With both the government and employers now firmly focused on encouraging workers out of home-working and back into physical workplaces, how should anxious returnees be managed? Should it just be an HR issue or one where mental and emotional health support, led by occupational health, is the key? A recent webinar offered some guidance. Nic Paton reports.
The past few months has seen the gradual transition out of lockdown and towards, as prime minister Boris Johnson said in July, getting “back to work if you can” and at least the hope of “normality by Christmas”. In that time, there has been much talk about whether, now so many of us have experienced home-working, we’ll see a permanent adjustment to what we mean by ‘the workplace’. Will the challenges of commuting on public transport, the need for socially distanced workspaces and simply the realisation learned over the past few months that technology is now such that, for some of us at least, home-working can work mean we see a longer term rethink about where and how employees work?
One factor at play here that has perhaps been less discussed is the role of anxiety. Certainly, there has been recognition that the prospect of venturing back out again into a physical working environment is something that, for many, is fuelling worry, anxiety and, potentially, a reluctance to return.
But, as an employer, assuming you can show (probably with the help of occupational health) that your workplace is ‘Covid secure’ and assuming you would prefer to see your employees back physically in some shape or form, how should you be responding to this? Should it be seen as an attendance/HR, even disciplinary, issue? Or should employees who are anxious about being asked to come back be viewed more sympathetically, as needing mental or emotional health support and intervention, perhaps via occupational health? Or does it need maybe to be a spectrum encompassing both?
Untangling health anxiety and return to work
To try to unpick some of these issues, and to offer advice to OH practitioners among others, the Royal College of Psychiatrists recently held a webinar looking at health anxiety in the workplace, with an emphasis on Covid-19 and return to work.
Chaired by Professor Neil Greenberg, chair of the college’s occupational psychiatry special interest group, the discussion brought together consultant occupational psychiatrist Dr Phil Johnson, consultant clinical psychologist Dr Nick Grey and consultant psychiatrist Dr Dan Sherwoood to address issues around what is anxiety, facilitating the return to work of anxious employees, and understanding functional impairment in the context of Covid-19.
Dr Grey, a consultant at Sussex Partnership NHS Foundation Trust, emphasised that, while we nowadays know a lot about anxiety – its ‘fight, flight and freeze’ response and the impact of its physical symptoms, for example – understanding its impact in the current unprecedented circumstances is less clear-cut.
“People have very different gauges of risk and gauges of what is risky behaviour, whether that be Bournemouth beach or the centre of Soho. We are all of us living with risk and we are all of us somewhere on a continuum between taking lots of risks and taking no risks. It may be that, with Covid-19 coming in, we have changed where we are on this risk continuum,” he pointed out.
The crucial thing to remember is that anxiety is often about perception of risk rather than its actuality or likelihood, he highlighted. “Even if something is very unlikely to happen, people will feel anxious if they think, ‘if this happened, it would be particularly awful’,” he said.
“We know that anxiety is a normal human experience and worry is a normal process. We know following traumatic events having some traumatic stress symptoms are normal in the days and weeks that follow. But what we also know is that most people will recover naturally from traumatic or very stressful experiences,” he added.
Role of CBT and IAPT services
When it comes to support or intervention, key questions need to include how long have symptoms lasted, how much do they interfere in someone’s life, how upsetting are they? Are the symptoms improving, worsening or remaining stable? How is it stopping them living the life they want? But, also, could it be evidence of post-traumatic stress disorder, something that has been flagged up as a issue particularly for healthcare workers and those who have been seriously ill with Covid-19.
“This [PTSD] is one of the diagnoses that is really missed, and we really need to ask about the symptoms people are experiencing. If people are talking about worry and feeling scared, we need to check out what the context of that is, rather than just thinking of it just as ‘anxiety’ as a whole,” said Dr Grey.
Assuming it is an anxiety disorder that needs treatment, the National Institute for Health and Care Excellence recommends cognitive behavioural therapy (CBT) as the treatment of choice, Dr Grey also highlighted, and most commonly available through Improving Access to Psychological Therapies (IAPT) services. “If we can understand people’s worst fears, and understand some of these key processes, then we can work with them to change these things.
“One of the things that we as health professionals sometimes fall into the trap of, is that something when people are feeling anxious we are just going to tell them that everything is going to be all right. But what we should be trying to do is providing information, not continual reassurance, particularly for chronic anxiety problems,” Dr Grey said.
“Advice for staff in workplaces, advice for clients, advice for us all, is that typically we want to rely on trusted sources of information. We want to perhaps limit our exposure to news and media reporting and, actually, stick to what the known facts are from these trusted sources of information.
“We should recognise that we may have acute levels of stress in response to particular circumstances, and to normalise that. But to be aware that that is different from a chronic anxiety problem. Finally, if people developing chronic anxiety problems then, actually, psychological interventions that work are available,” Dr Grey said.
Managing and supporting the anxious employee
Dr Johnson, of Sarum Occupational Health, addressed more directly the question of the anxious employee and their return (or not) to work. “We live in interesting times; we don’t have a rulebook anymore. Our reliance upon evidence seems to be limited. It is hard to work out what is right and what’s wrong. Uncertainty, as we all know, is a powerful cause of anxiety, and anxiety maybe understandable, it may be something else; it may be many things, whether we call it irrational, idiosyncratic, situational, all might apply. But we are dealing with difficult situations,” he emphasised, first off.
People can often be anxious about returning to work at the best of times, whether after a time away for illness or even just coming back after a fortnight’s holiday away, he pointed out. So, given the length of time many people have been away from the physical office environment, this could well be amplified, he suggested.
