Developing a Mentally Healthy Workplace: Part 1
Mental health is an increasingly important topic in the workplace. It is estimated that, at any point in time, one in six working age people will be suffering from mental illness, which is associated with very high personal and economic costs. Mental illness is one of the leading causes of sickness, absence and long-term work incapacity in Australia and is one of the main health related reasons for reduced work performance. Individuals with mental health problems, and their caregivers, are some of the most stigmatised and marginalised groups in the workplace and often miss out on the many benefits work can offer.
There is increasing evidence that workplaces can play an important and active role in maintaining the mental health and well-being of their workers. Every business has a legal and moral responsibility to provide a safe and fair workplace. Creating a mentally healthy workplace has many benefts for both employers and employees. A well designed workplace should support individual mental health and lead to reduced absenteeism, increased employee engagement and improved productivity.
Factors contributing to a mentally healthy workplace
A number of risk and protective factors have been identified that may contribute to the level of mental health in the workplace. Traditionally discussions around workplace mental health have focused on how only a few specific aspects of a job may cause mental health problems. It is also important to additionally consider the role of factors at the level of work teams, organisational factors, aspects of home/work conflict and the potential role of individual level risk factors. Below are work factors which have been identified that can enhance workers’ mental health and psychological resilience.
The evidence-based risk and protective factors identified at each level include:
- The design of the job – demands of the job, control in the work environment, resources provided, the level of work engagement, the characteristics of the job and potential exposure to trauma.
- Team/group factors – support from colleagues and managers, the quality of interpersonal relationships, effective leadership and availability of manager training.
- Organisational factors – changes to the organisation, support from the organisation as a whole, recognising and rewarding work, how justice is perceived in an organisation, a psychosocial safety climate, positive organisational climate, and a safe physical environment.
- Home/work conflict – the degree to which conflicting demands from home, including significant life events, interfere with work.
- Individual biopsychosocial factors – genetics, personality, early life events, cognitive and behavioural patterns, mental health history, lifestyle factors and coping style.
The research evidence suggests that these factors interact in complex ways. As such, focusing on a single risk factor in isolation is unlikely to create a mentally healthy workplace. Nevertheless, many of the work-based factors identified can be modified and employers should feel confident that there are strategies and interventions they can use to make a difference and make a workplace more mentally healthy.
Developing a Mentally Healthy Workplace: Part 2
Research informed workplace strategies for a mentally healthy workplace
The mental health of a workforce can be enhanced by minimising the impact of known workplace risk factors and maximising the impact of potential protective factors. In order to create a more mentally healthy workplace, strategies are needed at the individual, team and organisational level. While the importance of the workplace to mental health is well established, there has been a relative paucity of high quality studies assessing the effectiveness of work-based interventions. However, based on the best available research evidence, we conclude that there are six key domains which workplaces need to address to maximise the mental health and well-being of their workforce.
A number of evidence-based or evidence-informed strategies were identified for each of these domains:
- Designing and managing work to minimise harm – enhance flexibility around working hours and encourage employee participation, reducing other known risk factors and ensuring the physical work environment is safe
- Promoting protective factors at an organisational level to maximise resilience –build a psychosocial safety climate, implement anti-bullying policies, enhance organisational justice, promote team based interventions, provide manager and leadership training and manage change effectively
- Enhancing personal resilience – provide resilience training and stress management which utilises evidence-based techniques, coaching and mentoring, and worksite physical activity programs
- Promoting and facilitating early help-seeking – consider conducting well-being checks, although these are likely to be of most use in high risk groups and should only be done when detailed post-screening procedures are in place, use of Employee Assistance Programs which utilise experienced staff and evidence-based methods and peer support schemes
- Supporting workers recovery from mental illness – provide supervisor support and training, facilitate partial sickness absence, provide return-to-work programs, encourage individual placement support for those with severe mental illness, provide a supportive environment for those engaged in work focused exposure therapy
- Increasing awareness of mental illness and reducing stigma – provide mental health education and training to all staff
Developing a Mentally Healthy Workplace: Part 3
It is estimated that at any one time, one-sixth of the working age population is suffering from symptoms of mental illness, most commonly depression and anxiety. A further one-sixth of the population will be suffering from symptoms associated with mental ill health, such a worry, sleep problems and fatigue, which, while not meeting criteria for a diagnosed mental illness, will still be affecting their ability to function at work. This creates huge costs to individuals, businesses, the economy and society in general.
Mental illness is now the leading cause of sickness absence and long-term work incapacity in most developed countries. Mental illness is associated with high levels of presenteeism, where an employee remains at work despite experiencing symptoms resulting in lower levels of productivity Economic analyses consistently show that mental health conditions, such as depression and anxiety, are costing Australian businesses between $11 and $12 billion dollars each year through absenteeism, reduced work performance, increased turnover rates and compensation claims. Given such figures, it is not surprising that patient groups, health professionals, businesses, economists and policy makers all agree that workplace mental health is a major issue which needs addressing.
In turn, researchers have focused on identifying risk factors in the workplace that may be harmful to employee mental health and have also aimed to identify the most effective intervention strategies that address such difficulties. Despite the increasing interest in the relationship between mental health and work, it has so far proved difficult to translate the emerging research evidence into practical solutions for the business sector. As a result, there has been a tendency for employers and society in general to conceptualise individuals with mental health difficulties as being incapable of sucessfully engaging in employment. Sadly, this misconception has fueled the stigmatisation of mental health and has meant many people with mental health problems cannot enjoy the many benefits of work.11
In reality, the majority of mental illness seen in the workplace is treatable and in some cases may be preventable. Employers and workplaces can play an active and siginficant role in maintaining the health and well-being of their workers as well as assisting the recovery of mental health disorders. It should be noted that most businesses are not charities and that enhancing the mental well-being of employees is not their primary consideration. Every business has a legal and moral responsibility to provide a safe and fair workplace. Efforts focused on workers mental health should bring benefits both for the individual and for the employer or the organisation as a whole. From the individual’s perspective, this would equate to a healthy balanced lifestyle and psychological well-being. From an employer’s perspective this is likely to result in reduced absenteeism and presenteeism and increased employee engagement and productivity.
Given the high economic and personal costs that result from workplace mental illness, there are clear advantages associated with providing a mentally healthy workplace.
Developing a Mentally Healthy Workplace: Part 4
What is Mental Health?
According to the World Health Organisation (WHO) mental health is defined as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her or his community”. Mental health is an important contributing factor to an individual’s overall health status. Mental health is not merely the absence of mental illness but rather a state of well-being.
Mental health disorders are typically characterised by the presence of symptoms to the extent to which they disrupt an individual’s ability to function across different areas of life including managing relationships and maintaining work. The inability to participate fully in day-to-day life is considered one of the hallmarks of having a mental disorder. The consequences of mental disorders can be reduced through appropriate support and clinical treatment. Even for individuals with a severe mental disorder such as schizophrenia, appropriate medication, support and psychotherapy can allow the affected person to engage in daily activities such as pursuing meaningful work.
This series of emails, currently Part 4, aim to identify features of the workplace that enable all workers regardless of whether or not they have a mental illness to function with optimal mental well-being. Terms such as ‘mental health’, ‘mental well-being’, and ‘psychological well-being’ are used interchangeably throughout as are ‘mental ill health’, ‘mental illness’ and ‘mental disorder’. Where the terms ‘mental health problem’ or ‘mental health issues’ are used these suggest that an individual may be symptomatic but not yet to the point of clinical disorder or illness.
Developing a Mentally Healthy Workplace: Part 5
Relationship between Mental Health & Work
How work affects a person’s mental health is a complex issue. Findings from several systematic reviews have highlighted that work can be beneficial for an individual’s overall well-being, particularly if good quality supervision is present and there are favourable workplace conditions. In addition, researchers have found that individuals frequently identify work as providing several important outcomes including a sense of purpose, acceptance within society and opportunities for development and may therefore play a pivotal role in a person’s recovery from mental health difficulties.
Findings from unemployment research also highlight the importance of work and well-being. Unemployment is associated with many of the symptoms of mental disorders and a recent meta-analysis of over 300 studies provides convincing evidence that unemployment is psychologically damaging and suggests that mental strain is often the result of rather than the cause of unemployment. This suggests that being at work is on balance protective, however both unemployment and employment are likely to be on a continuum, with support during unemployment alleviating mental health symptoms and poorly designed work exacerbating mental health symptoms.
