EAP is to meet mental health needs of employees as well as support non-clinical struggles, using only one tool of measurement across all presenting issues would not work. One tool would not meet the criterion of being sensitive to the issue at hand, measuring change to monitor progress, and showing effects over the course of counseling.

In other words, the tool might not show improvement, even when improvement is in fact present. One method employed when using clinical tools to measure non-clinical issues involves not reporting on those clients that do not reach the clinical threshold (Schneider et al., 2020).

This approach conflicts with the best practice of doing an “intention-to-treat” analysis approach where all cases receiving treatment are included in the analysis. It also means that the percentage of cases relevant to a single clinical outcome tool, like the PHQ-9, is further dwindling.

It is key that clinical evaluative tools be used in the specific context of a condition or presenting issue and population. Best practice is to use outcomes related to the objective of EAP: to help employees reach optimal functioning at work, and to evaluate progress over time for clients, specific workplaces, and the overall book of business for EAP providers.

If we want to measure the general success of an EA program, we want to measure improvements in work relevant outcomes like absenteeism, presenteeism, and workplace distress. Conversely, when we want to measure condition-specific success of treatment, a more specific tool measuring clinical progress is required in addition to the general measure of life impact. For applied contexts like EAP service delivery, the ultra-brief version of the clinical outcome area represented in the PHQ-4 (2 items from the PHQ and 2 items from the GAD), is recommended. Also suggested is the brief 5-item version of the WOS.

Support for Mental Health from EAPs is Needed More than Ever

Behavioral health issues have been exacerbated during the ongoing COVID-19 global pandemic (Abdalla et al., 2021). Results of the National Health Interview Survey and the U.S. Census Bureau (Panchal et al., 2021) showed that in the first half of 2019 (before the pandemic) 1 in every 10 Americans reported symptoms of depression or

anxiety – but after the pandemic had taken hold this rate quadrupled to over 4 in every 10 adults in January of 2021 (i.e., 11.0% vs. 41.1%).

Since early 2020 and continuing during the pandemic, the EAP industry has greatly expanded the number of methods to deliver counseling (Couser et al., 2020; Hughes & Fairley, 2020). Traditional emphasis on face-to-face interactions between employee and counselor in an office switched to reliance on technological modalities of delivery. This change in modality coincided with most EAPs also experiencing higher overall utilization rates for the number of employees using counseling (and most other EAP work/life and organizational services, too).

The pandemic has resulted in higher usage levels for many providers of EAP services. For example, the International Foundation of Employee Benefit Plans (2021) found that the average level of EAP use among 237 employers in the U.S. increased from 7.4 counseling cases per 100 covered employees in year 2019 to 9.2 in year 2021. Similar results were also obtained from an industry-wide survey of 57 EAPs in the U.S., which found the average clinical case level utilization rate had increased from 7.4 counseling cases per 100 covered employees in year 2019 to 9.4 in year 2021 (Attridge, 2021).

Most EAPs also reported increases in the rates of use of specialty services for organizational consulting and for personal financial or legal issues since the economic downturn associated with the pandemic.

Summary

The increased use of EAPs makes it even more important to use the most appropriate outcome measures. Shining our light in the place we need to be looking, and not relying on the support of a single lamp post that may not shine on a large enough area, will ensure that we have a clear understanding of each client’s circumstances. Using an array of tools facilitates our provision of care most suited to individual needs, and our measurement of when these needs have been met and their circumstances improved for the better.

A more detailed list of tools and measurement resources follows the list of references for this article.

Dr. Ivan Steenstra is the Director Research & Analytics at LifeWorks. He is a human movement scientist and epidemiologist with a PhD in Public and Occupational Health. He has over 40 peer reviewed and indexed publications and presented his work at numerous peer reviewed conferences. He is based in Toronto and can be reached at ivan.steenstra@lifeworks.com.

Barb Veder is Vice President, Chief Enterprise Clinician, and Clinical Services Lead at LifeWorks. She can be contacted at barb.veder@lifeworks.com

LifeWorks thanks Kelly Beaudoin, Katie Clegg, and Mark Attridge who also contributed to this article.

