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Managing mental health

Author: Sarah Silcox

Contributing authors: Dr. Barbara Mariposa and Emma Mamo

Summary

  • Failing to manage employees' mental health can cause a number of organisational problems, for example sickness absence, poor employee morale and reduced productivity. (See The business case for managing mental health at work)
  • It is important for employers to understand the issues surrounding mental ill health before taking steps to deal with it. (See Understanding mental ill health)
  • Employers' strategic framework for managing mental health at work should include a mental health policy that links to their other relevant policies and procedures, for example those relating to stress management, recruitment, absence management and flexible working. (See Mental health strategy and policy)
  • Employers have an important role to play in tackling the stigma attached to mental health in the workforce by raising awareness and understanding of the issues among employees. (See Promoting understanding about mental health)
  • Line managers play a key role in supporting employees who have a mental health condition, and employer should make sure that they provide comprehensive guidance and training for managers on how to do this effectively and with confidence. (See The role of line managers in supporting mental wellbeing and Training line managers)
  • Recruitment is one of the key areas where there is potential for employers to discriminate against individuals with a mental health condition, and organisations should make sure that they have a good understanding of disability discrimination law. (See Mental health and recruitment)
  • Employers should be aware of the therapies that are available for employees experiencing a mental health problem, and ensure that this information is available to managers and employees. (See Therapies available for people with a mental health condition)
  • Employees experiencing a mental health problem can be reluctant to disclose that they have a condition, so it is important that line managers encourage disclosure in a sensitive way. (See Encouraging disclosure about a mental health condition)
  • Absence management policies and procedures relating to mental ill health need to support the timely referral of employees to specialist help where appropriate. (See Making timely referrals to occupational health)
  • Maintaining regular contact can help to prevent individuals on long-term absence through mental ill health from feeling isolated, and the development of an action plan will be essential for an effective return to work. (See Supporting employees taking absence related to mental ill health)

Overview

This section of the XpertHR good practice manual discusses the steps that employers need to take to ensure a mentally healthy workplace. It covers: the business case for managing mental health at work; understanding mental ill health; raising awareness about mental health; supporting employees experiencing poor mental health; and managing absence related to mental illness.

The business case for managing mental health at work

Managers need to understand stress, distress and mental illness, and how to minimise these and offer effective support, irrespective of whether or not the poor mental health is related to organisational factors. The organisational costs of poor employee mental health extend beyond the direct cost of absence related to mental ill health to, for example, raised staff turnover and lower productivity. Poor management leading to decreased wellbeing can also result in less tangible indirect impacts including reduced employee morale, low levels of engagement, employee errors and erosion of trust. Reputational damage may also occur in the event of a high-profile employment tribunal claim, as long-term mental illness is a disability under the Equality Act 2010 (see Disability discrimination and mental ill health).

The Government-sponsored Thriving at Work report estimates that poor mental health costs employers between £33 billion and £42 billion a year, due to absence, presenteeism and staff turnover.

Promoting good mental health and supporting employees who have a mental health problem can boost employee commitment to and engagement with the organisation, and enhance employee retention, productivity and performance levels.

Sickness absence, staff turnover and employee morale

Whether or not employees have a pre-existing mental health condition, it is clear that workplace practices can impact on their mental wellbeing. Poor workplace practices can lead to significant ill health through stress, burnout and poor management. There is a clear financial business case for employers to take positive steps to improve workplace practices. Office for National Statistics data shows that, in 2017, 21.9 million days were lost because of poor mental health (including stress, depression, anxiety and more serious conditions), accounting for 8% of all days lost. However, research has also shown that many employees fear ascribing their absence to mental ill health and will actively cite other reasons.

Being off work for long periods with a mental health problem can affect an individual's ability to cope with the demands of work when they return to the workplace. Extended periods of work inactivity can worsen the physical symptoms of some mental health conditions. However, at least 70% of employees who take absence due to mental ill health do return to work and 83% of employers say that they do not regret hiring someone who develops or has a mental health problem. Good return-to-work policies, put into action, are fundamental for successful return to work (see Action plans).