Promoting mental health and well-being is not at the expense of the overall workplace. Research has shown that well-being is positively related to work performance. A study examining data of over 5000 employees in a customer services organisation in the U.S. found that work performance (using supervisory performance ratings) were highest when staff reported high levels of psychological well-being and job satisfaction. Overall, findings from the research literature suggest that developing a mentally healthy workplace is worth pursuing for its multiple benefits to individuals as well as organisations.
Developing a Mentally Healthy Workplace: Part 6
What defines a Mentally Healthy Workplace?
A mentally healthy workplace can be conceptualised as one in which risk factors are acknowledged and appropriate action taken to minimise their potential negative impact on an individual’s mental health. At the same time protective or resilience factors are fostered and maximised. Mental health in the workplace is multifaceted and each workplace will have different risk and protective factors for mental health.
Potential risk or protective factors of mental health include:
- The design of jobs
- Group processes
- Organisational systems
- Conflicting demands of home and work
- Individual biopsychosocial factors
Since factors from these different levels and sources are likely to interact in complex ways, mental health issues cannot simply be addressed by isolating and improving risk factors in one area. The lists of factors are also by no means definitive, but rather serve as key exemplars. The following emails will examine the literature on how a mentally healthy workplace is influenced by factors from these different sources.
Developing a Mentally Healthy Workplace: Part 7
Factors within the Workplace
Research suggests that the way in which the job is designed may influence mental health. The majority of studies examining these factors have focused on the following elements of the job which will be discussed further:
- Demand and control
- Resources and engagement
- Job characteristics
- Exposure to trauma
It is important to note that the design of jobs is NOT a fixed feature of the workplace that once created by management is set in stone. Features are malleable and can be perceived differently by employees.
Perhaps the most researched job design elements are the physical, emotional and cognitive demands associated with jobs. Jobs vary in whether they are high or low on physical, emotional and cognitive demands and there is evidence that these demands have implications for the prevalence of mental health problems. For example, jobs that are characterised by high emotional and/or cognitive demands (e.g. teachers, nurses, social workers, lawyers, industrial workers, sales people) tend to have high rates of mental health problems There is also evidence that emotional demands, particularly when not accompanied by confidence to manage the demands are associated with higher sickness absence.
The reasons for the association between job demands and elevated risks of mental health problems are not entirely clear, but it is likely related to the presence of other risk factors, such as low job control and low social and organisational support. According the Job Demand-Control-Support theory, jobs with high demands (e.g., time pressure) but low control (e.g., low decision making authority) are ‘high-strain’ jobs and bear the greatest risk of illness and reduced mental well-being.
Providing employees with sufficient resources to perform their work, such as control, enables them to more actively engage with their tasks and to craft their job to experience success. There is also evidence that having the right kind of support in the workplace reduces the adverse impact of high strain jobs on an employee’s well-being. Support also provides employees with confidence to engage in workplace changes, which is important in today’s increasingly uncertain and challenging environments. In addition, other job resources such as providing appropriate high-quality feedback, variety, and learning opportunities have been found to be positively associated with work engagement – a state of work-related well-being characterised by vigour, dedication and absorption.
Job characteristics are also important for individual well-being. For example, according to the Job Characteristics Model, jobs that allow for skill variety (working on a varied range of tasks), task identity (being connected to a whole piece of work rather than a fragment), task significance (doing meaningful work), autonomy (discretion to make decisions) and feedback (from others and the work itself) are likely to be associated with higher levels of psychological well-being. More recently, the Vitamin Model further extended this list to include other job characteristics that are important for psychological well-being such as external pressure to perform, environmental clarity (e.g., role clarity), contact with others, availability of money, physical security (e.g., workplace safety), valued social position, supportive supervision, career outlook (e.g., job insecurity) and equity.
There is evidence linking each of these job characteristics with employee well-being outcomes. For example, a number of studies have found job insecurity and having a temporary contract are both associated with increased mental health problems. For each of these work characteristics, there is also evidence that ‘more’ is associated with higher psychological well-being, at least up to moderate levels, but like vitamins, too much may not be helpful. Moreover, some job characteristics relate particularly to some types of well-being. For example, external pressure to perform is more strongly linked to anxiety, whereas low control is more strongly related to depression or dissatisfaction. Whilst there are various models in the literature that describe the impact of job characteristics on individuals, the potential risk factors largely depend on the nature of the job itself. The overall message from each of these models is that it can be protective to design jobs that have an appropriate balance between demands and resources.
It is also important to note that although there have been a number of studies identifying some jobs as high risk occupations, there is little obvious similarity between these jobs, suggesting the job characteristics that contribute to the increased risk are often complex and mixed. A person’s job title or occupation does not automatically equate to a certain type of working environment.
Another important characteristic of the job that may be potentially a risk factor is exposure to traumatic events. Occupations with regular exposure to such events (e.g. police officers, paramedics, fire officers, military personnel, medical staff and reporters) are associated with an increased risk of a variety of mental health problems, including depression, acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). A recent review estimated that one in ten emergency workers currently suffer from symptoms of PTSD. Despite such figures, it should be noted that exposure to trauma or other adverse situations does not always lead to mental illness. Even in these high risk occupations, the majority of people will be resilient to workplace trauma, and that while post-traumatic symptoms are common, the vast majority of workers exposed to a traumatic event will not develop a mental illness.
Developing a Mentally Healthy Workplace: Part 8
Factors within the Workplace
In addition to how jobs are designed, team or group factors have also been examined as possible contributors to workers’ mental health. Team factors are relevant to large organisations with many formal teams/departments as well as smaller businesses where teams are informal and fluid. According to team research, team ‘inputs’ (e.g. leadership) affect team processes such as the quality of team relationships, which in turn affect both team and individual outcomes (e.g. well-being). We will focus on three team factors that have received the most research in relation to individual mental health outcomes, that is:
- The level of support received from colleagues and managers
- The quality of interpersonal relationships; and
- Manager training and leadership
A number of research studies have highlighted that the amount and quality of social support in a workplace may influence the mental health of workers and protect them from the detrimental effects of high strain jobs. Such support is often best provided within the work group.
A literature review focusing specifically on 14 longitudinal studies found that high psychological demands and low social support were the strongest and most consistent factors associated with an increased risk of depression. In addition, low work-related social support is associated with an increased likelihood of mental health problems and/or prolonged sickness absence. A prospective cohort study among 9631 male employees of France’s national gas and electricity company found that low satisfaction with social relations and low social support at work was associated with a 10% to 26% excess in sickness absence which persisted over six years.
Comradeship or closeness within a group may be a mitigating factor in the development of post-traumatic stress disorder (PTSD). A study of UK Armed Forces examining the relationship between combat exposure and mental health found that higher levels of leadership, good team morale and unit cohesion were associated with lower levels of PTSD symptoms. Similarly, a separate study found that in addition to increasing rates of probable PTSD, low levels of support post-deployment were also associated with increased alcohol misuse and more common mental disorders.
Taken together, these findings suggest that social support in the workplace is a significant factor that may have a protective effect against mental health difficulties. In addition, higher levels of perceived support from the wider organisation is also associated with indicators of psychological well-being. This will be further discussed under organisational level factors.
The quality of interpersonal relationship is another important contributing factor to workplace mental health. In many occupations, interpersonal conflict is the most frequently reported source of workplace problems and workplace stress. A study among 135 American police officers found that poor emotional support and conflicted relationships significantly contributed to job strain and work stress. A recent review also reported evidence that the quality of relationships in the workplace is strongly associated with self-reported mental health. For example, a UK cross-sectional study of 728 employees found that poor work relationships was associated with an increased risk of poor mental health and reduced physical health. In contrast, positive human interactions have been associated with healthier patterns of cardiovascular, immunological and neuro-endocrine responses.
Conflicts with colleagues may also be indicative of more serious problems such as workplace bullying. It has been estimated that workplace bullying costs Australian employers a minimum of $6 billion per annum. Bullying is usually characterised by individuals being exposed to negative interactions from colleagues or managers for a prolonged period of time, particularly where there is an imbalance of power between the victim and the perpetrator(s). Workplace bullying has been associated with various mental and physical health problems. Studies have also found that employees who were bullied had lower levels of job satisfaction and high levels of anxiety, depression, and PTSD.
A large cohort study of hospital workers in Finland found that those who reported persistent workplace bullying were four times more likely to have developed depression over a two-year follow up period. In addition, workplace bullying has been found to affect not only individuals who are direct targets but also reduces the job satisfaction of bystanders.
While the importance of social support and positive interactions in the workplace is clear, managers and supervisors play a key leadership role in the welfare of their staff and can significantly contribute to the enhancement of mental health. In a healthy workplace, managers and supervisors value the opinion of their employees and provide appropriate feedback and support. Moreover, a manager’s actions, opinions and support may be a more potent influence on an employee at risk of mental illness than others in the workplace.