References

Abdalla, S. M., Ettman, C. K., Cohen, G. H., & Galea, S. (2021). Mental health consequences of COVID-19: a nationally representative cross-sectional study of pandemic-related stressors and anxiety disorders in the USA. BMJ Open, 11(8), e044125. http://dx.doi.org/10.1136/bmjopen-2020-044125

Attridge M. (2021, September 22). Trends in workplace mental health during the COVID-19 pandemic: Implications for vendors of EAP services. Virtual presentation to the meeting of the Workplace Collaborative. http://hdl.handle.net/10713/16887

Couser, G. P, Nation, J. L., & Hyde, M.A. (2020). Employee assistance program response and evolution in light of COVID-19 pandemic. Journal of Workplace Behavioral Health, 36(3),1-6. https://doi.org/10.1080/15555240.2020.1821206

Hughes, D., & Fairley, A. (2020). The COVID chronicles an employee assistance program’s observations and responses to the pandemic. Journal of Workplace Behavioral Health, 36(3),1-20. https://doi.org/10.1080/15555240.2020.1844569

International Foundation of Employee Benefit Plans. Mental health and substance use disorder benefits: Survey results 2021. [White paper.] Author: Held, J. Brookfield, WI: IFEBP. 2021. https://www.ifebp.org/store/Pages/Mental-Health-Survey-2021.aspx

Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., et al. (2021). The implications of COVID-19 for mental health and substance use [White paper]. Kaiser Family Foundation. https://pameladwilson.com/wp-content/uploads/4_5-2021-The-Implications-of-COVID-19-for-MentalHealth-and-Substance-Use-_-KFF-1.pdf

Roy-Byrne, P. P., & Wagner, A. (2004). Primary care perspectives on generalized anxiety disorder. Journal of Clinical Psychiatry, 65[supll 13], 20-26.

Schneider, R. A., Grasso, J. R., Chen, S. Y., Chen, C., Reilly, E. D., & Kocher, B. (2020). Beyond the lab: Empirically supported treatments in the real world. Frontiers in Psychology, 11, 1969. https://doi.org/10.3389/fpsyg.2020.01969

Wittchen, H. U. (2002). Generalized anxiety disorder: prevalence, burden, and cost to society. Depression and Anxiety, 16(4), 162-171. https://doi. org/10.1002/da.10065

The Tools

The Generalized Anxiety Disorder Screener (GAD-7) is a 7-question instrument that screens for the presence and severity of symptoms of anxiety (Spitzer et al., 2006). This is one of the most widely used screening and outcome tools available for anxiety. The GAD-7 has been shown in past research to have adequate levels of reliability and validity (Kroenke et al., 2007; Löwe et al., 2008). Since its release in 2006, the PHQ has been cited in over 14,000 scientific papers (according to Google Scholar, November 2021).Sample items include the following: (a) Feeling nervous, anxious, or on edge; and (b) Not being able to stop or control worrying. Instructions refer to how much the statement applied to the person over the past 2 weeks. Scores were categorized into levels of severity: low = 0 to 4, mild = 5 to 9, moderate = 10 to 14, and severe = 15 to 21. Clinical status for anxiety is defined as moderate or higher severity (scores of 10+).

The Patient Health Questionnaire (PHQ-9) is a tool that is becoming more popular to measure the effectiveness of EAP counseling. The PHQ-9 is widely used for screening, diagnosing, monitoring and measuring the severity of depression (Kroenke, 2012). This scale has been used in many research studies and has established validity and reliability (Kroenke et al., 2001; 2002, Lowe et al., 2004). Since its release in 2001, the PHQ has been cited in over 24,000 scientific papers (according to Google Scholar, November 2021). The instructions state: “Over the last 2 weeks, how often have you been bothered by any of the following problems?” It has four response options of: (0) Not at all; (1) Several days; (2) More than half the days; and (3) Nearly every day. The PHQ-9 is scored by adding together the scores for all 9 items. Higher scores on this measure indicate greater depression. Scores are categorized into five levels of severity: Minimal = 0 to 4; Mild = 5 to 9; Moderate = 10 to 14; Moderately Severe = 15 to 19; and Severe 20-27. Based on recent reviews (Kroenke, 2012; Martin et al., 2006) clinical at-risk status for depression was categorized as Moderate or above (i.e., scores of 10+).

