Everyone will at some point have to deal with an employee or colleague who is showing signs of mental distress. This is not because we are in the middle of a sudden epidemic of mental illness – the incidence and prevalence of both common (depression, anxiety) and more severe mental health problems has been fairly stable over the past 20 years. It is because mental ill health is common in both the working and the general population – so common that it could be described as a normal feature of the human condition.
With a lifetime incidence of one in four in the general population and an annual incidence of one in six in the working population, it can happen to anyone. But is it an epidemic caused by modern working life?
Causes
It is fashionable to suggest that the stresses of modern working life are to blame for the rise of work-related ‘stress’ and sickness absence. Stress is not a disease, and it is by no means clear that this phenomenon is related to actual levels of mental illness in the workplace. Self-report data from the Health and Safety Executive (HSE) suggests that as few as one-fifth of people signed off with mental health problems attribute them directly to the workplace.
Clearly having a mentally healthy workforce is important, not just for employee welfare, but also for productivity. But even the most healthy workplace in the world will not eliminate mental illness or the need to manage mental distress.
If mental ill health is so common why not just accept it and continue as before? The reasons why change is needed are both humanitarian and financial. The humanitarian argument should already be apparent to anyone who has had a friend or relative who has become mentally ill. But the financial argument is equally compelling. Using official statistics, the Sainsbury Centre for Mental Health has calculated that mental ill health costs every employer just over £1,000 per employee per year (see Table 1).
Recognition
The first step towards dealing with a problem is recognising that it exists. Surveys show that employers tend to underestimate the prevalence of mental ill health in their workforce. In one survey, half of the respondents thought that no-one in their workforce would ever have a mental illness. Why is this?
One important reason is that most employees try very hard to keep quiet about mental ill health. Thornicroft has shown that the levels of stigma and discrimination experienced by people with a diagnosis is high and rising. Although for the most part unintentional, it permeates mundane social interaction to such a degree that he likened it to institutional racism.
Prevention
Although workplace programmes to promote mental health and awareness may not prevent people from becoming mentally ill, they can be effective in improving employee wellbeing. First they signal to employees the organisation’s commitment to mental wellbeing, and to eliminating stigma and discrimination.
Thornicroft breaks the problem down into three parts:
1 Ignorance (not having the correct information)
2 Stereotyping (labelling/jumping to conclusions based on prejudice)
3 Discrimination (behaving in an unfair way to disadvantage people because of their mental health problems).
Workplace mental health programmes should aim to empower employees to care for their own mental health, and provide enough information to counter ignorance and prejudice. Most important is ensuring that behind the positive messages is a clear policy that discrimination is both unacceptable and unlawful.
A number of big companies have run their own mental health awareness and wellbeing promotion programmes. BT has made creative use of its intranet to engage employees and measure the impact of its Workfit programmes, and there are many examples of off-the-shelf programmes that are available at little or no cost for employers that are keen to try things out, but do not have the time or expertise to develop their own programmes. There is also excellent general advice on managing for health and mental wellbeing from the Health and Safety Executive.
Symptoms
Often it is those working most closely with a person who will notice changes in their behaviour – withdrawal, tearfulness, irritability or poor performance. Any of these are signs that someone is having an off day or a temporary crisis. Simply asking what is wrong will often elicit a perfectly understandable reason for the behaviour, and often all that is required is some time and space to come to terms with the problem. Most people get over emotional crises without needing professional help or time off work. However, if the problem has gone on more or less continuously for around four weeks, then it is likely that the person is not recovering and may need additional help and/or medical advice.
How do you know whether a person is genuinely distressed rather than lazy, putting it on or bloody-minded? The short answer is that there is no simple formula – those who know the person well are likely to be the best judges. If an employee has been functioning in a perfectly satisfactory way and then suddenly goes downhill, it is a reasonable assumption that something has gone wrong. The only way a doctor can diagnose mental illness is by talking to the person, trying to set their present state in the context of their history, and checking what they say against standard diagnostic criteria.
Management
Even when people have reached ‘clinical’ levels of mental illness most recover quite quickly, and treatment, when needed, is usually successful. However, even when symptoms are no longer so apparent, people often find coming back to work very difficult.
To avoid medicalising what are essentially interpersonal problems, I have used the term ‘distress’ to cover a range of behaviours that would indicate clinical levels of mental illness. This is not to minimise the role of the clinician in treating mental illness, but rather to emphasise that the barriers to recovery and return to work/productivity are often due to the breakdown of relationships in the workplace. This begins at a very early stage, because colleagues and line managers are often the first to know that something is wrong.
Unfortunately, when it becomes clear that the distress or distressing behaviour is indicative of something more serious, most people feel out of their depth. Conversation becomes difficult there is a sense of walking on eggshells, maybe a strong desire on the part of those around the distressed individual to refer the matter on to an ‘expert’ who can assuage their own fears and will know what to do.
The person in distress may also feel afraid and be all too aware that friends and colleagues are seeing and treating them differently. At first they may drive themselves extra hard to prove that they are still up to the job and avoid seeking help in case it gets out that they are having to see a doctor or counsellor, thus becoming irretrievably labelled as a psychiatric case. The longer this continues, the harder it becomes to resume ‘normal’ relationships. Thus begins the downward spiral that, if unchecked, leads to disability and long-term unemployment.
Although the hard evidence on the details of vocational rehabilitation from mental ill health is not yet strong, we do know enough to improve dramatically what happens now, which has led to the staggering number of people with mental illness on long-term benefits.