There is a body of research that reports that managers and supervisors who are provided with the appropriate mental health training not only feel more confident in discussing mental health matters with employees, but workplaces where supervisors have had such training demonstrate reduced psychological distress among employees. Managers may also need guidance on how to provide high-quality performance feedback. As noted previously, performance feedback is an important component of most jobs, but if done poorly can be perceived as threatening or bullying.
There is also evidence that effective leadership is associated with better well-being outcomes for employees. In particular transformational leadership, a leadership style associated with creating a vision of the future, inspiring and motivating, stimulating employee growth and showing consideration for individual employees has been shown to increase psychological well-being and be associated with reduced levels of depression and anxiety. The effect of positive styles of leadership is likely to enhance psychological wellbeing through increasing trust, improved support and teamwork, enhanced job design and organisational climate, which is discussed in more detail in the future email. It should also be noted that optimal leadership practices are changing over time and will vary between different organisations. Within large organisations, managers often have to lead people spread over geographically large areas, with communication via email and teleconferencing. Within smaller organisations, communication will tend to in person, with mangers often working side by side with those they lead. Each of these situations create particular challenges for managers needing to build supportive relationships with workers.
Developing a Mentally Healthy Workplace: Part 9
Factors within the Workplace
Risk and protective factors at the organisation level refer to systems or norms affecting the organisation as a whole and processes that are implemented across the entire business. These may include policies and procedures as well as more informal systems such as organisational culture. The evidence base for preventive organisational strategies is limited in comparison to individual level strategies not because there is only weak evidence, rather organisational level research is often difficult to conduct. Nevertheless, there is some preliminary evidence that suggest organisational factors deserve further study. These factors include:
- Organisational changes
- Organisational support
- Recognising and rewarding work
- Organisational justice
- Organisational climate
- Psychosocial Safety Climate
- Physical environment
- Stigma in the workplace
As the nature of work is rapidly changing many workers find that they are facing a working environment that is increasingly uncertain. Changes within an organisation such as restructuring, downsizing and layoffs are common and most workers will need to deal with career transitions. Job strain and job insecurity are common effects associated with downsizing. An international review examining the impact of organisational restructuring and job insecurity on health found numerous adverse effects including increased work-related injury, occupational violence, cardiovascular disease and mental illness. Long term follow-up of companies who have gone through a downsizing have shown that even amongst the employees who did not lose their jobs, rates of mental illness, sickness absence and permanent disability remained high for up to 10 years after the downsizing. Another outcome of job security is presenteeism and poor work performance. Rates of suicide also increase when there are higher levels of job insecurity and unemployment, particularly among men.
While uncertainty and a changing environment potentially occur unexpectedly there are a number of factors at an organisational level that can help reduce the negative impact on workers. One such protective factor is known as organisational support. The notion of organisational support is based on the idea that employees tend to assign their organisation humanlike characteristics, and that managers and their behaviour is viewed as a proxy for the level of support provided by an organisation. A recent review of the literature found good evidence linking higher levels of perceived organisational support with improved job satisfaction and more positive mood ratings.
The way in which an individual’s work is recognised and rewarded could also contribute to mental health. Recognition and reward in a work environment refers to appropriate acknowledgment and gratitude of employees’ efforts in a fair and timely manner (e.g. financial rewards such as bonuses and pay rises; promotions and career opportunities). The Effort Reward Imbalance model is based on this concept and proposes that the most stressful work condition is one in which the work reward does not match the effort made.
Two major reviews of this model suggest that high effort-reward imbalance is strongly associated with an increased risk of common mental disorders such as depression, anxiety and adjustment disorder in the workplace. While the research has identified that effort/reward imbalance is a notable risk factor in the workplace, few studies have explored whether improving this aspect of the workplace results in improved mental health among employees. More broadly, an organisation’s specific culture and climate (“how things are done around here”) may also impact employee mental health, although there has been relatively little research linking organisational culture and climate to mental health outcomes.
Organisational justice incorporates some aspects of the Effort Reward Imbalance model and refers the fairness of rules and social norms within companies. These include perceptions of justice relating to resources and benefits distribution (distributive justice), the methods and processes governing that distribution (procedural justice) and interpersonal relationships (interactional justice), such as respect and information provided by management.
Two recent literature reviews found that the majority of studies examining the relationship between justice and mental health found low levels of relational and procedural justice were strongly associated with an increased likelihood of mental health problems and stress related disorders including adjustment disorder.
An important construct within the organisational literature that has been linked to employee well-being is organisational climate. Organisational climate is the shared perceptions and meaning people attach to their experiences at work. and shared beliefs about the organizations policies, procedures and practices and the behaviours that are expected, rewarded, and supported. In short, this refers to a more holistic construct that incorporates perceptions about the broad range of work characteristics described earlier such as leadership, clarity of organisational goals, performance feedback, and supervisory support, which operate at both the work team and organisational level. Australian research on organisational climate has revealed that a positive organisational climate is associated with higher levels of occupational well-being (morale and lower stress) and can act as protective factor against operational stressors.
A dimension of organizational climate that may be particularly relevant to well-being is the psychosocial safety climate (PSC) or the climate for mental health and psychological safety. This has been conceptualised as the perception of an appropriate balance between management concern for their workers’ mental health and their productivity. The model is based on four related principles which define the level of PSC in an organisation:
- Senior management commitment to stress prevention
- The priority management gives to mental health and psychological safety
- Organisational communication upwards and downwards in relation to psychological health and safety; and
- The level of participation and involvement by managers in activities related to mental health promotion
Currently there is some early observational evidence that organisations with high levels of PSC are less likely to allow the creation of individual jobs with excessive psychological risk factors (such as high job strain). The evidence also suggests and that if individual risk factors are present, organisations with high PSC will tend to have more robust policies and support processes in place to help mitigate the impact of these potential risks. In spite of the evidence highlighting the importance of the PSC, like many other potential risk factors, the various components of an organisational climate do not operate in isolation. There is some research which suggests the strength of a safety climate is partially a result of the leadership style and communication networks. As a result, the impact of any new intervention may depend on the presence or absence of other sub-climates of the organisation.
A physically safe environment has also been found to be a contributing factor to workers’ mental health. A review onto the impact of occupational factors on mood disorders found evidence of exposure to physical environmental factors at work that affected workers mental health. Environmental risk factors in general workplace settings included poor lighting, temperature conditions, exposure to noise, and exposure to infectious agents. These poor environmental conditions have been associated with mood changes, sleep patterns, energy levels, anxiety and depression in workers.
Mental illness remains one of the most stigmatised groups of disorders in the workplace. In one study, 50% of employers reported they would “never” or “rarely” employ someone they knew had a psychiatric disorder. The stigma surrounding mental illness may also effect others’ impression of an individual’s capability at work. As a result, individuals with mental illness are more likely to be employed in low status or poorly remunerated jobs, or employed in roles which do not adequately match their skills or level of education. Individuals who are caregivers of a family member with mental illness may also be reluctant to disclose their family circumstances in fear of consequences to their employment. Such stigma in the workplace is likely to make individuals more reluctant to discuss any symptoms or difficulties they are facing, thereby delaying treatment or access to care and making it more unlikely that a workplace can become part of a rehabilitation process. A responsible workplace should make every effort to reduce stigma and encourage help-seeking and support for individuals and caregivers facing mental health difficulties.
Developing a Mentally Healthy Workplace: Part 10
Factors within the Workplace
While research has typically focused on how an adverse working environment can impact on employee mental health, there is no work environment or type of trauma that automatically leads to mental illness in all people. The aetiology of mental health is complex and non-work factors also contribute and impact performance at work. Any suggestion of simple cause and effect relationships between work and mental health are likely to be inaccurate. Factors outside of the workplace that may be important include conflicting demands between work and home life, stressful life events, as well as individual biopsychosocial factors. These factors will be discussed in the following section.
In the last two decades there has been growing concern about how conflicting demands at work and at home affects an individual’s mental health. This refers to pressures at home that can affect the individual at work. Some examples of home-work conflict are when marital distress, abuse and violence, dependent children or older persons, particularly those with cognitive or behavioural disorders or financial strain increase strain at work. According to the applied Stress/Health Model to caregivers of individuals with cognitive or behavioural impairment, caregivers often face difficulties such as absenteeism, exhaustion at work, and missed opportunities for career promotion. There is also evidence to suggest that when the demands at home impact or spill over to work, this has an exacerbating effect on depression and anxiety. Other negative consequences of work-family interference include low job and life satisfaction, high turnover intentions, physical and psychological strain, burnout, and sickness absence.