If employers do not promote good mental health and support employees who have a mental health condition effectively, this can result in increased staff turnover. Employees who are stressed or have a mental illness, and who do not feel supported by their employer, are more likely to consider leaving the organisation. It is often the case that employees' work situation aggravates their mental ill health. As well as considering resigning from the organisation, which could be seen as a natural and healthy reaction to remove themselves from harm, employees with a mental health condition may become disengaged from the organisation if they do not feel supported. If even one employee experiences low morale, this can affect employees within the wider team. Therefore, employers that do not manage mental wellbeing may experience low morale among wider sections of staff.

Lost productivity and "presenteeism"

Lost productivity among employees who continue to work despite having a significant mental health problem is a major component of the total cost of mental ill health at work. Many employees find it difficult to raise the matters that are causing them stress and distress and that can lead to illness, for example a heavy workload, poor work relations, bad management or unclear work roles, because they are fearful of the repercussions.

Many employees with a pre-existing mental health problem prefer not to disclose it to their employer, and continue to work even though their mental health may be impacting on their ability to do their job. The practice of employees continuing to work even though unwell is known as "presenteeism". Employees in professional jobs and on executive grades are particularly prone to attend work when they are unwell mentally because they are concerned about being stigmatised if they are known to have a mental health problem. In addition, some employees may be concerned that their career could suffer if they take time off sick.

Disability discrimination and mental ill health

Disability is a protected characteristic under the Equality Act 2010. For a mental illness to fall within the definition of disability, an employee has to show that:

  • they have a mental or physical impairment;
  • the impairment affects his or her ability to carry out normal day-to-day activities;
  • the adverse impact of the impairment is substantial; and
  • the adverse impact is long term.

Mental impairment covers a wide spectrum relating to mental functioning, including conditions with symptoms such as anxiety, low mood, panic attacks, phobias or unshared perceptions, in addition to mental illnesses.

The duty to make reasonable adjustments in the case of those coming within the definition of having a disability is a unique feature of disability discrimination law, and a failure to comply with the duty constitutes discrimination under s.21 of the Equality Act 2010, unless the employer lacks relevant knowledge of the employee's disability.

The risk of encountering stigma at work and fear of being discriminated against as a result of having a mental health condition understandably prompts some employees to disguise a problem, attributing their underperformance or absence from work to physical health issues. This makes it hard for people with an illness to receive the support they need in terms of reasonable adjustments and professional help. The onus is on employers to make it possible by exhibiting an explicit and demonstrable zero tolerance approach to stigma, from the top of the organisation. It will then be easier for them to fulfil their legal duties concerning the employment of people with disabilities.

Accidents at work

There is an association between mental ill health and workplace accidents; employees who are stressed, anxious or depressed may find it harder to focus on a task. Employers have a duty of care to manage all potential sources of risk, including those arising from mental ill health.

Corporate governance and reputational risk

Failing to manage employees' mental health can damage an organisation's reputation as an employer, particularly if this results in high-profile legal action, for example an unfair dismissal or discrimination claim. Conversely, positioning the organisation as a mentally healthy workplace through the development of positive management and effective wellbeing strategies can strengthen its reputation as a good employer and its corporate responsibility profile.

Understanding mental ill health

The first step to taking better care of employees with a mental illness and minimising the risk that someone may get ill involves understanding mental illness and the factors at work that protect from and prevent distress. This means employers having an awareness of why it is usually not obvious that an individual is experiencing poor mental health and understanding the risk factors associated with mental ill health. It also means employers having knowledge of the relationship between stress and mental ill health, as well as the wide spectrum of mental health conditions.

The incidence of mental ill health

Mental ill health is often invisible in the workplace: surveys suggest that line managers significantly underestimate its prevalence in their team. Mind's Workplace Wellbeing Index found that one in 10 employees rate their mental health as currently poor or very poor. Of these, 26% said that this was due to problems at work, while 50% said it was due to a combination of problems at work and outside work. In addition, 40% of employees rating their mental health as poor or very poor had taken time off work as a result.

