With the abundance of guidance and research available, OH practitioners should now be well placed to help ease the stigma of mental ill health, says Jane Downey.
According to recent research, six employees out of 10 with diabetes keep their condition secret for fear of discrimination and bullying (Paton, 2011). If employees with diabetes fear discrimination, how much greater must the fear be for employees with mental health conditions, described as the "number one" stigma by Corrigan (2005)?
This is echoed in the statistics, which reveal that only 21% of people with long-term mental health conditions are in employment; this reduces to between 4% and 8% for those who have a "severe mental health condition" (Rinaldi and Perkins, 2002). This is despite the fact that research on the "Individual Placement and Support" (IPS) model of vocational rehabilitation clearly demonstrates that a large proportion of people with severe mental health conditions can attain and retain jobs as long as they are provided with appropriate support (Becker et al, 1994; Burns et al, 2007). So, why in these supposed enlightened times is this problem so difficult to resolve? And what can OH practitioners do to alleviate the effects of mental health stigma in their workplaces?
First, we need to assess what is understood by the term "stigma". Biernat and Dovido (2000) define stigma as "a social construct that devalues people because of a distinguishing characteristic or mark". Corrigan (2005) categorises it into two types: "public stigma" and "self-stigma".
Public stigma consists of three elements: stereotypical thinking as a result of ignorance; negative attitude, which leads to prejudice; and negative behaviour, which leads to discrimination. Self-stigma occurs when members of the stigmatised groups internalise the attitudes towards them, which leads to self-defeating beliefs and behaviours, including isolation and avoiding treatment and disclosure that can have not only serious repercussions on their personal life, but also their employment status and opportunities.
A study carried out by Lyons et al (2009) in the North of England comparing the experience of mental health users in 1997 with those in 2007 found that the high levels of stigma and discrimination experienced in the employment settings in the initial study were echoed in the later one. Most of the stigma and discrimination experienced related to recruitment and, in particular, returning to work following a mental-health-related absence.
Regarding the latter, the data revealed examples of employees being ridiculed and bullied by both colleagues and managers, as well as a change in behaviour towards them by colleagues once their diagnosis had been revealed. This labelling or "stigmatisation by diagnosis" is a known phenomenon and was first discussed by Goffman (1963). Lyons et al (2009) suggest that one of the ways of managing this type of stigma would be to intervene early by implementing strategies such as "talking therapies", thereby reducing the likelihood of sickness absence and the resultant labelling occurring in the first place.
Stigmatisation by diagnosis has other insidious and negative effects as it compromises the normal day-to-day social interactions between people that are vital to fostering good working relationships and often results in the stigmatised employee withdrawing from the group and underperforming as a consequence.
Discriminatory behaviour prevents people who have a mental health condition openly identifying with fellow workers with a mental health condition."
This and other related discriminatory behaviour prevents people who have a mental health condition openly identifying with fellow workers with a mental health condition. Therefore, the potential for this group of employees to demonstrate their strengths and actively support their peers is seriously undermined, as well as placing the added burden of managing their condition in secret (Krupa et al, 2009).
Mental health guidance and research
So, what does the guidance for managing mental health stigma in the workplace advise and what is the evidence base for it? The major reports that have influenced the guidance include Waddell and Burton's "Is work good for your health and wellbeing?", which led to Dame Carol Black's seminal "Working for a healthier tomorrow", which stressed the importance of tackling mental health stigma in employment.
Black's 2008 report was supported by the Royal College of Psychiatrists' "Mental health and Work", which provided ample evidence from a wide range of research that people with mental health conditions experience stigma at recruitment and during employment, and are often viewed as weak and unreliable by work colleagues.
Over the past 10 years there have been a number of campaigns such as "Moving People", "SHIFT", "See Me" and, more recently, the "Time to Change" campaign, which is a joint collaboration between charities Rethink and Mind that is being evaluated by the Institute of Psychiatry. Time to Change is one of the largest anti-stigma campaigns to date and its strategy of using a high media profile while utilising "joined-up working" appears to be paying off. Surveys indicate that since the campaign was launched there has been a 4% reduction in reported discrimination and a 2.2% improvement in the attitudes of the public towards people with mental health problems.