Stressful life events could also be the cause of disruption or spill over to an individual’s work performance and employment. There is now a substantial body of evidence suggesting there is an excess of life events in the months preceding a depressive episode. Negative life events appear to be more important prior to a first episode of depression, supporting a ‘kindling hypothesis’, where subsequent episodes of depression become more autonomous and less related to life events. There is also evidence that life events involving loss, humiliation, entrapment and associated with significant change in daily life may be particularly strong risk factors for depression.
Another instance of significant life event which may have an impact on the individual’s employment for many is the diagnosis of a chronic or serious medical condition. Such adjustments will result in a degree of psychological distress in most, and in some may contribute to the onset of a psychiatric disorder. The combination of physical and mental illness is especially likely to lead to poor occupational outcomes. Social support may be important in predicting the psychological consequences of adverse life events. A prospective study of working-class females demonstrated that those with limited social support were more likely to develop depression following a stressful event.
Although spill over of family strain to work can lead to negative consequences, families can also enrich work and work can enrich family life. A meta-analytic review of work-family enrichment found that it was a protective factor for individuals’ physical and mental health (psychological distress and depression), life and job satisfaction as well as emotional attachment to an organisation. Researchers also suggest that work-family enrichment can result from supervisor support for non-work factors, supportive organisational culture, a redesign of jobs to include more control over working hours, variety, social skills, learning opportunities, as well as more respectful and meaningful work.
The individual determinants of mental health are complex. There are a range of biological, psychological and social factors which will determine each individual’s risk of developing mental illness. Such factors include an individual’s genetic makeup, early life events, personality, cognitive and behaviour patterns, prior mental health problems and neurobiological changes. All of these factors interact with the range of work and non-work factors outlined above to influence an individual’s mental health. The importance of these individual factors has often been neglected when considering the impact that work may have on mental health. However, there is increasing evidence which suggests that the impact of work-related risk factors on mental health disorders can only be understood when personal biopsychosocial factors are considered.
There is also evidence suggesting that substance misuse, particularly alcohol is more common amongst those with mental illness. It is a major barrier to recovery and has been associated with worsening outcomes. Some workplaces may have a culture encouraging excess alcohol use. This may create specific substance misuse problems or complicate mental health issues.
It is important for workplaces to understand the role of individual factors because some of these factors may be modifiable. Individual resilience training seeks to modify the responses to potentially stressful situations in order to reduce the risk of adverse outcomes, such as mental ill health. These interventions will typically try to focus on unhelpful patterns of thinking or behaving, such as a tendency for catastrophic thinking or coping via avoidance. Considering lifestyle factors may also enhance an individual’s resilience. There is good evidence that individuals who engage in regular leisure time physical activity, have a healthy weight and a balanced diet are at decreased risk of future episodes of mental illness. However, modifying such factors can be difficult and the impact of such modifications is yet to be fully understood.
The workplace can have a key role in promoting and maintaining mental health. Mentally healthy workers have been found to be more productive and less likely to take sickness absence. As such, it is in everyone’s interest for the workplace to be as mentally healthy as possible. Defining what makes a mentally healthy workplace is not simple and involves the consideration of the design of jobs, teams and organisational factors. At each of these levels there are a range of risk and protective factors which can have an impact on the mental health of individuals. The impact of home-work conflict and individual biopsychosocial factors should also be considered. Many of these factors can be easily modified within an organisation, meaning employers should feel empowered to make alterations within their workplace to make them more mentally healthy. In the next section we will examine the evidence for the effectiveness of specific initiatives targeting some of the factors outlined above.
Developing a Mentally Healthy Workplace: Part 11
This section aims to identify research informed workplace strategies to create a mentally healthy workplace. These strategies aim to minimise the impact of workplace risk factors and maximise or improve the impact of potential protective factors. Health interventions are often classified as being aimed at primary, secondary or tertiary prevention. Primary prevention interventions are proactive in the sense that it aims to reduce exposure to psychological and physical risk factors in the workplace among healthy employees. Secondary prevention interventions aim to manage symptoms and, in the context of the workplace, are typically implemented after an employee develops symptoms or begins to complain of stress. These interventions also aim to equip employees with coping strategies to deal with stressors in an adaptive manner thus reducing the likelihood of mental health issues. Finally, tertiary prevention interventions are reactive and aim to minimise the impact that a diagnosed disorder has on daily functioning.
Workers who become unwell rarely move straight from being ‘healthy’ to being on long term sickness absence. There is usually a series of stages that an employee will pass through as they develop symptoms. Recognition of this ‘journey’ is important, as different interventions will be required for workers at each stage. In order to provide a mentally healthy workplace, an employer needs to ensure there are mental health strategies targeting each of these stages, with a combination of primary, secondary and tertiary interventions. Workplaces also need to ensure there are mental health strategies based at an individual, team and organisational level. These strategies should be applicable to workers across all levels from leaders and senior executives to non-executive workers.
Based on existing research we believe that a mentally healthy workplace can be achieved via interventions in six key domains:
- Designing and managing work to minimise harm
- Promoting protective factors at an organisational level to maximise resilience
- Enhancing personal resilience
- Promoting and facilitating early help-seeking
- Supporting workers’ recovery from mental illness
- Increasing awareness of mental illness and reducing stigma
The first three of these domains map onto the concepts of primary and secondary interventions, while the fourth and fifth relate to tertiary interventions. The sixth domain underpins all three levels of preventative interventions. The table below provides an outline of the types of intervention and the research informed workplaces strategies to create a mentally healthy workplace, each of which will then be discussed in detail in this ongoing series of emails.
|Intervention level||Research informed workplace strategy|
|Job design||1. Designing and managing work to minimise harm
|Team/Organisational||2. Promoting protective factors at a team and organisational level to maximise resilience
|Individual||3. Enhancing personal resilience
|Organisational||4. Promoting and facilitating early help-seeking
|Organisational||5. Supporting workers’ recovery from mental illness
|Organisational||6. Increasing awareness of mental illness and reducing stigma
Developing a Mentally Healthy Workplace: Part 12
As previously discussed there are many work-based risk factors that have been associated with an increased risk of adverse mental health outcomes. While the relationship between each potential risk factor and mental health outcomes is complicated and often dependent on the presence or absence of a variety of other factors, it is generally accepted that minimising exposure to known risk factors should be a part of good workplace mental health strategies. However, there have been very few studies examining the effect of modifying known workplace risk factors. The one exception to this is in increasing employee control, which in its broadest sense refers to employees’ ability to actually influence what happens in their work environment. Two popular methods of enhancing employee control are:
- Enhancing flexibility around work hours
- Encouraging employee participation
Increased job control has been found to predict better mental health outcomes among employees. Enhancing flexibility around work hours (e.g. start times, rostered days off) and encouraging employee participation (e.g. committees or problem solving teams) are two popular methods of increasing employee control described in the research literature. Providing flexibility not only has promising outcomes for employees facing mental health problems but also for carers of individuals with mental illness. There is promising evidence for the use of such strategies in the workplace being associated with improved mental health outcomes for employees as well as overall workplace productivity and reduced absenteeism.
A high quality review assessed the effects of increased employee control and choice on health outcomes via flexible working interventions. The review examined 10 studies that measured self-reported psychological health outcomes before and after flexible working interventions and found that flexitime, overtime and fixed-term contracts did not have a significant effect on self-reported psychological health outcomes. However, self-scheduling of shifts by employees and the process of gradual or partial retirement were associated with significant improvements in mental health, a finding in line with the Job Demand-Control-Support (JDCS) model. Longitudinal studies have also found that flexible workplace policies reduce work-family conflict, predict higher levels of organisational commitment and reduce turnover intentions. Interestingly, these outcomes were found to extend to all employees not just users of the policies, suggesting a universal appeal to flexible workplace policies.
Another review examined 18 studies that evaluated strategies aimed at enhancing employee control such as problem solving committees, education workshops and stress reduction committees. This review concluded that there was some promising evidence that improved control was significantly associated with psychosocial health improvements among employees. For example in a quasi experiment, employees in one of two call centres participated in a committee to increase control over work planning and involvement in one-on-one meetings with managers to improve work processes and personal development planning. The intervention improved employee mental health and reduced absenteeism, and these results were even stronger for employees with greater psychological flexibility (i.e., the ability to persist with or change behaviour depending on the situation in the pursuit of goals and values). These findings suggest that strategies which increase employee control may serve to enhance well-being and protect against mental health difficulties.