How well organisations feel that they support employees with a mental health problem does not always tally with the employee experience. Business in the Community's Mental Health at Work Report 2017 found that, while 51% of senior managers or directors felt that their organisation supported employees who experience a mental health problem very well or fairly well, only 13% of staff felt able to disclose a mental health issue to their line manager. Encouraging employees to disclose a mental health problem at work remains challenging, despite ongoing public campaigns and initiatives by mental health charities and other organisations designed to reduce the stigma associated with mental ill health.

A wide spectrum of mental health issues

The World Health Organisation defines good mental health as: "A state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her own community." The term "mental ill health" covers a range of conditions ranging from mild ones, for example mild depression and anxiety, to more serious and enduring conditions such as bi-polar disorder, psychosis and schizophrenia.

There are links between substance abuse and mental ill health, creating a real challenge for employers in untangling how best to support an individual who is affected by both types of problem.

Employers should be aware that people with mental illnesses can have extended periods of being well, especially when their workplace is flexible and supportive. Given the wide spectrum of conditions covered by "mental ill health", proactive employers are developing overarching mental wellbeing frameworks with resources for managers to use to support employees in different ways, depending on the individual's needs.

Stress and mental ill health

A degree of pressure is inevitable sometimes both at work and in life outside work, but excessive pressure can tip over into stress, defined by the Health and Safety Executive as "the adverse reaction people have to excessive pressure or other types of demand placed upon them".

Stress is a psychological state not a medical condition, although it is associated with a number of physical symptoms, including a raised heartbeat and rapid shallow breathing. The state of stress, however it arises, is also characterised by changes to the way a person thinks, feels and behaves. Prolonged exposure to unmanageable stress is linked to the development of more serious psychological conditions, including anxiety and depression. Therefore, managing stress effectively should form a core part of an employer's risk-management approach to supporting mental health at work.

Work-related stress can trigger an episode of mental ill health in an employee who has otherwise successfully managed an underlying condition without that condition previously affecting his or her work. A number of factors, including those listed below, can cause excessive pressure at work. Whether an employee experiencing stress develops a mental health problem, or an employee's existing mental health condition becomes exacerbated by stressful events at work, the employer needs to help the employee who is in distress.

The link between stress, specific mental health conditions and a range of physical conditions means that employers should tackle employees' mental and physical health at work as part of a holistic health and wellbeing strategy.

For more information on stress see Health and wellbeing > Stress management and Policies and documents > Stress at work policy and procedure.

Environmental risk factors

Each organisation is different and should develop a framework to foster a mentally healthy working environment that suits its own needs. However, there are certain generic factors about which employers need to be mindful when considering the mental health of individuals and the organisation.

The typical environmental risk factors that can adversely affect employee mental health include:

  • long working hours;
  • lone working;
  • a lack of job security;
  • unrealistic or unmanageable workloads, expectations or deadlines;
  • little employee involvement in decision-making and planning;
  • ineffective matching of jobs to individuals' skills and competencies;
  • organisational change;
  • negative relationships or poor communication between individuals and management;
  • a lack of organisational support for managers and employees;
  • ineffective action by the organisation on tackling destructive behaviour such as bullying and harassment; and
  • high-risk roles (for example some medical roles) and high-pressure environments (for example public-facing work such as social work).

A stress questionnaire (for an example, see Policies and documents > Stress questionnaire) may be useful in identifying which of these factors could be trigger points for individual employees. Line managers are likely to be the most appropriate people in an organisation to make adjustments, for example to workloads or deadlines, to relieve the pressure on employees.

Organisational change

Employees' mental health is particularly vulnerable during organisational change, which in many of today's organisations is almost continuous. This makes it vital for employers to adopt a risk-management approach by:

  • assessing the potential impact of organisational change on employees' mental health;
  • avoiding too many changes at the same time;
  • consulting employees before changes occur to ensure that issues affecting their work environment and mental wellbeing are not overlooked;
  • training and supporting employees whose role will change as a result of the change programme; and
  • evaluating the impact of the change programme to learn from the experience and improve the management of future change initiatives.

The HR function and managers should try to normalise change for individuals so that they do not see it as a threat. Major factors in terms of harm minimisation include transparency, effective communication and involvement. Where possible, the employer should support employees by providing access to an occupational health team and employee assistance programme. Organisational change will not be effective if it adversely affects employees' mental health, particularly if the change impacts negatively on staff morale.