Professor Thornicroft's book Shunned: Discrimination against people with mental illness and the "International study of discrimination and stigma outcomes in mental health (INDIGO)" provide a solid research base on mental health stigma and discrimination. The findings and recommendations from these reports and research helped form the backbone of the "National strategy for mental health and employment", published by the Government in December 2009.
This represents a new era of mental health policy, emphasising the development of mental health services with a strategy that stresses the importance of initiatives to assist people with mental health conditions attain and retain employment. The four main policy documents are: "New horizons", a blueprint for the vision of the new framework; "Working our way to better mental health; Realising ambitions"; and "Work, recovery and inclusion".
"Working our way to better mental health" sets out to change attitudes to mental health. It goes on to say that this will be achieved by "challenging mental health stigma and the prevailing culture of low expectations by, and towards, people who have mental health conditions".
Underpinning all of the recommendations made in these documents, particularly "Working our way to better mental health" and "Realising ambitions", is the need for employers to provide a culture that genuinely embraces diversity and concentrates on acknowledging a person's capabilities rather than just their disabilities.
"Realising ambitions" is an independent review that was commissioned by the Department for Work and Pensions and led by Dr Rachel Perkins. Its key objectives are: helping people with mental health conditions to access services across primary and secondary care; and assessing and advising how services can work together more effectively to assist people to attain and remain in employment.
There is a need for employers to provide a culture that genuinely embraces diversity and concentrates on acknowledging a person's capabilities rather than just their disabilities."
It reiterates research findings that employment outcomes are not directly related to diagnosis and severity of symptoms but rather that motivation and the personal belief that you can work are better indicators of success (Tsang et al, 2000; Grove and Membrey, 2005).
As negative assumptions are a regular hurdle for people with mental health issues to negotiate, "Realising ambitions" emphasises the importance of "dispelling the myths and stereotypes" that surround mental ill health and advises employers to question their assumptions and revise their views.
The report highlights the fact that people with mental health conditions often have fluctuating symptoms, but with the appropriate adjustments and support many can work effectively and productively.
It is very critical of how pre-employment health assessments were administered in the past and, subsequently, this procedure has been thoroughly revised as a result of the Equality Act 2010. It uses BT as an example of best practice because of the organisation's non-discriminatory and innovative approach to recruiting, employing and supporting employees with mental health conditions.
"Working our way to better mental health" is a cross-governmental national mental health and employment strategy led by Black and a team of expert advisers on mental health and employment. It stresses the importance of providing a working culture where employees can feel confident that the effects of their condition can be discussed, understood and acted upon without fear of discrimination. It emphasises the important part that this plays when implementing strategies such as early intervention and rehabilitation to assist with job retention.
Similarly, the National Institute for Health and Clinical Excellence guidelines for promoting mental wellbeing at work (2009) advise managers on the importance of creating an awareness and understanding of mental wellbeing while reducing the potential for discrimination and stigma as a result of mental health conditions. They are encouraged to apply this philosophy to all of their workplace processes such as job design, selection, recruitment, training, development and appraisal.
OH and HR interventions
So, how can OH utilise the guidance to inform its practice? As discussed in the guidance vision, organisations need to aim to provide a culture where people feel confident that the effects of their condition can be discussed, understood and acted upon without discrimination. Below are some suggested interventions that occupational health and HR professionals can implement to enable this vision to become a reality.
Equality/diversity policies: OH and HR have a responsibility to ensure that organisations have equality/diversity policies that are in line with the disability requirements of the Equality Act 2010 and to ensure that people with mental health conditions are treated accordingly.
Organisations have a responsibility to ensure that they avoid discrimination in the areas of: recruitment; training and development; career development; redundancy and dismissal; and day-to-day working life.
The benefits of "disclosure", particularly relating to reasonable adjustments, need to be highlighted in the policy. However, disclosure will be much more likely if an employee or applicant feels confident that they will not be subsequently discriminated against. It is imperative in such cases that the confidentiality of personal and medical information is safeguarded and that, when a person's disability status is known, all unnecessary and potentially damaging disclosures will be avoided and will only occur: with the explicit consent of the individual; when it helps to facilitate the person's ability to do the job; and if it is absolutely necessary within the law.