Developing a Mentally Healthy Workplace: Part 13
The six domains of evidence based workplace mental health interventions
Whilst designing work effectively and increasing employees control and autonomy can be beneficial to the individual worker, promoting protective workplace factors at an organisational level can help to maximise resilience across multiple levels. This section will outline the number of ways that workplaces can promote resilience at a team and organisational level:
- Building a psychosocial safety climate
- Developing anti-bullying policies
- Enhancing organisational justice
- Promoting team based interventions – employee participation and group support
- Providing manager training and enhancing leadership capability
- Managing change effectively
The term psychosocial safety climate (PSC) refers to a workplace climate in which the level of management concern for workers’ mental health ensures that mentally unhealthy workplaces are less likely to develop. There is some observational evidence that organisations with high levels of PSC have greater levels of mental health. There is some evidence from other observational studies that the impact of bullying depends on the levels of PSC in organisations. However, are not aware of any interventional studies testing the effect of creating a positive PSC within an organisation. Nonetheless, according to the PSC model, the psychosocial safety climate of an organisation should be improved by ensuring senior management have a commitment to mental health and psychological safety, managers are actively involved in mental health promotion and by ensuring good level of organisational communication around psychological health and safety promotion.
While the responsibility for bullying must rest with those involved, the organisational climate and culture may facilitate bullying behaviours in the workplace. A lack of policies or regulations against bullying can be perceived as indirectly condoning this behaviour in the workplace. For example, a recent Scandinavian study examined measures to counteract workplace bullying and found anti-bullying policies that emphasised the role of supervisors to be the most commonly adopted practice, although evidence on the effectiveness of such policies is still lacking. Researchers also recommended that policies should be specific and explicit and include guidelines for managers on their role in countering bullying.
Low levels of organizational justice have been shown to be associated with poorer worker mental health, and higher levels of absenteeism. Despite the strength of this observational evidence, there has been very little published research examining whether increasing organizational justice improves workers’ mental health, although there is some evidence that changing organizational justice changes work attitudes such as job satisfaction. For example, in a field experiment in a large insurance company, researchers manipulated the assignment of temporary offices during a renovation so that employees occupied offices usually assigned to higher, lower or the same level employees (private or shared office with different dimensions) in order to change perceived organizational justice amongst workers. The researchers found that employees’ perceptions of fairness and justice in the workplace were altered and that this influenced overall performance and job dissatisfaction. Other field experiments have manipulated organizational justice in a performance appraisal system and found similar findings in terms of job satisfaction and intention to remain with the organization. However the impact of such changes on mental health remains untested.
Mentally healthy workplace activities can also be promoted at the team or group level. Often these activities involve providing education and training in new knowledge, skills and abilities. Two evidence based team interventions that appear to effectively prevent the deterioration of mental health in the workplace are employee participation and resource-enhancing support groups.
Researchers examined the impact of participation in a Japanese manufacturing company where employee morale had declined primarily due to increasing demands in workload. To try and boost employee morale as well as performance, the company piloted a RCT of a team-based participatory activity for assembly line workers. The participatory activity focused on workplace environment improvements, active employee involvement, shared work-related goals, and action planning to reduce workplace stress. This type of intervention has many links with those designed to increase employee control, which were discussed earlier. The group was compared to a control group that did not receive the organised activity. The pilot study found that while employees in the control group (who did not receive the participatory intervention) continued to experience deterioration in mental health, the group who received the participatory team-based intervention maintained their earlier levels of mental health. It is difficult to know why the control group got worse, but there was a suggestion that the team-based participatory activity may have improved the workers’ resilience to the increasing demands within the organisation. The intervention also had an organisational benefit of work performance improvements across some technical areas.
Another RCT examining the impact of a resource-enhancing group intervention based on career management preparedness found a significant reduction in depression symptoms in the resource-enhancing groups as compared to the control group that did not receive the intervention.
Based on the available research evidence, it appears that team based activities may not only be effective at preventing the deterioration of mental health, but they can also be beneficial to organisations in terms of productivity.
Managers have a key role in building resilience and maintaining the welfare of their staff. To be able to effectively carry out their responsibilities as a manager they should be provided with appropriate tools and training.
A recent systematic review identified three RCT and four non-randomised controlled trials that tested the effect of manager training on workers’ mental health. While there was some variation in the results of these studies, the overall conclusion was that providing managers with knowledge and skills relating to mental health appeared to have a favourable effect on workers’ mental health, at least in the short term. There is also some evidence that the effectiveness of manager training is dependent on a high proportion of managers undertaking the training, and that any impact on manager knowledge and behaviour may diminish over time. As a result, mental health education aimed at managers should ideally be implemented as part of an organisation wide initiative and should allow for the possibility of regular update sessions. As noted earlier, leadership style, in particular transformational leadership, can improve employee psychological well-being. There are several intervention studies which have shown that leadership training can lead to behavioural change and enhanced leader capability, which should have a positive impact on the mental wellbeing of the broader workforce.
During times of significant change to organisations (e.g., restructuring, mergers, acquisitions), employees can experience high levels of job stress, anxiety and uncertainty, especially about how change will affect the nature of their work, job security and career paths. However, there are evidence-based strategies that organisations can use to help employees cope with change and alleviate stress levels. One key management strategy is the use of open and realistic communication. A longitudinal field experiment which compared employees who received realistic information about a merger in one workplace, to a workplace without this communication, provides strong evidence of the efficacy of the provision of accurate and up-to-date information about changes in reducing psychological stress, uncertainty and absenteeism. Effective communication can be achieved via multiple channels. One example is to provide managers with formal training in strategies to communicate the core values of the new culture so that all managers are giving similar messages. Other channels include newsletters designed for the life of the change to inform employees at all levels and processes like weekly briefings. In addition to effective communication, there is evidence that participation in the change initiative reduces stress and increases the likelihood of change being successful. Common strategies for participation include formal meetings, representation on organisational change committees and information discussions, including “brainstorming” of goals and strategies.
Reviews of change studies also highlight the importance of leadership support. Through the effective communication of the organisation’s vision, the words and actions of the transformational leader can inspire people to take control and be empowered during times of change. Such transformative managers tend to be person-oriented, spending their time talking and working with people, listening to views from all levels, and are judged to be a strong source of emotional support as people cope with change. Justice perceptions are particularly important during downsizing and are related to perceived threat of the change, reduced absenteeism and voluntary turnover.
Developing a Mentally Healthy Workplace: Part 14
The six domains of evidence based workplace mental health interventions
Organisations are increasingly dynamic and employees will always experience some degree of stress and uncertainty as well as potential exposure to traumatic events. While most individuals have the resilience and ability to adapt and cope with psychosocial risk factors, interventions have been developed to try and aid or enhance individual resilience. There are three main areas of research focused on enhancing personal resilience. These are:
- Cognitive behavioural therapy (CBT)-based stress management/resilience training
- Resilience training for high risk occupations
- Coaching and mentoring; and
- Worksite physical activity programs
To date most research evidence on resilience training is based on cognitive behavioural therapy (CBT), stress management interventions (SMI), stress inoculation training (SIT), and acceptance commitment therapy (ACT). Resilience training can be applied to a general workforce as well as to higher risk occupations such as the military and emergency services. There is also some evidence that suggests worksite physical activity programs can be beneficial in enhancing resilience.
In most workplaces employees can be proactively prepared to deal with the pressures of work by increasing their coping skills or personal resilience. A recent meta-review summarising the evidence for a range of workplace interventions found that stress management programs can be useful for those workers reporting stress. While there is mixed evidence for general stress management programs, there are more promising results when stress management programs specifically utilise cognitive behavioural therapy (CBT) techniques. Cognitive behavioural therapy is based on the underlying rationale that an individual’s affect (emotions) and behaviour is determined by their cognitions (thoughts), with therapy aiming to change the individual’s specific misconceptions and maladaptive assumptions and coping strategies. An example of a stress management intervention (SMI) based on cognitive behavioural principles can be seen in a RCT which compared office workers randomly assigned to an Acceptance and Commitment therapy (ACT) group to a waitlist control group. ACT is a form of mindfulness based behavioural therapy focused on acceptance and commitment to making changes. Participants attended three sessions and were taught how to experience or accept their undesirable thoughts, feelings, and physical sensations without trying to change, avoid, or otherwise control them. Homework assignments were distributed throughout. Those who received the SMI with a cognitive-behavioural focus had significant improvements in mental health and other work related variables compared to the control group.
