Triage: the (mostly) missing link in OH mental health

Occupational mental health cases are normally not emergencies. Yet, supporting management and HR to adopt a triage approach to initial evaluation and any subsequent intervention can pay dividends, as Dr William Badenhorst and Dr Lorenzo Grespi outline.

The Collins Dictionary defines triage as “the process of quickly examining sick or injured people, for example after an accident or battle, so that those who are in the most serious condition can be treated first”.

With its wartime origins, applying triage to the evaluation and management of occupational mental health problems may seem surprising as, after all, most occupational mental health cases are not emergencies. Mental health clinicians would be less surprised, as NHS mental health teams adopt triage to plan the initial evaluation and subsequent steps for addressing conditions of any level of severity: from mild psychological difficulties to acute psychiatric disorders.

About the authors

Dr William Badenhorst is a consultant psychiatrist and deputy medical director of Grespi. Dr Lorenzo Grespi is a consultant psychiatrist and medical director of Grespi

Mental health problems present in different ways, including as physical ailments or poor performance, and therefore need to be recognised and understood in order to plan effective interventions. Mental health difficulties require interventions specific to their nature and circumstances. Needless to say, the sooner the general direction of travel is identified, the better.

In contrast, when triage does not occur, certain standard HR approaches can make things worse, wasting resources and causing frustration or breakdowns in employer-employee relationships. Classic examples include well-meaning employers telling employees on sick leave to “take all the time off they need” before returning to work; recommending to see EAP counsellors as a clichéd response to any psychological difficulty; or commencing performance management before considering whether technical incompetence or psychological difficulties are at the root of the issues.

As highlighted by Charlotte Duggan in her Occupational Health & Wellbeing paper back in the spring (Use triage to help crack mental health, May 2018, vol 70, no 5), doing nothing when mental health problems arise can lead to serious consequences. We agree with Duggan that triage in mental health is an important tool for deciding what to do. However, we disagree with the notion that generically trained staff in EAP services are well placed or qualified to carry out this role, as we will clarify in a further section of this paper. We will also outline the specialist characteristics of occupational mental health triage, describe the skills set required, and argue that HR should be empowered to take up the driving seat for initiating the process with the help of specialist providers.

Triage and HR

Drawing on an approach with origins in the battlefield makes sense when considering the pressures faced by HR: complex situations, high emotional temperatures, overt conflicts, potential reputational damage, medico-legal implications, management’s expectation that problems should be swiftly resolved.

Managers may struggle to reconcile the employer’s duty of care to employees with the company’s business requirements. On the other hand, neglecting to recognise or not making reasonable adjustments for an employee’s mental health needs may lead to challenges under the Equality Act 2010.

The process is also often affected by generic or medically questionable sick notes for “stress”: a catch-all expression (rather than a real medical diagnosis) that mostly clouds the nature, source and diagnostic relevance of underlying mental health conditions.

It is therefore crucial that HR should allow time for triage.

We hasten to point out that, as long as the triage takes place early and is jointly carried out by HR and triage mental health specialists, the process mostly amounts to a 15-20 minutes focused telephone conversation.

Effective triage allows HR to form a clearer picture of the situation and remain in charge of the occupational mental health process. It identifies a pathway that addresses the employee’s mental health needs and the employer’s duty of care.

Triage involves the following questions:

  • What is the nature of the problem?
  • How urgent is it?
  • Who are the parties involved?
  • Is a mental health problem causing or contributing to the situation?
  • Is a clinical opinion needed? Or a legal opinion? Or both?
  • What can be gained from these opinion(s)?
  • What should be done next and why?
  • What is the extent of the employer’s duty of care?
  • Who’s is doing what, when and how: HR, line-manager, clinician, lawyer

The answers may seem obvious. However, when HR managers are facing complex situations involving unwell employees, GPs, managers and the wider workforce, it can be difficult to think clearly.

We would like to point out that counsellors are mostly unequipped to triage, recognise and assess serious mental health conditions, as well as address the medico-legal implications for the organisation.

In addition, clinicians such as occupational health nurses who have not worked in multidisciplinary mental health teams generally do not have an in-depth picture of the professional competencies of mental health disciplines and may therefore be unable to direct employees to the most appropriate specialists.

Our experience as a specialist mental health service provider leads us to recommend that employers consider these factors and take due diligence in the commissioning of occupational mental health services.

Triage and mental health awareness

There is no doubt that mental health problems are better addressed when recognised early and dealt with proactively. However, this process is more effective when it is underpinned by a corporate framework on occupational mental health.

An occupational mental health and wellbeing plan and an occupational mental health and wellbeing policy help clarifying where employers and employees stand when mental health problems arise at work. In contrast, generic occupational health policies tend to provide a poor frame of reference for the management of complex occupational mental health situations.