Pre-employment health screening: Under the Equality Act 2010, employers can no longer ask job applicants questions about their disability or health, including their sickness absence, before the applicant has been offered a job, except in a few specified circumstances. The purpose behind this change was to ensure transparency and prevent disability discrimination, providing clarity that a job offer has been withdrawn as a result of health or disability rather than qualifications or experience.
Training of managers: Occupational health practitioners can provide general mental health awareness training to managers. This can reveal the deleterious effects that stigma and discrimination have on employees with mental health conditions and points out how common these conditions are within the working population, for example, one employee in six will be suffering from a common mental health problem such as depression or anxiety at any one time, according to the Mental Health Development Unit.
OH and HR professionals in organisations should challenge the negative assumptions and generalisations that are made about people with mental health conditions."
OH practitioners can also train managers on how to identify the early signs of mental distress, how to handle conversations with their employees sensitively and appropriately in order to intervene early, and access interventions such as reasonable adjustments and/or counselling as soon as possible. This is not only more likely to prevent an exacerbation of the condition but also reduce the likelihood of stigmatisation by diagnosis.
Challenge the assumptions and stereotypes: OH and HR professionals in organisations should, at every opportunity, challenge the negative assumptions and generalisations that are made about people with mental health conditions, such as:
- "They are incompetent and cannot work." Research has proven that diagnosis and severity of symptoms are not an indicator of work outcomes, but having had a job, wanting to work and believing you can work are better indicators of success (Grove and Membrey, 2005). Although the majority of people in employment with mental health problems have common conditions such as anxiety and depression, a large proportion of people with severe mental health conditions can attain and retain jobs as long as they are provided with appropriate support (Becker et al, 1998; Burns et al, 2007).
- "They don't want to work." Research by Secker et al (2001) demonstrated that the majority of people with a mental health conditions do want to work.
- "People with mental health conditions are dangerous or unpredictable in the workplace." Unfortunately, the media plays a major role in emphasising incorrectly the correlation between mental illness and violence. Thornicroft's research (2006) showed that 40% to 70% of articles on mental illness in the newspapers were related to violence. This skewed reporting results in people being concerned when they hear someone has a mental health condition, which results in them increasing their social distance and leaving the person in question isolated and unsupported - conditions that are more likely to exacerbate their symptoms and raise the risk of them behaving unpredictably.
Rehabilitation following sickness absence: Should an employee need to take sickness absence, managers should be encouraged to keep in regular contact with the employee and liaise with occupational health, which will advise on an appropriate return-to-work plan. The plan should not only include, where necessary, reasonable adjustments such as a phased return, but advice to managers on ensuring that the returning working environment is a supportive one in which they lead by example and clearly demonstrate that bullying or discrimination will not be tolerated.
Consider becoming a "Mindful Employer": Mindful Employer is an initiative run for employers, by employers, which is led by its developer, the Devon partnership NHS Trust for Employers.
The initiative is aimed at increasing awareness of mental health at work and providing support for employers in recruiting and retaining staff. It can assist employers in putting good practices in place in order to ensure that employees and job applicants who declare mental health issues receive the right level of support without fear of discrimination.
Charter signatories are entitled to display the Mindful Employer logo as a sign that they are working towards the aspirations of the charter. For further information visit the Mindful Employer website.
There is much work to be done, but the research is now more coordinated and this complex issue is, at last, beginning to be tackled more effectively as "attitude" surveys are beginning to demonstrate.
However, as much as we like to deny it or find it unpalatable to accept, we are all at fault to a greater or lesser degree and we cannot put all of the blame on employers. Research carried out by Rinaldi and Perkins (2004) demonstrated that many health professionals were not encouraging unemployed people with mental health problems to return to employment because many believed that they were incapable of it.
A New Zealand study carried out by Kidd and Finlayson (2010) on 19 nurses who had suffered from mental illness demonstrated that stigma and intolerance of vulnerability by nursing colleagues was a common feature of their experience. This is not an uncommon feature of nursing, as in a number of studies nurses have demonstrated the attributes of an oppressed group by being fervently intolerant of vulnerability in their colleagues (Roberts, 1983; Ross and Goldner, 2009).
The reasons behind this particular stigma and that influence attitudes can be very complex and often subconscious. However, all nurses have a responsibility to assess and review their attitudes accordingly. OH practitioners have a particular duty as they need to ensure that they influence, where possible, organisational policy and culture for the better.
