After nearly three decades at the forefront of wellbeing, Eugene Farrell stepped, immediate past chair of the EAP Association UK, back from the treadmill earlier this autumn. Here he reflects on how wellbeing, and within that EAP provision, has changed and where it might be heading next.
After 28 years of working for a major medical insurer and employee assistance provider (EAP), I left full-time work at the end of September.
It seemed an appropriate moment to review the changes I have seen in mental health and wellbeing over that time.
I first encountered an EAP in 1996, visiting ICAS in Milton Keynes; this was to change my working life. The notion of EAPs was not well understood at that time, with just a handful of providers in the UK, which had established a UK chapter of the US-based EAP Association (EAPA).
This set out standards for wellbeing providers to follow, although following very different approaches to that seen in the USA, where EAPs were strongly rested in the world of alcohol and substance abuse.
The demands of multinationals, such as BP and Johnson & Johnson, sparked the demand for UK-based providers.
EAPs and wellbeing
Back then, the fee per person was often £40 or more, with funding based upon pre-payment of blocks of counselling sessions or paying for wellbeing sessions on an ‘as used’ basis.
I was working on developing an EAP from the ground up. Upon entering the market as a new provider, it was clear that pricing could be challenged and this was not popular.
The support provided by EAPs in the UK has remained much more about non-work issues than work issues, with personal stress being a major reason to contact an EAP.
Relationships were the number one reason people contacted the EAP. Back at that time, there was no open discussion about mental health, work stress was the major employer theme, wellbeing was really not a thing at all.
However, the 1994 case of Walker vs Northumberland County Council had established that employers did have a duty of care for mental injury – and work pressure and stress became the major discussion point.
Even with this case law, it was a time when EAPs had to be explained to buyers, and especially to employees.
Changes in delivery model
It was a tough sell, with many employers resisting supporting employees. ‘Man up’ as a response was prolific; there was a fear that admitting to being affected by stress would be negative to employment prospects. One employer even told me that those affected by stress were “just weak people”!
Over a few years, more EAP providers became established and models of delivery changed. Telephone mental health assessment was still relatively new, the internet was not prolific and smartphones yet to be invented.
Some providers had a second level of assessment, with clinical psychologists undertaking assessments by phone or face to face. That, however, was a model that proved too expensive to maintain.
All the providers used a network of independent counsellors around the UK to deliver counselling in the same short-term models we still see today.
EAPs developed stress management training for employees and managers, at that time we had to explain what stress was, its signs and symptoms and encourage people to seek help and support. Anxiety and depression were mentioned in passing, something that was going to change in a few years.
Outcomes were not routinely measured in the early days, and discussions around positive outcome were still rare. The ‘CORE’ outcome measure was launched in 1998, and was adopted by some of the EAP providers to show that EAP counselling worked.
Some providers used the pre-post measure for every counselling case, and others used a sampling method.
Nevertheless, this clearly demonstrated that EAP counselling short-term models worked. McCleod’s 2001 Counselling in the workplace: The Facts. A Systematic Study of the Research Evidence very much set the tone and impetus for providers to begin to discuss outcomes more.
Today, we see other measures such as WOS, GAD7 and PHQ-9 being used. And, still, we see that counselling achieves positive outcomes.
The Health and Safety Executive, meanwhile, was strongly promoting the management of stress at work, publishing its Management Standards in 2004 and introducing risk assessment for stress.
There was no mention of non-work stress or the effects of an employee’s life and current experiences upon their work, however. EAPs argued that support should be provided for the whole person.
I would go to HSE launch events and promote EAPs as support and non-work issues being important, too. They probably saw me as a bit of a nuisance!
In 2007, the then Sainsbury Centre for Mental Health published its report Mental Health at Work: Developing the business case, in which the cost to business of presenteeism associated to mental health was seen as twice that of absence.
This very much created a business case to support the provision of greater mental health support from within the workplace. Performance become a cost issue for business.