The Patient Health Questionnaire (PHQ-4). The ultra-brief version of the PHQ-9 and GAD-7 measures is called the Patient Health Questionnaire 4 or PHQ-4 (Lowe et al., 2010). Past data on over 5,000 patients determined this measure has acceptable psychometric reliability and validity. Symptoms of depression in the past two weeks were assessed with the following: How often were you bothered by little interest or pleasure in doing things? 2) How often were you bothered feeling down, depressed or hopeless? Symptoms of anxiety in the past two weeks were assessed with the following: item 1) How bothered were you by feeling nervous, anxious, on edge? item 2) How bothered were you by not being able to stop or control worrying? Total score is determined by adding together the scores for each of the 4 items. Scores are rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12). At-risk status is defined as Moderate or more severe (scores of 6+).

The Workplace Outcome Suite (WOS) is a brief, psychometrically robust tool that documents the impact of EAP workplace intervention (Lennox et al., 2010; 2018; Attridge et al, 2018). The WOS, endorsed by the Employee Assistance Professionals Association (EAPA), is a well-established outcomes measurement tool that continues to grow in employee assistance provider use, popularity, and available data for reporting. It has been used in over 50 studies in the EAP contexts It has five scales: Work Presenteeism, Life Satisfaction, Work Absenteeism, Work Engagement, and Workplace Distress. It has acceptable scale reliability and validity for a brief measure (Morneau-Shepell, 2020) and norms for EAP counseling use (LifeWorks, 2021).

Measurement Resources

ANXIETY– GAD-7

Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care, 46(3), 266– 274. https://doi.org/10.1097/MLR.0b013e318160d093

Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092

DEPRESSION – PHQ-9

Kroenke, K. (2012). Enhancing the clinical utility of depression screening. Canadian Medical Association Journal, 184(3), 281-282. https://doi.org/10.1503/ cmaj.11200

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ‐9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9):509-515. https://doi. org/10.3928/0048-5713-20020901-06 Kroenke, K., Spitzer, R. L., Williams, J.B., Monahan, P.O., & Löwe, B. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine, 146(5), 317-325.

Levis, B., Benedetti, A., & Thombs, B. D. (2019). Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: Individual participant data meta-analysis. British Medical Journal, 365, 1476. https://doi.org/10.1136/bmj.l1476

Löwe, B., Unutzer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004). Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Medical Care, 42,1194–1201. doi:10.1097/00005650-200412000-0000

Manea, L., Gilbody, S., & McMillan, D. (2012). Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): A metaanalysis. Canadian Medical Association Journal, 184(3):E191-E196. https://doi.org/10.1503/cmaj.110829

Martin, A., Rief, W., Klaiberg, A., & Braehler, E. (2006). Validity of the brief patient health questionnaire mood scale (PHQ-9) in the general population. General Hospital Psychiatry, 28(1), 71-77. https://doi.org/10.1016/j.genhosppsych.2005.07.003 BOTH ANXIETY & DEPRESSION – PHQ-4 (GAD-2 + PHQ-2)

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care, 11, 1284-1292. https://www.jstor.org/stable/3768417 Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2009). An ultra-brief screening scale for anxiety and depression: The PHQ–4. Psychosomatics, 50(6), 613-621. https://doi.org/10.1016/S0033-3182(09)70864-3

WORKPLACE OUTCOME SUITE

Attridge, M., Sharar, D., DeLapp, G., & Veder, B. (2018). EAP works: Global results from 24,363 counseling cases with pre-post data on the Workplace Outcome Suite (WOS). International Journal of Health & Productivity, 10(2): 7-27. http://hdl.handle.net/10713/8962

LifeWorks. (2021). Workplace Outcome Suite (WOS) Annual Report 2021: Global benchmarks for EAP counseling. White paper. Author: Attridge, M. Toronto, ON: LifeWorks.

Lennox, R. D., Sharar, D., Schmitz, E., & Goehner, D. B. (2010). Development and validation of the chestnut global partners workplace outcome suite. Journal of Workplace Behavioral Health, 25(2), 107-131. https://doi.org/10.1080/15555241003760995 Lennox, R. D., Sharar, D., Schmitz, E., & Goehner, D. B. (2018). Validation of the 5-item short form version of the Workplace Outcome Suite©. International Journal of Health and Productivity, 10(2), 49-61. http://hdl.handle.net/10713/8973

Morneau Shepell. (2020). Workplace Outcome Suite (WOS) annual report 2020: Part 1 - decade of data on EAP counseling reveals prominence of presenteeism. Author: M. Attridge. White paper. Toronto: Author. http://hdl.handle.net/10713/13758

New Anti-Discrimination Laws Forthcoming in 2022

| By Robin Sheridan, JD

As 2022 moves into high gear, the federal government, as well as certain state and local governing entities, continue to prioritize the importance of anti-discrimination laws. Indeed, many new laws were passed and signed in 2021 that went into effect in 2022.