A recent Finnish study conducted a RCT with 17 public and private organisations to determine the effects of providing in-house resilience training. The one week program aimed to develop employees’ skills and abilities in managing their careers as well as to help prepare them mentally to deal with career setbacks. The training involved a variety of techniques including stress inoculation training (SIT), identifying skills and abilities, utilising social networks, managing conflict, stress management and developing a work-related plan for the future. At seven month follow-up, the results of the trial found that not only had depressive symptoms amongst participants decreased, but so had their intention to retire early. Participants’ mental resources had also increased in comparison to the group that did not receive the training program. Those who particularly benefited from the program were employees with high levels of depression or exhaustion and younger employees.
There are certain occupations in which exposure to potentially traumatic events can be expected to occur. The most obvious of these ‘high risk’ occupations are the military and emergency services. The majority of research on resilience training has been completed with these specific occupational groups.
A systematic review of primary prevention for post-traumatic stress disorder (PTSD) amongst military personnel assessed a number of pre-deployment interventions that aimed to increase coping skills and resilience amongst soldiers. Psychoeducation involves giving people preparatory information about potential stressful events and the symptoms they may experience after trauma. The aim is that familiarity with this information will result in people finding these situations less disturbing and enable them to recognise symptoms that form part of a normal reaction. Stress inoculation training (SIT) was also reviewed, which involves exposing workers to mild stressors in order to foster psychological preparedness and promote resilience against more major stressors. The authors concluded that SIT has the advantage as it can be provided in a group format, making it potentially efficient and inexpensive, and can potentially increase resilience. A RCT conducted amongst recruits within the Australian Defence Force found that those who undertook a brief cognitive behavioural program aimed a modifying causal attributions, expectancy of control, coping strategies, and psychological adjustment had more positive emotions and less psychological distress at the end of their training. More recently, resilience programs in the military have also incorporated teaching aimed at arousal reduction skills to be utilised immediately after a stressful event.
Taken together these findings suggest that resilience programs can help individuals at increased risk to better manage work-related stressors and challenges in a way which should be beneficial to an individual’s mental health. However, it should be noted that the available evidence only supports more involved resilience programs, not biref one off teaching sessions.
The functions of mentoring and coaching relationships overlap but they are separate types of developmental relationships. While both involve a collaborative relationship between coach and coachee or mentor and mentee, coaching, is focused on improvement in current performance, skill and wellbeing. Mentoring, on the other hand, involves longer term acquisition of skills and career development. An extensive review of the coaching and mentoring literature revealed few empirical studies which evaluate the effectiveness of coaching. Most studies are observational, tending to emphasise practice-related issues rather than present rigorous evaluations of coaching interventions. For example, one study found that coaching focused on strengths and goals fostered some increased resilience amongst medical students. Another four studies were conducted in the life/personal coaching domain and indicated that coaching can facilitate goal attainment, enhance psychological and subjective well-being and resilience, while reducing depression, stress or anxiety. There are also two RCT studies of workplace coaching, with one finding evidence for the effectiveness of coaching on health, life satisfaction, burnout and psychological well-being. There is also some evidence that coaching and mentoring are associated with higher levels of job satisfaction and commitment to the organisation and several small scale pre-post coaching comparisons (without random allocation) showing that coaching may enhance well-being.
The positive effects of physical activity on mental health have been well documented yet the impact of workplace promoted physical activity is less clear. One RCT study provides a good example of how workplace physical activity may enhance mental health outcomes for employees. In this RCT, workers were randomised into an intervention or control group with the intervention group being required to exercise twice a week for 13 weeks with 13 sessions supervised by a fitness coach. It was found that those in the intervention group significantly improved their psychological self-report ratings compared to those in the control group. However, at follow-up, elevated psychological scores held steady only for those who continued to exercise on their own. Nevertheless, the short-term impact of promoting physical activity in the workplace on employee mental health is promising.
An Australian RCT investigating the effects of a workplace physical activity program found similar positive results. A 24-week aerobic and weight training exercise program plus behaviour modification was designed for employees of a casino company with the aim of enhancing mental health and quality of life outcomes. The study found significant improvement in all outcomes including a reduction in depression symptoms for the group that received the training program compared to the group that was on the wait-list.
Some researchers have also suggested that regular physical activity may confer relative resilience to the adverse effects of stressful events. Early research on physical activity and resilience used animals but more recently this has been investigated in employees, specifically US military personnel who were undergoing pre-deployment survival training. Aerobic fitness was inversely associated with measures of immediate event related stress, suggesting physical fitness may buffer some stress responses.
Developing a Mentally Healthy Workplace: Part 15
The six domains of evidence based workplace mental health interventions
There is increasing evidence that early presentation and treatment are associated with improved outcomes from mental illness. Despite this, many people with common mental health problems such as depression or anxiety, do not seek help early. There are a range of reasons for this, such as stigma, fear of negative consequences, lack of knowledge, difficulty accessing appropriate support and time pressure. There are a number of ways in which the workplace can help reduce these barriers for early help-seeking, including:
- Well-being checks or health screening
- Employee Assistance Programs and workplace counselling
- Appropriate response to traumatic events
Despite the importance of such activities, there are a number of important limitations to the research evidence in this area, particularly around health screening and EAP providers, which will be discussed.
Employees at increased risk for mental health problems may be identified via the type of work they do, exposure to potentially traumatic situations or low level symptoms detected via health screening or wellness checks. Some organisations have begun performing well-being checks, either using face to face interviews of self-report measures. This could be considered a form of ‘health screening’.
A RCT on screening for depression conducted amongst a US workforce found that screening followed by telephone support and care management, resulted in lower self-reported depression scores, higher job retention and more hours worked among employees. This telephone outreach and care management program encouraged employees to enter outpatient treatment (psychotherapy and/or antidepressant medication), monitored treatment continuity and attempted to enhance the treatment progress by providing recommendations to treatment providers. Another RCT based in the Netherlands suggested screening patients and providing those with low level depression symptoms with a minimal contact (mainly self-help) cognitive behavioural intervention resulted in decreased lost work days. This research has been replicated in Australia in the Work Outcomes Research Cost-Benefit (WORC) Project where the model of early identification and encouragement to seek help has been found to be highly cost effective with increased employee well-being.
Screening prospective employees for psychological vulnerability may be considered by organisations as part of their employee selection process. However, to date there is limited evidence that pre-employment screening is effective. In recent years a number of western militaries have considered the role of pre-deployment screening in an attempt to identify those at increased risk of mental health problems, however, a recent review found screening in the military had failed to reduce the incidence of psychiatric causalities and potentially good soldiers were rejected because of this process. The fact that simple screening has been unable to work even in the high-risk setting of the military, where pre-exposure screening should be most likely to be effective, makes it difficult to recommend pre-employment screening in other settings at this time.
Although wellness checks have the potential benefit of identifying symptoms before they develop into an established disorder, they are not without risk. Such programs have the potential to falsely label individuals suffering from common transient distress and make them feel more vulnerable or unwell. Despite these concerns, there is some limited evidence for the role of screening in the workforce in certain situations, but only when appropriate and detailed post-screening procedures are in place.
Employee Assistance Programmes (EAPs) and counselling are common workplace interventions which many organisations provide as a support service for staff. Two reviews produced by the British Association for Counselling and Psychotherapy have reported that counselling interventions in the workplace may assist in reducing symptoms of stress, anxiety and depression among employees.
While both of these reviews collated large amounts of data, they were significantly compromised by the methodological limitations of the studies reviewed. Although many of these studies described evidence of high client satisfaction, there were very few high quality studies examining health outcomes. For example, only one true RCT was included in the first review, and the results suggested there were no benefits from counselling. Aside from the lack of robust evidence, quality control within EAP providers varies, meaning the practitioners employed may be relatively inexperienced and it is not clear exactly what type of psychological interventions are being delivered.
Due to these concerns it is difficult to provide a definitive conclusion regarding the evidence base for EAP services. An EAP service using appropriately qualified staff and evidence-based therapeutic approaches is likely to be beneficial. However, it can be difficult for an employer to know if such conditions are being met.
Potentially traumatic events can occur in any workplace. Workers who are exposed to such trauma may be at increased risk of a variety of mental health problems, including depression, acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). However, even after a serious traumatic event, the majority of workers will be resilient. Despite this, workplaces should ensure the response to a potentially traumatic event aids and promotes recovery.