“We have a situation that presents itself as the major variable in the occupational health approach to these situations. One of the problems we have is one of anticipation, and that is ‘what is it that awaits you when you reach the office, what are your anticipations and what are you fearing?’. Many people have a prior poor absence history, attendance issues, performance problems; there are inter-personal issues that go with being in the office. And few of these, if any, will have been improved by 16 weeks away from work,” said Dr Johnson.
“We will have all come across people who feel they are much better having had three months off work with their problems, whether they be physical or mental health-related. And they come back to us as occupational health physicians and say, ‘it’s fine, I’m better’. And within two or three weeks of being back they’re not better, and they never were. So the problems that people are experiencing before they went off on furlough are not going to have improved over the intervening period.
“There are many reasons that people are going to be worried about coming back, or putting forward their worry about coming back. These may include ‘I’m shielding’, ‘my partner is shielding’, ‘my medical condition’ and I’ve come across relatives or friends who are holding up their relatively minor medical conditions as a reason for shielding. ‘I don’t trust my colleagues to behave safely’. ‘I work with people who I wouldn’t trust at the best of times; now I can’t’. ‘They (work) are not providing the correct masks, gloves or whatever it might be’. ‘I have a disability’. Any number of reasons I am hearing at the moment for ‘I can’t go back to work’.
“Obviously, it is a risk assessment process, and many of us are involved in advising on those who may or may not be able to go back to work. But assessing people’s ability to return to work is a complex process, and there is a lot of anxiety around those issues,” he pointed out.
“So, how do we manage the anxious person returning? First of all, we need to understand the situation. What is causing the problem for the individual at this time? This is where we may need to resort to expert advice, and actually to get in someone who really understands the psychiatry and psychology involved,” Dr Johnson advised.
“Second, define the issues with the agreement of the individual. Try to understand how things are presenting, and why they are presenting at this time, and looking for adjustments, temporary adjustments that can build confidence and help somebody get back to work. Third, try to make sure there is an adequate review built into the process.”
For the employee, the focus needed to be, “what can you do about your situation and how can I advise about your circumstances?”. For managers and HR it needed to be more “what can you do about the situation, how can you help with the individual and team, and what adjustments are necessary”. And at a senior leadership/organisational level, the focus needed to be “how should we/what can we, the chief medical officer or whoever else occupational health is advising, do to help them to make it all happen?”, Dr Johnson pointed out
“To do that it is necessary to discern the nature of the anxiety, the actual cause, the underlying problems that get us to where we are. And therefore have a way to try and make progress. Without an understanding of the situation we can’t possibly any meaningful advice,” he added.
Functional impairment and Covid-19
Finally, Wing Commander (retired) Dr Dan Sherwood, a consultant psychiatrist at the Defence Rehabilitation Centre in Loughborough (but, he emphasised, speaking in a personal capacity), addressed the question of functional impairment associated with Covid-related symptoms.
“People who have recovered from any severity of Covid-19 infection are going to be worried about the longer term effects of that illness, because we don’t know what they will be, and we are getting conflicted and sometimes sensationalist reporting about what those longer term effects could possibly be,” he pointed out.
“There will be people who have had a traumatic experience linked to the pandemic. People who have required critical care for treatment of Covid, but also of course the frontline and essential workers. Then there are of course people who have pre-existing medical vulnerabilities – the shielders – who are going to be particularly worried.
“There are people who have an increased vulnerability to anxiety; so people who were already being treated for an anxiety disorder prior to the pandemic, or people who have a past psychiatric history that makes them more likely to develop anxiety symptoms in response to unpredictable stressors or unpredictably stressful situations.
“Then there are groups of people who will perhaps struggle more – people who already have health anxiety or people who have conditions such as obsessive compulsive disorder, who have obsessional thoughts about contamination or illness.
“Finally, there is the understandably ‘worried well’, because these are uncertain times. People are going to be worried about change and uncertainty, the health of relatives and loved ones; there will be a group of people who have symptoms of anxiety who are not necessarily ‘ill’ – they do not have an anxiety disorder – but their anxiety symptoms impairing in some way, and it is important to think about those people as well,” he highlighted.
So, how might all this affect how people function in the workplace? Anxiety can affect people’s ability to work effectively and independently, with others, and to engage in safety-critical tasks, Dr Sherwood advised. For a proportion, it can even prevent them from working at all.
It can affect decision-making and the prioritising of tasks, time management, and stamina. It can cause sleep disturbance and fatigue, the ability to focus on instructions and memory. “I think it is plausible that people with Covid-related anxiety may develop ‘safety’ behaviours, such as excessive hand-washing, particular PPE rituals; they may change the way they travel to and from work. And this can interfere with task completion,” highlighted Dr Sherwood.
Managers may, naturally, feel personal responsibility for ensuring the health and safety of team during the whole transition from home to ‘normal’ working (and this could well, of course, be a gradual or blended process). “It is important that we are alert to symptoms of anxiety or general distress in employees who are working with minimal supervision or support. An individual who is fatigued, hyper-aroused or preoccupied with worry is more likely to make mistakes. This doesn’t mean that they are unable to work entirely, but you need to give consideration to their ability to engage in safety-critical tasks,” said Dr Sherwood.
At a practical level, an occupational report or workplace assessment will be an obvious first step. But it will also be important, and perhaps on an ongoing process, to be assessing fitness to work, the working environment, stress attached to the role, the level of supervision and peer rapport, the individual’s engagement in safety-critical tasks, vulnerability to worsening symptoms of mental and physical illness, impact of that on the rest of the workforce and, crucially, the individual’s insight into their diagnosis, he emphasised.
“I think it is plausible that there will be a higher preponderance of workplace absences as lockdown lifts, and certainly in the early stages. And, if so, I think that that will have an impact potentially on the morale and psychological wellbeing of the reduced workforce, and increasing the likelihood of occupational burnout,” Dr Sherwood concluded.
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