Yet, as these new laws begin to pass, the variations and the timing at which the three levels of government (federal, state, local) enact these laws create challenges for employers. And while these new laws will not lead to every dispute ending like Tesla’s $137 million discrimination suit, many will impact employees and employers significantly. To read more about this landmark suit, check out an online article such as this one at https://www. npr.org/2021/10/05/1043336212/tesla-racial-discrimination-lawsuit

New Anti-Discrimination Laws Around the United States

Starting out West, the Oregon Crown Act, which became effective January 1, 2022, adds two definitions to the state statute, defining “protective hairstyle” and “race.” Specifically, Oregon defines “protective hairstyle” as: a hairstyle, hair color, or manner of wearing hair that includes, but is not limited to, braids, regardless of whether the braids were created with extensions or styled with adornments, locks, and twists.

In doing so, Oregon joins states like New York, New Jersey, Virginia, Colorado, Washington, Maryland, Delaware, Connecticut, New Mexico, and Nebraska in preventing race-based hair discrimination. Continuing with the westernmost states, California signed a new anti-discrimination law related to health care. The new law signed October 1, 2021 (to be effective January 1, 2023) will require approved schools of nursing and nursing programs to include one hour of implicit bias training as part of the program’s graduation requirement. Registered nurses will also be required to complete one hour of implicit bias continuing education within the first two years of licensure.

Similarly, down South, new anti-discriminations laws at both the city and state levels highlight the new anti-discrimination protections. In Charlotte, North Carolina, their City Council added more protections against employment discrimination effective Jan. 1, which ban bias on the basis of familial status, sexual orientation, gender identity, gender expression, veteran status, pregnancy, and natural hairstyles. Durham County in the same state also banned bias on the basis of natural hairstyles or textures, joining the aforementioned states and numerous other cities around the country. Additionally, in the South-Central region of the US, Texas passed two significant amendments to the state employment law that collectively went into effect on September 1, 2021. These amendments to the Texas Labor Code expand sexual harassment protections for employees in essentially all workplaces. Complainants can now wait longer to file. Specifically, employees go from having a 180-day limitation to a 300-day period in which to file sexual harassment allegations with the Texas Workforce Commission.

This expansion, notably, does not apply for all other types of discrimination and harassment claims filed with the Commission, as the deadline remains 180 days. Additionally, not only can an employer be charged for violating the state’s prohibition on sexual harassment, but individual managers can be charged as well. Finally of note, coverage of the state laws now extends to employers with as few as one employee.

Moving to the Midwest, Illinois signed into law an amendment to the Illinois Human Rights Act on March 23, 2021, prohibiting employers from considering an applicant and an employee’s criminal conviction record when making employment decisions, subject to two exceptions.

The amendment adds a definition of “conviction record,” creating more stringent requirements than federal or Illinois law on the use of a candidate’s conviction record during employment decisions. In short—as for the exceptions— the first exception relates to whether the position presents an opportunity for the individual to commit a similar offense, as it pertains to their conviction during the course of their employment.

The second exception relates to whether the individual’s employment would create an unreasonable risk to safety or property. Adding to this complexity, Illinois employers are now required to consider numerous mitigating factors when determining whether the use of a conviction record is allowable and must also engage in an interactive process with the applicant or employee before use of a conviction record.

Continuing with America’s Heartland, the Dane County Board in Wisconsin unanimously voted in January 2021 to expand its anti-discrimination ordinance to include an individual’s hair. This vote highlights both the continued trend of prohibiting discrimination based on hairstyle but also delineates how an employer is bound not by just state law. Another example of the need to be aware of local ordinances is found in Ingham County Michigan, which became the first Michigan county to ban hair discrimination against public employees.

Finally, states and cities throughout the Northeast continue to add anti-discrimination laws. New Jersey passed the “New Jersey Cannabis Regulatory, Enforcement Assistance, and Marketplace Modernization Act” in 2021. The law prohibits employers from discrimination against medical cannabis users while maintaining drug-free work environments at their discretion.

Importantly, while federally speaking marijuana is not legalized, as of April 2021, states like Connecticut, Delaware, Rhode Island, New York, and Maine have taken it upon themselves by creating employment protection laws for authorized medical marijuana users. Virginia, for example, prohibits employers “from terminating, discipling, or otherwise discriminating against an employee “for such employee’s lawful use of cannabis oil pursuant to a valid written certification.”