Previously it was thought that critical incident stress debriefing (CISD), a form of group psychological intervention designed to reduce distress following trauma, was a ‘good idea’ and likely to help people. As a result it was very widely implemented. However, CISD has now been subjected to robust evaluation and found to not only be of no benefit in reducing outcomes such as PTSD, but to possibly have a number of detrimental effects. It is now thought that the stimulation of emotional ventilation so soon after a traumatic event may be harmful. The example of CISD highlights the need to ensure any policies or initiatives aimed at preventing or alleviating mental health problems amongst workers, especially those at high risk, are evaluated fully and based on the best available evidence.
In the case of a traumatic event in the workplace, many employees will have some symptoms in the immediate aftermath of a critical incident, but in the vast majority these will resolve. Rather than offering routine emotional debriefing after a traumatic incident, individuals should be offered simple support, comfort, have their immediate needs met and have some form of ongoing monitoring. This can typically be provided by colleagues and supervisors using training such as mental health first aid.
Some organisations whose workers have repeated exposure to trauma have implemented peer support schemes, where peers are trained to lead a system of post-incident procedures. In general, peer support workers are not expected to provide psychological management of those affected by a traumatic event, but to keep employees functioning and identify those who require more specialist help. A particular type of peer led program developed in the UK military is Trauma Risk Management (TRiM). TRiM describes an organisational approach to trauma management and resilience. Regular members of staff are trained as “TRiM practitioners”, who are then tasked with leading a system of post-incident procedures and providing peer support and education in the aftermath of a traumatic event. TRiM practitioners are not expected to provide psychological management of those affected by a traumatic event. TRiM has been used with great success in the UK military and police officers and when subjected to a randomised controlled trial was found to have a beneficial impact on organisational functioning without the adverse effects associated with alternative debriefing-focused strategies. There are now evidence-informed peer support guidelines available for use in high-risk organisations. These include eight key recommendations on (1) goals of peer support, (2) selection of peer supporters, (3) training and accreditation, (4) role of mental health professionals, (5) role of peer supporters, (6) access to peer supporters, (7) looking after peer supporters, and (8) program evaluation. These guidelines also suggested that peer support need not be limited to traumatic incidents and could be extended to employee mental health and well-being more generally.
Developing a Mentally Healthy Workplace: Part 16
The six domains of evidence based workplace mental health interventions
There is a widely held assumption that an employee suffering from ill health of any type, but particularly mental ill health, needs to be fully recovered before they can return to work. This notion is out-dated and can potentially hinder an employee’s overall recovery. In most cases, early return to work can play a significant part in a person’s functional and overall recovery from mental illness. Typical standardised treatment approaches will often alleviate symptoms of mental illness yet this does not automatically translate to functional improvements such as return to work and presenteeism. To facilitate a worker’s functional recovery from a mental health issue, there are a number of research supported workplace approaches that employers can provide including:
- Supervisor support and training
- Partial sickness absence
- CBT based return-to-work programs
- Work focused exposure therapy
- Individual placement and support
These approaches are often termed ‘tertiary prevention intervention strategies’ as they aim to provide the individual with therapeutic relief and to minimise the impact a mental health condition may have on the individual and the organisation. These strategies address mental health issues at the individual level (reducing symptoms) and at the organisational level (e.g. re-integrating the worker into the workplace) and place considerable emphasis on the idea that when an employee is diagnosed with a mental illness they may intially require some modification of their work duties, however this does not render them incapable of completing all of the work tasks that they were previously engaged in. Rather, these strategies consider early return to work as playing a curical role in a worker’s recovery.
One of the most valuable ways in which a workplace can provide support for employees in their recovery is regular communication from managers or supervisors. As mentioned earlier, managers and supervisors play an important role in the welfare of their staff and in the prevention of long term disability. Ideally, they should be able to assist in identifying workers who are struggling, facilitate early assistance where required, manage sickness absence and be an active partner in early return to work and rehabilitation.
There is emerging evidence that early and regular contact from managers during a sickness absence episode is associated with a more rapid return to work. However, many managers feel reluctant to contact an employee who is off sick or to engage in a conversation with a worker who may be showing signs of illness. This is particularly so when the illness in question is a mental disorder. In an attempt to address this issue, a number of organisations have started to provide mental health training for managers, with evidence suggesting that managers value such initiatives and feel more confident in discussing mental health matters following specific training in this area.78
While assisting managers and supervisors in becoming more knowledgeable about mental health issues may help them to support at risk or affected workers, it is arguably not enough. In addition, managers would benefit from the opportunity to develop and practice skills required to effectively support workers on sickness absence or those involved in a workplace rehabilitation program. There are now clear guidelines about the role managers can play in sickness absence, regardless of the underlying cause. These include, but are not limited to, behaviours which facilitate regular conversations with an employee, maintaining a focus on the employee’s well-being and being able to develop an appropriate return to work plan.
To assist individuals in their recovery from mental illness, workplaces could consider supporting those struggling with mental health issues by providing more flexibility around work hours, position duties and responsibilities. There is good evidence that in most situations, being in work is associated with improved physical and mental health. There is also clear evidence that the longer an individual is away from work, the more difficult it is for them to return. This may be further complicated by the likelihood of a worker experiencing increased anxiety around the return-to-work process. Allowing individuals to remain in contact with their workplace during an episode of illness reduces the barriers to them returning to full time work and is likely to reduce the incidence of long term sickness absence.
Traditionally, when an individual feels they may be too unwell to be at work, they consult with their medical practitioner (usually a GP) who declares they are either fit or unfit for work. If the GP feels an individual may be unfit for work, a sick certificate is issued which directs how long that individual should remain away from work. A number of European countries are now promoting more flexible approaches to sickness absence certification, which may allow more focus on what an ill worker can do, rather than what they cannot. Such approaches have been called ‘fit notes’ or partial sickness absence. Rather than encouraging an extended period of absence from work, employers and organisations can play an active role in helping the return-to-work process by considering a range of work adjustments, including partial sickness absence.
Return to work (RTW) programs were traditionally developed as a response to safety concerns around reintegrating employees with physical injuries back into their place of employment. More recently however, the occupational rehabilitation industry has expanded their RTW programs to also address mental health problems.
A systematic review examining the effectiveness of RTW programs for people with depression and/or anxiety found that Cognitive Behavioural Therapy (CBT) based RTW programs were usually more effective than treatment without CBT. The review also found that the use of CBT led to less psychological distress, improved work satisfaction and reduced depression. Other reviews have suggested that RTW using problem solving therapy is also able to facilitate a two week earlier return to work amongst employees with adjustment disorder compared to no treatment or treatment as usual.
Interestingly, a quasi-experimental study comparing ‘standard’ CBT with work-focused CBT, where the therapist integrated work into the treatment from very early, found significant effects in favour of work-focused CBT. Amongst those who were already on sick leave because of depression, anxiety or adjustment disorder, those who received work-focused CBT returned to work an average of 65 days earlier, even though both treatment produced a similar decrease in mental health symptoms. These results once again highlight the potential limitations of standard, symptom focused treatments and the need for occupational rehabilitation to be incorporated into treatment from a very early stage.
Workplaces can also play an active role in the recovery of individuals that have been affected by work-related anxiety or post-traumatic stress disorder (PTSD). Work focused exposure therapy provides the opportunity for employees to gradually learn how to deal with anxiety-provoking work situations. This process is typically guided by a skilled professional such as a psychologist and may involve a number of visits to the workplace prior to re-commencing work duties. Work focused exposure therapy may then continue via external one-on-one sessions with the psychologist throughout the course of the RTW program. During this process, supervisors and managers should strive to provide a supportive environment to the worker, as this is likely to enhance the therapeutic outcomes and RTW process.
Two recent reviews examined the effectiveness of work focused exposure therapy across a range of occupations and reported promising outcomes including earlier return-to-work rates. One of the reviews also found that avoidance of the work area where the injury occurred was a major barrier to overall recovery and successful return to work. The researchers also found that work focused-exposure therapy for PTSD resulted in an average return to work rate of 85% at 6 month follow-up.
Thus far, most of the research discussed in this report has focused on common mental illnesses such as depression and anxiety, as they represent the vast majority of mental ill health in the working age population. However, individuals suffering from severe mental illness, such as schizophrenia and bi-polar affective disorder, also suffer from major challenges in the workplace. Recent research has found that the proportion of Australian adults with a psychotic disorder who are in employment (either part-time or full-time) has remained fixed at around 20% over the last 12 years. This represents a massive lost opportunity, both for the affected individuals and employers. Most individuals with severe mental illness want to work and there are many examples of those with severe illness proving to be very reliable and valuable employees in spite of their illness.
The low rates of employment amongst those with severe mental illness (SMI) are due to multiple barriers preventing entry to and retention in work at every stage of the occupational journey. Individuals with SMI are more likely to under-achieve in education, less likely to find employment, less likely to be promoted and more likely to leave the workforce early.