Gradually, more mental health language stated to enter into the discourse; anxiety and depression were openly talked about, in some ways seen a more complex form of stress; employees with stress problems would self-label themselves as depressed. Although not always clinically accurate, this was helpful in terms of opening minds beyond stress.
Increasing volume of conversation
Over time, the work of mental health charities such as Mind, EAPs, occupational health providers and a few celebrities increased the volume of conversation around mental health.
The future of EAPs lies in digital support. Apps and online are replacing traditional telephone assessment and in-the-room counselling and support.”
Wellbeing at work was just beginning, with fruit bowls and Indian head massages. Some key influencers who shaped the change in mental health attitudes were the late Stephen Bevan, Peter Kelly, Nick Pahl, Steve Boorman, and Dame Carol Black, to name but a few.
I would like to think I played my part also in press articles and conference presentations, as well as judging awards for both Personnel Today and OHW+! Over the years I have covered many different subjects ranging from stress, to resilience, crisis and trauma, counselling, technology and apps.
Conferences had begun to feature more mental health topics. The Health and Wellbeing at Work Conference, for example, had very much supported the EAPA in the UK, allowing its AGM to take place at the conference and featuring EAPA board members such as myself in its speaker line-up.
Employers were keen to hear more about what EAPs could do and talk the talk of mental health. This led to the emergence of specialist mental health conferences we now see.
Happiness, too, began to enter the dialogue of mental health, with publications by Martin Seligman in 2002 and Richard Layard in 2005. Seligman of course went on later to promote the concept of being able to ‘flourish’ in his 2011 book (it was way before its time).
This area opened a new discussion around mental health but in a slightly different way. The 2017 Stevenson/Farmer Report was another seminal development in workplace mental health, providing both analysis and a template for support that organisations could follow.
The EAP market had initially included large corporate providers as well as small privately owned providers. Unfortunately, the pressure on pricing forced many smaller providers out, with takeovers and mergers.
No longer were providers able to command £40 per capita per annum, and today we would see something less than £10 per employee.
This made it impossible for smaller providers to survive and, today, the market is dominated by large providers. It is interesting though to see the emergence of new, tech-based providers who come from a new place not hampered by the past.
‘Seismic’ shift of Covid-19
The Covid-19 created a seismic shift in attitude to mental health; there became a realisation that mental health was really really important and affected all of us, both at work and at home.
EAPs have always responded to market shifts and evolved. They will continue to do so, I am sure. Mental health has always been here and it will always be important.”
Shame and stigma significantly fell away and a new openness began. I am pleased to see now that EAPs hardly ever have to be explained.
As reported by the UK EAPA, the market size grew from £32.2m in 2003 to £118m and has become a standard workplace support.
EAPs in the UK had always included non-clinical services such as legal information, debt advice and health information. The US and European markets have very much followed what we did here, with the inclusion of such services.
Europe has always lagged behind the UK in workplace mental health support; the EAPA never did grab a firm foothold, with only Ireland and Greece being established, both of which have since faltered.
The EAEF (Employee Assistance European Forum) grew in importance in Europe, setting standards for employee assistance work, an area that I played a part some 10 years ago in developing.
I am pleased to say that mental health awareness and stigma reduction has progressed significantly; members of the Royal Family have become involved, together with mainstream media and this is indeed positive.
Of note are the additional areas that border workplace mental health and, indeed, the work of EAPs. Coaching, for example, is emerging as a new trend, providing a less stigmatised support, particularly for cases that are less clinical.
Neurodifference has entered the frame along with gender and identity, ethnicity and the ‘me too’ momentum around domestic and other violence. All of which are now part of the workplace landscape.
Finally, to my mind, the future of EAPs lies in digital support. Apps and online are replacing traditional telephone assessment and in-the-room counselling and support.
EAPs have always responded to market shifts and evolved. They will continue to do so, I am sure. Mental health has always been here and it will always be important.
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