These protections are also seen at city and local levels. Effective January 1, 2022, a majority of Philadelphia employers will be prohibited from requiring prospective employees to perform a drug test for the presence of marijuana as a precondition of employment (subject to exceptions), joining New York City (effective May 10, 2020) and the state of Nevada.

Conclusion

It is evident from this survey of the new anti-discrimination laws enacted in 2021 and forthcoming in 2022 that lawmakers are continuing to add important protections for employees. Employee assistance professionals should be aware of the changes impacting both their practice and their clients’ employment.

Special thanks to Joseph Ho, Law Clerk, for his contribution to this article. Questions should be directed to Robin Sheridan, rsheridan@hallrender.com, 414-721-0469, or another Hall Render attorney. Special thanks to law clerk Joseph N. Ho, for his assistance in drafting this article. Legal Lines articles are provided for informational purposes only. For legal advice regarding how the issues in this article relate to specific circumstances, Hall Render recommends that EAPs seek out their regular counsel who can provide appropriate context and advice for a particular situation.

Robin Sheridan is an attorney with Hall, Render, Killian, Heath & Lyman, P.C., the largest health care-focused law firm in the country. Please visit the Hall Render Blog at http://blogs.hallrender.com/ for more information on topics related to health care law.

The Facts Don’t Lie

Statistical Truths about the Business Value of EAPs

| By Mark Attridge, PhD, MA

The facts don’t lie. I have been researching and delivering professional trainings about the return on investment (ROI) for employee assistance programs for over 25 years – and there is a wealth of research that strongly supports the effectiveness of EAPs. See my review in 2019 on making the business case for EAPs and workplace mental health. Despite the evidence, some employers, benefits consultants, and insurance brokers still question the value of EAPs. This article presents succinct and data-driven facts that answer critical questions about the business value of EAPs, and it offers an ROI case study.

Q1. Which “quality of life benefit” is purchased the most by employers in the United States?

A recent national survey by the Bureau of Labor Statistics (BLS) conducted in March of 2021 asked employers which benefits they pay for as part of employee overall compensation. Six types of “quality of life” benefits were specified in the report. Among civilian workers (both private sector and state and local government employers), EAP topped the list, being offered by 55% of all employers. Each of the other five kinds of benefits were not as popular: wellness programs (offered by 45% of employers), flexible work schedules (13%), child care (11%), subsidized commuting (9%), and flexible workplace (7%). Other surveys of HR leaders about employee benefits also usually find that EAP is ranked number one among voluntary benefits.

Q2. How many employers in the United States provide an EAP?

The same BLS survey also asked employers which benefits were part of their paid employee compensation. My analysis of over 6.6 million employers reveals that over 3.2 million private sector employers purchased an EAP

last year. That is a lot of profit-seeking business executives who invested in an EAP for their workforce. The report also indicates that over 182,000 public sector organizations purchased an EAP last year. That is a lot of leaders in government who decided it was in the best interest of the public to spend tax dollars on an EAP.

Q3. Does providing an EAP benefit vary by the size of the employer?

Based on the same BLS data, the rates of private sector workers with access to EAP benefits varied dramatically by company size: 29% of companies with 1-49 workers have an EAP; 49% with 50-99 workers have and EAP; 68% with 100-499 workers have and EAP; and 84% with 500 or more workers have an EAP. The same pattern exists for employees of state and local government organizations: 61% of public sector organizations with 1-49 workers have an EAP; 68% with 50-99 workers have and EAP; 70% with 100-499 workers have an EAP, and 90% with 500 or more workers have an EAP. These trends reflect how larger employers tend to pay higher wages and have richer employee benefits than do smaller employers, with the public sector being higher than the private sector in both areas. However, smaller size employers account for over half of the U.S. workforce and they are the fastest-growing market for EAPs (see JEA article by Carney & Knoepke).

Q4. How many workers have access to an EAP?

Based on the BLS data, roughly 58.4 million private sector employees had access to an EAP (based on 51% of 114.5 million total workers represented in their study). Another 14.6 million workers at the state or municipal levels of government had an EAP (based on 79% of 18.5 million total workers). Also, all 1.1 million workers at the federal level of government have access to an EAP that is part of the larger Federal Occupational Health program. When combined, about 74.1 million U.S. workers had an EAP benefit in year 2021. This adds up to a significant number of workers who have access to EAP services.