First response
The ability to identify and respond appropriately to mental distress in the workplace should be in every manager’s toolkit. These are skills that can be learned and applied as long as the organisation’s culture and policies are supportive. The Sainsbury Centre for Mental Health is piloting a line manager training programme developed by ‘Beyondblue’, the Australian national depression programme. These are short courses designed to enable managers to have greater confidence that they are not making things worse by showing them helpful ways of relating to people in distress. These courses have now been delivered to more than 17,000 managers in Australian workplaces and the evaluations are positive.
A key part of the training is signposting where people can go for help. Clearly GPs are very important, but organisations with occupational health departments or employee assistance programmes will be able to provide a range of practical support alongside medical support if necessary.
Keep in touch
It is good practice to keep in touch with employees who are off sick, and this is no different for people with mental health problems. This should be enshrined in the organisation’s policies and conditions of employment to eliminate any suggestion of discrimination or harassment.
If the line manager feels anxious about what to say, give them a script. The main aim in the initial phase (the first week or two) is to reassure the employee about their continuing membership of the workforce and the expectation of recovery and return to work. This can be done in a number of direct and indirect ways, and can be combined with the offer of practical support. For many this will be sufficient. By the time the person has been off for four to five weeks, it is time to move on to the next level of intervention.
Case management
Once a person has been off for a month or more, the barriers to returning to work – social as well as psychological – may well be becoming more complex. They will also be different for each person, so it is very important to understand the nature of the difficulties.
Here a case manager from outside the immediate line management structure can be very helpful. The primary role of the case manager is to help negotiate the return-to-work plan and is therefore rather like a coach, who joins the workplace team to help restore smooth running and productivity.
The case manager’s role should be informed by the bio-psychosocial model of rehabilitation, and the first step is to assess the needs of both the employee and the employer. The early intervention gap in the UK has been recognised by national director for health and work, Dame Carol Black, in her recent review of the health of the working-age population, so it is hoped that things will improve over the next few years.
When case managing mental health issues there are two particular issues to be addressed:
1. The self-confidence of the person in distress and their ability to manage both their own depression and anxiety and the social relationships in which their working lives are embedded
2. The fears, anxieties and even prejudices of the rest of the people in the workplace.
To be able to help with the first of these, the case manager does not need to be a trained counsellor, but it certainly helps if they understand and have been trained to use problem-solving methods, motivational interviewing or other basic-level cognitive educational techniques.
If the employer has a range of help and support on offer, then the case manager can signpost the employee to this and encourage take-up. If not, then it will be important that they know the kinds of support that are offered through websites, literature and local mental health services.
The return-to-work plan will need to take account of all factors – so when thinking about what adjustments could be made in the workplace or a temporary reduction of hours as part of a phased return to work, the possible reaction of colleagues will have to be factored in and dealt with. Likewise, the employee may not want everyone to know all about what has been wrong in their lives or about their use of mental health services. What to disclose to whom and when therefore has to be a part of the plan.
What next?
For a small minority of people returning to work can be a long process. Where there are serious levels of mental ill health, it is important that the person receives evidence-based treatment as per the National Institute of Clinical Evidence guidelines.
It is important to note however that cognitive behavioural therapy, although very helpful in returning people to health and functionality, does not in itself get people back to work. For this to happen, the barriers to returning need to be addressed in an atmosphere of trust and optimism.
To summarise:
Identify and respond to mental distress sooner rather than later, but do not rush into medicalising the problem.
Keep in contact if a person goes off work and if after one month they do not seem to be recovering as expected, consider case management to establish the nature of the issues and barriers and work out a return-to-work plan.
For the minority of cases where the employee needs more time, keep in touch, ensure close communication between medical and employment support services, and prepare the ground for return to work carefully, taking account of the social relationships in the workplace.
Results
Where an organisation can offer continuing contact and support, the results can be very positive. BT reports that company policies designed to keep people in work such as those described in this article have reduced their losses from sickness absence by about 30%. Even more remarkably, 75% of their employees who have been off work for more than six months return to their old jobs. Royal Mail has also achieved large savings and hence a big return on investment from similarly proactive policies.
The challenge for UK plc is to find ways of incentivising and supporting smaller employers to do the same. This is all the more important during the current economic downturn and large-scale job losses.
It is up to all of us – not just the government – to improve how we manage mental health in places where we can make a difference, and the workplace is certainly one. In the words of the new mental health campaign to challenge stigma and discrimination, it is ‘Time to Change’.
Bob Grove is an employment programme director, Sainsbury Centre for Mental Health
References
1 Sainsbury Centre for Mental Health (2008) Mental Health at work: developing the business case
2 HSE (2008) Stress -related and psychological disorders: historical picture 1990s
3 Health and Safety Executive (2007)Self-Reported Work-Related Illness 2005/06. Available at Shaw Trust (2006) Mental Health: The Last Workplace Taboo. London: Shaw Trust
4 Thornicroft, G. (2006) Shunned : Discrimination against people with mental illness. Oxford OUP
5 Waddell, G, Burton, AK & Kendall, N (2008) Vocational Rehabilitation: what works, for whom and when? London TSO Download
6 Black, C. (2008) Working for a Healthier Tomorrow London TSO
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7 Wilson A. (2007) The commercial case for health and wellbeing. Presentation at National Employment and Health Innovations network meeting July 2007 Download
8 Marsden, D & Moricone, S (2008) The Value of Rude Health Report for Royal Mail Group by the London School of Economics