Detailed groundwork and collaborative working carried out by researchers, mental health pioneers and charities is starting to demonstrate a change in public perception."
BT and other organisations have proved that, even in hostile economic climates, businesses can, with a little creative thinking and an open attitude, harness the potential of all their employees, including those with mental health conditions, so that both employer and employee can benefit.
Huge progress has been made over the past 40 years in ensuring that employees do not suffer discrimination as a result of their race, gender or sexuality, but it has been a harder battle to challenge effectively the stereotypical thinking and negative attitudes and behaviours relating to mental health conditions.
However, it appears that all the detailed groundwork and collaborative working carried out by researchers, mental health pioneers and charities is starting to demonstrate a change in public perception. The OH profession should ensure that it is part of this perception and make its contribution to ending the needless suffering and lost opportunities that this stigma has created, and continues to create, for millions of individuals.
Jane Downey MSc (org psychiatry and psychology), SCPHN (OH), RGN is a consultant on occupational health and wellbeing at Wellbeingworks4Business.
Becker DR, Drake RE, Concord NH (1994). "Individual placement and support: a community mental health center approach to vocational rehabilitation". Community Mental Health Journal, 30, pp.193-206.
Black C (2008). "Working for a healthier tomorrow: a review of the health of Britain's working age population". London: The Stationery Office.
Burns T, Catty J, Becker T, Drake RE, Fioritti, A, Knapp M, Lauber C, Rossler W, Tomov T, van Busschbach J, White S, Wiersma D (2007). "The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial". The Lancet, 370 (9593) pp.1,108-1,109.
Biernat M, Dovido JF (2000). "Chapter 4: stigma and stereotypes" from Social Psychology of Stigma. Guildford Press.
Corrigan P (2005). On the Stigma of Mental Illness. American Psychological Association.
Cross-government report (2009). "National mental health and employment strategy, working our way to better mental health: a framework for action".
Department of Health (2009). "New horizons: towards a shared vision for mental health - consultation". London.
Goffman E (1963). Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, New Jersey: Prentice Hall.
Grove B, Membrey H (2005). Sainsbury Centre for Mental Health. "Briefing paper 37: doing what works".
Krupa T, Bonnie K, Cockburn L, Gewurtz R (2009). "Understanding the stigma of mental illness in employment". Work 33 pp.413-425.
Kidd JD, Finlayson MP (2010). "Mental illness in the nursing workplace: a collective autoethnography". Contemporary Nurse, 36.
Link B, Phelan JC (2001). "Stigma and its public health implications". The Lancet, 367, pp.528-529.
Lyons C, Hopley P, Horrocks J (2009). Journal of Psychiatric and Mental Health Nursing, 16, pp.501-507.
National Institute for Health and Clinical Excellence (2009). "Promoting mental well being at work". Clinical practice guideline. London: DOH.
Paton N (2011). "Diabetics suffer in silence, says charity". Occupational Health, July 2011.
Perkins R, Rinaldi M (2002). "Unemployment rates among patients with long-term mental health problems. A decade of rising unemployment". Psychiatric Bulletin, 26, pp.295-298.
Perkins R, Farmer P, Litchfield P (2009). "Realising ambitions: better employment support for people with a mental health condition". London: TSO.
Rinaldi M, Perkins R (2004). "Vocational rehabilitation". Psychiatry, 3, pp.54-56.
Roberts SJ (1983). "Oppressed group behaviour: implications for nursing". Advances in Nursing Science 53 pp.21-30.
Ross CA, Goldner EM (2009). "Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature". Journal of Psychiatric and Mental Health Nursing, 16 (6) pp.558-567.
Secker J et al (2001). "Challenging barriers to employment, training and education for mental health clients: the client's perspective". Journal of Mental Health, 10, 4, pp.395-404.
Thornicroft G (2006). Shunned: Discrimination against people with mental illness. Oxford University Press.
Tsang H, Lam P, Bacon NG, Leung O (2000). "Predictors of employment outcome for people with psychiatric disabilities: a review of the literature since the mid-80s". The Journal of Rehabilitation, vol.66, 2000.
Waddell G, Burton AK (2006). "Is work good for your health and well-being?" London: TSO.
Royal College of Psychiatrists report. "Mental health and work 2008", commissioned for Dame Carol Black's "Working for a healthier tomorrow 2008".