Q5. How much does an EAP cost?

Although there is no reliable public data source to answer this question, I can offer some estimates from my consulting experience. In general, as in most industries, the larger the size of the employer, the lower the price of the EAP. On average, using the recent 2021 BLS data on the percentage of micro, small, medium, and large sized employers that have an EAP, with corresponding per employee per year (PEPY) pricing of $30, $25, $20, and $15, respectively, I estimate the purchase cost in the U.S. for the average private sector employer to be $22 per employee per year (PEPY).

Q6. How much is America spending on EAPs?

Again, there is no credible national source to answer this question. But if we multiply the 74.1 million employees estimated to have an EAP benefit by my estimate of a $22 PEPY cost of the benefit, the result is $1.63 billion dollars.

Q7. What is the hourly cost per employee to provide an EAP over a year?

A full-time employee typically has a schedule of 40 hours of work expected per week. Over all 52 weeks in a year, this becomes 2080 total benefit-related work hours. The $22 PEPY cost when divided into the 2080 hours of compensated work time for the year is just one cent per hour.

Q8. How much is the EAP cost as a percentage of the total employee benefits cost?

According to the most recent Bureau of Labor Statistics’ national survey of employers in September 2021, the average private sector employer paid $26.36 in hourly wages and another $10.88 per hour for employee benefits. These benefits include financial contributions to employee retirement and savings, health insurance, paid leave, and many other voluntary benefits – such as EAP. Over a full year, the typical cost of benefits adds up to $22,630 per employee. Of this sum, the $22 annual cost of the EAP benefit per employee is only about one percent of the total benefit cost.

Q9. How many workers use the EAP for counseling?

How EAPs report their level of program use is not standardized and can be done in different ways. The clinical case rate is one of the most important metrics. The rate measures how many people during the year used the EAP for counseling per every 100 employees covered by the EAP benefit. In the past, this rate usually was about 5% or 5 counseling cases per 100 employees for external vendors of EAPs. Two new large national surveys – one that I did of 95 EAPs and the other by the International Federation of Employee Benefit Plans of 237 U.S. employers – both indicate this average rate in the U.S. has increased recently to 7.5% in year 2019 and now to 9.5% during the pandemic. However, the clinical case use rate for a specific employer can vary substantially from the average, with some being much lower (especially for employers who have a “free EAPs” that have extremely low use while their cost is hidden inside other insurance benefits) while other employers who integrate their EAP into the organization enjoy higher use in the 10-20% range.

Q10. How much EAP utilization is needed for a break-even ROI?

When the financial return for the program is equal to the cost of the investment in the program – $1 in return for every $1 invested – it is considered a cost-neutral or break-even type of business investment. How many employees need to use the EAP to get enough workplace-related cost savings from program outcomes to produce a $1:1 ROI? The answer to this question from research using EAP industry average results for the Workplace Outcome Suite© (WOS) is just one employee. See the 2020 LifeWorks white paper Part 1 for details and examples of ROI for small, medium, and large size employers in the U.S.

ROI for EAP: Simple Case Study Example

In the soon to be released 2021 WOS Annual Report by LifeWorks, I analyzed longitudinal data from over 28,000 EAP cases in the U.S. across many different EAPs to estimate reductions in the hours of work absence and the hours of unproductive time while working (called presenteeism). In the month just prior to using the counseling, the average employee client reported missing almost 8 hours of work and had 57 hours of lost productive time.

After counseling, at the longitudinal follow-up, the average employee client reported missing less than 4 hours of work and had lowered their lost productive time to 41 hours per month. This difference from Pre to Post, after some conservative adjustments, was used to determine that an employee in similar degree of personal distress who did not use the EAP would have lost 48 hours of productive time over a three-month acute episode.

The national average in hourly compensation in the BLS September 2021 report was $37.24 (wages + benefits) for private sector employees. Based on best practices in applied economics, compensation was multiplied by 1.3 to more realistically represent the influence that a healthy employee exerts on the shared productivity of coworkers and on overall work production. Thus, the business value per hour of productive work was $48.41. Using these inputs, the estimated cost savings was $2,324 for each EAP counseling case. Note that this result excludes additional savings in health care treatment costs and other outcome areas associated with a more comprehensive ROI model.