There are currently two main types of vocational rehabilitation schemes operating within Australian mental health services to address the issue of unemployment amongst individuals with SMI; pre-vocational training and supported employment. Pre-vocational training involves individuals undergoing an extended period of training and work experience prior to being placed in competitive employment while supported employment focuses on early acquisition of competitive employment followed by ongoing support. A detailed review of multiple RCT studies found that amongst those with SMI, the supported employment approach was significantly more likely to lead to employment than more traditional types of pre-vocational training. One particular form of supported employment that has produced significant positive employment outcomes for individuals with SMI is individual placement and support (IPS). IPS is based on the philosophy that anyone is capable of gaining competitive employment, provided the right job with appropriate support can be identified. IPS programmes focus on finding early employment for those with severe mental illness and then provide individual support within a job. RCTs of IPS suggest that it can achieve employment rates of 50 to 60% amongst those with severe mental illness.
From an employer’s perspective there are some important implications from this research. Individuals with severe mental illness can be valuable, effective and reliable workers. However, there are many barriers preventing them from finding appropriate work. Support programs are available which can assist those with SMI enter and remain within the workforce, but their success is reliant on employers providing opportunities to those with mental illness.
In October 2012, the Parliament of Victoria’s Family and Community Development Committee released a report inquiry into the workforce participation by people with mental illness. The report highlights the social and economic benefits of workforce participation by those suffering from mental illness and made a number of recommendations to increase participation rates. These include changing perceptions of mental illness in the workplace, increasing flexibility to prevent those with mental illness from leaving early, creating diverse and flexible employment pathways including supported employment, fostering healthy and supportive workplaces and improving linkages between mental health and employment support services. The Victorian Government recently released a response to the report indicating their strong support for the intent for the Inquiry’s recommendations.
There is a general move amongst most mental health services towards a ‘Recovery Model’ of care. This requires services to be less focused on symptom reduction and more interested in maximising functional performance and well-being. Improving the occupational outcomes for those with severe mental illness should be a key component of recovery focused care. There are a number of studies that suggest peer-support schemes, where patients are supported by those with a lived experience of mental illness, may help those with mental illness feel more in control of their care and can provide a catalyst for or practical examples of functional recovery.
Developing a Mentally Healthy Workplace: Part 17
The six domains of evidence based workplace mental health interventions
Those suffering from mental illness are one of the most stigmatised and excluded groups in society. This stigma is often extended into the workplace. All of the interventions and strategies described above require there to be awareness and acceptance of mental health problems. There has been a range of mental health education programs developed which have been shown to improve levels of knowledge and attitudes to mental health. Such programs may be delivered to individual workers or at an organisational level. Examples of effective initiatives or programs are:
- Mental health first aid
- Mental health education
These initiatives can have an important impact on the overall organisational culture. Although this has yet to be tested in a research setting, the development of a mental health policy or establishing a clear governance structure for mental health issues within an organisation can also help raise awareness and the profile of mental health in a workplace.
There are a variety of mental health education programs currently offered to workplaces. One particular type of mental health education which has an evidence base is Mental Health First Aid, which aims to educate workers on how they could help others who were in a mental health crisis and/or in the early stages of mental health problems. An RCT of Mental Health First Aid training amongst 301 employees of two large government departments found a number of benefits including improvements in mental health knowledge, stigmatising attitudes, confidence, and help provided to others. The trial also had an additional and unexpected finding that mental health education appeared to have some benefits to the mental health of participants themselves.
There are many workplace strategies informed by research evidence that can effectively contribute to creating a mentally healthy workplace. These strategies should be targeted across multiple levels of the workplace; the individual workers, managers, work teams and at an organizational level. Based on the available research evidence, we suggest there are six key domains in which workplace mental health strategies should be implemented to maximise worker mental health:
- Designing and managing work to minimise harm
- Promoting protective factors at an organisational level to maximise resilience
- Enhancing personal resilience, generally and for those at risk
- Promoting and facilitating early help-seeking
- Supporting workers’ recovery from mental illness and during stressful life events
- Increasing awareness of mental illness and reducing stigma
It should be noted that there is an important difference between the strength of research evidence currently available and the likely impact of an intervention. Some interventions, by their nature, are easier to conduct research on and so may have a stronger evidence base. This allows us to be more certain regarding any possible benefits of risks with these interventions, but it does not necessarily mean they will be the most effective. Whilst there are limitations to research evidence in workplace settings there are nevertheless practical steps that a workplace can take to create a mentally healthy workplace.
Developing a Mentally Healthy Workplace: Part 18
PRACTICAL RECOMMENDATIONS FOR DEVELOPING A MENTALLY HEALTHY WORKPLACE
One of the main aims of this series of emails is to inform practical, evidence-based advice on how to develop a mentally healthy workplace. Initially we outlined the evidence of how various job, team, organization and non-work factors can combine to determine the extent to which work and the workplace can contribute to or threaten good mental health. Based on this evidence we proposed a model of how individual risk factors can combine with work and non-work factors to determine mental health outcomes. Then we focused on the various types of workplace interventions or strategies and examined the research evidence for the effectiveness of these in aiding mental health. Finally we combine all of the information outlined in into some simple, practical guidance for workplaces.
As discussed previously, there are significant gaps in the research evidence around workplace mental health. To date there have not been enough well conducted intervention studies to conclude with absolute certainty what is and is not effective at improving workers’ mental health. Despite this caveat, it is important to emphasise that what research is available strongly suggests there is much that workplaces can do to help the mental health of their employees. It is also important to recognise that organisations’ legal obligations are limited by what they can reasonably do at a particular time to ensure health and safety measures are in place. Individuals in the workplace are also responsible for their own health and safety and must not adversely affect other people’s health and safety. Additionally, we hope that the evidence contained will help convince organisations that there are sound economic reasons for them to invest in their worker’s mental health and that small, relatively cheap interventions may have a dramatic impact on employee wellbeing and performance.
Using the research evidence summarised in this report, it is possible to devise a template for workplace mental health interventions that, based on the best available evidence is likely to be effective. Traditionally, organisations have approached health and safety in the workplace from a risk management perspective. The risk management framework includes a stepped approach to identifying hazards, assessing the risks from the identified hazards, controlling the risks, reviewing the control measures and revising the controls if required. This approach is well established in the business community and should be able to be used to address some of the issues highlighted in this review. However, the complexity of mental health matters in the workplace needs to be addressed when considering how risk management approaches can be used to meet these challenges.
The difficulty with mental health risk factors is that the relationship between each risk factor and mental health outcomes is very complicated. Many potential risk factors, such as ‘stress’, can actually be beneficial in small doses. Further, the impact of any potential risk factor may depend on the presence or absence of other factors, such as support or perceived control, or on individual factors such as personality or coping skills. As a result, identifying and ‘controlling’ any one mental health risk factor in isolation may not prove to be beneficial.
An additional complexity is the difficult issue of how much mental illness or symptoms should be discussed. There is a risk that if mental health problems are over-emphasised or discussed in an alarmist manner, individual workers may begin to doubt their own resilience and feel more vulnerable to illness. Overzealous or poorly constructed attempts at screening also risk labelling otherwise transient minor symptoms as a medical problem. Some have suggested that the back pain epidemic of the 1970s and 1980s was partly a result of the very interventions which aimed to make workers aware of the risk of harm to their backs pain. The counter to these arguments is that mental health problems need to be discussed in the workplace and that, at present, lack of information and stigma prevent workers seeking help early.
Based on the available evidence, we proposed an approach that acknowledges the multifaceted, complex and inter-related nature of workplace mental health. This approach is not intended to replace current Work Health and Safety (WHS) processes or the Codes of Practice currently published by work health and safety regulators. Instead, it is a recommended approach that is complementary to existing WHS processes. The broad stages of this proposed approach map closely with many established occupational health and safety programs:
- Establish commitment and leadership support
- Conduct a situational analysis
- Identify and implement appropriate intervention strategies
- Review outcomes
- Adjust intervention strategies
Each of these steps requires consideration of a broad range of factors or interventions, related to individual workers, their jobs, work teams and the organization as a whole. The current evidence suggests that considering both risk and protective factors at each of these levels will provide the best chance of success. While there are five key stages involved, this procedure should be approached as a continuous and ongoing process. It should acknowledge the changing nature of work and recognise the need for continuous development in maintaining and enhancing a mentally healthy workplace.
We hope you have enjoyed this series of emails on Developing a Mentally Healthy Workplace.
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