We therefore recommend that employers incorporate in their employment framework an occupational mental health and wellbeing plan and an occupational mental health and wellbeing policy. Our next article in this two-part series will explore this issue in more detail.

Triage in practice, example one – identifying an underlying issue

A technician reported a minor incident at work in which he had stumbled and hurt his back. A studious worker, he took sick leave for several weeks and repeatedly visited his GP and his local hospital for ongoing physical symptoms, despite no definitive cause being found.

An occupational health assessment indicated that he had suffered a mild sprain which would not affect his work. He was then repeatedly signed off by his GP for “stress”.

When he announced that he would be returning to work, he met with his line-manger. During the meeting the manager noticed that his tone was unusually terse and disconnected. The employee also made various requests for adjustments, some of which had an awkward rationale.

His manager sensed something was wrong and became concerned that, given the high-risk nature of the employee’s duties, sub-optimal performance may potentially put the public at risk. A triage conference call was swiftly arranged, which included senior managers, a consultant psychiatrist and an employment lawyer.

It was agreed that the employee should be offered an occupational psychiatric assessment. Other options kept on hold were: returning to work; taking annual leave; making reasonable adjustments; or reviewing work duties.

The employee was found to have a depressive disorder which had remained hidden for many years. It also emerged that the ‘minor’ incident had exposed a pre-existing vulnerability, seemingly related to serious traumatic events from the past. This had triggered him re-experiencing in the present a catastrophic let down from the past, this time towards his employer.

Recommendations included optimum treatment of the depression and an intervention from an occupational therapist (OT) to help him develop a clearer picture of his psychological difficulties and how they could affect his capacity to carry out his work duties, as well as how his unresolved personal problems could be addressed.

After three OT sessions he reached the conclusion that the time had come for him to seek specialist help for his long-standing personal difficulties, and to resign from his post as he could not cope with the intrinsic pressures of his duties.

Thanks to the swift triage process, the company kept a step ahead of the significant risks that would have arisen had the employee’s condition not been spotted and appropriately managed. The employee’s departure was amicable, saving cost, management time and enabling the company to recruit a replacement in a planned fashion, while the individual was free to move forward positively in his life.

Triage in practice, example two – stumbling in the dark

A professional became unwell following a period of increased tension at work. She consulted her GP who signed her off for ‘stress’ and prescribed an antidepressant. Her employer referred her to their occupational health provider.

During the telephone occupational health assessment with a nurse – who, not untypically, had no experience in mental health work – the employee explained that she had suffered from “stress”, was improving but still struggled with concentration. The occupational health report did not make any reference to work and personal circumstances, diagnosis or risk. It stated that, although still stressed, she was fit to work and recommended that reducing the medication would improve her concentration.

She returned to work. However, as she had major interpersonal difficulties with colleagues, HR sought advice from us about how to manage the situation. Following a triage conference call an occupational mental health assessment was recommended, at which it emerged the employee was suffering from a depressive episode that actually required an increased dose of the antidepressant.

She also had serious personality problems, lacked support outside work, and was at moderate risk of a breakdown. The clinician highlighted that she was psychologically fragile and recommended a detailed plan that included support meetings with her line-manager, specialist help from our team and a further psychiatric consultation scheduled for a few weeks later.

This approach had the effect of decreasing the emotional temperature in the office, reassuring HR that they were not alone in facing potentially explosive situations, and helping the employee process during her clinical sessions the emotions which had escalated to aggressive behaviours towards colleagues.

But for the timely triage of the employee’s return to work, the employee would have run the risk of experiencing a serious deterioration of her mental health and destructive interpersonal relationships at work. This in turn could have led to longer-term professional and personal consequences for her and substantial cost to the company. Instead, her return to work was contained safely and her inter-personal problems ameliorated over time.

Conclusion – effective triage

Triage in occupational mental health should involve specialists with significant experience of addressing complex psychological difficulties through a multidisciplinary approach: an experience which is gained almost exclusively through many years of work in NHS mental health teams.

Skills include recognising potential psychiatric disorders from apparently minor clues; assessing risk; prioritising cases; identifying relational factors; indicating which discipline is best suited to carry out the initial assessment.

Triage specialists should also be experienced in the understanding of organisational dynamics as this is crucial to make sure that occupational mental health interventions are implemented effectively by complex organisations.

Ultimately, the key to effective occupational mental health management is to be prepared before problems develop. A positive culture encourages openness and shared responsibility for promoting and protecting health. Once problems arise, early triage carried out jointly by HR and a triage specialist ensures sound, timely and cost-effective management.

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