For a case study company with 100 employees who pays the typical $22 per employee per year price for the entire EAP service, it is a $2,200 total annual investment. In this example, it takes just one employee counseling case to cover the investment with the $2,324 in workplace productivity-related cost savings. However, consider that if this company had a 5% use rate of the EAP, their ROI increases to $5:1 and if it had the pandemic-level use rate of almost 10% of employees who used the counseling, their total ROI would be $10:1.

As an EA professional can plainly see, statistics don’t lie. EAPs provide a SOLID return on investment for businesses and other organizations!

Dr. Mark Attridge is an independent research scholar as President of Attridge Consulting, Inc., based in Minneapolis. He can be reached at mark@attridgeconsulting.com.

Suicide Discussion at Work is Vital

In the United States, suicide is the second leading cause of death for people ages 10 to 34, the fourth among people ages 35 to 44 and the fifth among ages 45 to 54, according to data from the Centers for Disease Control and Prevention.

A feeling of isolation can be overwhelming for people struggling with mental health issues and suicidal thoughts. But there are behavioral signs to look out for — and for managers and colleagues who interact with team members on a daily basis, spotting these signs can be lifesaving. Changes to normal behavior, an increase in absenteeism and a decline in productivity can be enough cause to reach out and check in on someone, Bert Alicea, a psychologist and executive VP of EAP and work/life services at Health Advocate, told Employee Benefit News.

“Workplace training can help others feel more comfortable asking direct questions about the situation and uncover potential risks or factors that may shift that person’s mindset,” Alicea stated. “Workplace leaders may ask what the workplace has to do with the mental health or the suicide risk of employees,” added Christine Yu Moutier, chief medical officer at the American Foundation for Suicide Prevention. “But the science is just so clear that suicide risk and prevention are related to a dynamic interplay between an individual’s internal factors like their DNA, their past trauma and the current environment. As working adults, we spend a lot of our time in our workplace culture.”

Read more at https://www.benefitnews.com/news/embracing-the-taboo-why-its-critical-to-discuss-suicideat-work.

Many Don’t Report Problems to HR

Employees are increasingly fearful of employer surveillance, according to a new study by Elements Global. The nationwide analysis revealed that the top HR-related queries, besides compensation and salary discussion, center around remote and workplace monitoring. Elements Global surveyed 1,000 American workers to find out more about their fears. Highlights include:

• 2-in-3 workers aren’t reporting issues to HR because they don’t think action will be taken.

• Roughly half (49%) don’t report issues to HR for fear of retaliation.

• 76% of workers using computers say they fear their boss monitors their communication.

• 3-in-4 remote workers are concerned their employer monitors when and how much they work. The good news: 83% of workers say they trust their HR manager or department. However, while a majority of people say they trust HR, that doesn’t mean they find HR effective, or that they don’t harbor other concerns when they consider making formal complaints. Two-thirds of workers say they’ve neglected to report something to HR because they didn’t think HR would fix the issue. The most frequently cited problems were having too much work, a personality clash, and bullying. A reluctance to make reports is not just about the specific nature of the issue, or the employee assuming that HR won’t act. There’s also a fear of retaliation to contend with – 49% of workers who have neglected to report something cited this fear. Given that personality clashes, bullying, and sexual harassment are oft-cited issues, it’s no surprise this fear of retaliation is a high bar to cross.

There is much room for progress in building trust and accountability at the center of employee-employer relationships, and the exponential rise in time spent working remotely will only make this issue more important. The EAP can play a key role.

Brainspotting - A Useful Adjunct to Trauma Therapy

| By Josh Delahan, LCSW

As EA professionals, we work with clients struggling with a multitude of presenting issues and provide solution-focused care. We each have our own go-to modalities and we often see clients improve. That said, what if there was an easily integrated modality that could substantially increase that improvement? For me, and over 13,000 other clinicians worldwide, that modality is Brainspotting – an approach that is useful for trauma of all kinds, including that resulting from COVID-19.

Background

Brainspotting (BSP) is a brain/body/mindfulness-based/relational approach developed by David Grand, PhD, a highlevel trainer, and author specializing in EMDR (Eye-Movement Desensitization and Reprocessing). It was during a performance-enhancement session of EMDR with an Olympic ice skater that he discovered BSP.

When Dr. Grand was guiding his client’s horizontal eye movements he noticed that her eyes tended to freeze at a specific point in her visual field. When Dr. Grand held her focus on that eye-position (not yet standard EMDR prac-