Bullying and harassment

Employers should take proactive steps to deal with destructive behaviour such as bullying and harassment in the workplace in order to provide a safe working environment for their employees. Less obvious forms of bullying or micro-aggressions must also be called out and dealt with as these can lead to considerable distress, especially when consciously or unconsciously targeted at employees who are already vulnerable. An employer could be held liable if an employee's psychiatric illness resulted from its failure to address a severe case of bullying. For more information see How to > How to deal with bullying and harassment in the workplace.

Being aware of the mental wellbeing of the workforce

Employers should be proactive in monitoring the mental wellbeing of their employees for the following reasons:

  • Building a business case for intervention. Collecting data on the mental health of the workforce, the prevalence of mental ill health and the effectiveness of employer interventions to protect mental health is a good way for HR and occupational health to demonstrate that there is an evidence-based case for developing a workplace mental health strategy and investing in appropriate programmes and interventions.
  • Understanding the mental health climate. Over time, collecting regular data will enable the organisation to build up a comprehensive and ongoing picture of mental health at work, enabling it to identify trends and shift the focus of the wellbeing strategy to target particular issues revealed by the data.
  • Gaining senior-level buy-in. The biggest stumbling block to the success of even the best mental health strategy is a lack of senior-level buy-in. The organisation's efforts must start from the top to be successful and it may be necessary for HR to present data about the current situation to generate interest and secure commitment. They must ensure that the senior leadership are informed about the organisation's efforts to foster a mentally healthy workforce, and how specific interventions are affecting employee health and productivity. Any monitoring or evaluation needs to include the senior team, who may themselves be unwell.

A general health questionnaire and more general employee surveys can provide the employer with some data on employee mental health. Managers can use the survey data to assess how their team is coping, and to identify areas requiring specific attention. The data may also identify risks to employees' mental health before they develop.

An employee assistance programme (EAP) can be a good source of aggregate data, for example the management reports provided by most EAPs can usually specify what proportion of the workforce are experiencing poor mental health. Information from an EAP can highlight issues in different parts of the organisation and provide the employer with a picture of employee morale and wellbeing across the organisation, particularly during periods of organisational change.

The HR and occupational health functions can develop and/or access a range of sophisticated tools to measure the level of mental wellbeing in the organisation:

  • Health risk appraisals (HRAs). HRAs are available through third-party providers, which supply the questionnaires and process the results. Employees complete an HRA survey online or on paper and receive a confidential report detailing their health status and the risks to their health. Provided that the response rate within the organisation is sufficiently high, the employer receives an aggregate report detailing workforce health, including mental health. Typically, the aggregate data provided by an HRA provides organisations with a baseline for subsequent initiatives targeting a particular aspect of mental health, for example resilience.
  • Health dashboards. Health dashboards are used to present data gathered through HRAs on various health areas, including mental health. Data should be presented as charts and graphs, as this allows for easy identification of where the organisation sits on the metrics most important to it. The organisation can use a "traffic light" system to categorise the health status of employees, enabling senior management to grasp quickly the scale of any particular mental health challenge.
  • Audits of mental wellbeing. Employers should consider carrying out a wide-ranging audit of employees' mental wellbeing, perhaps in conjunction with an exercise to measure employee engagement. Various online tools exist, and the data generated can be used to benchmark against similar workplaces. The software behind these tools enables HR and occupational health teams to compare wellbeing in different departments, locations and job levels. Reporting is becoming more sophisticated, allowing the participant organisations to provide their line managers with summary reports for their team. An audit creates the starting point for interventions to improve employee mental wellbeing by helping to identify mental health problems requiring attention, enabling the employer to target resources effectively.

Promoting understanding about mental health

Despite high-profile awareness-raising initiatives by the Government, mental health organisations and employers in recent years, stigma and discrimination around mental health still exist, including in the workplace. This stigma can affect employees' willingness to disclose a mental health problem to their employer because of the possible impact on their career.

Employers have an important role to play in tackling stigma at work by raising awareness of and encouraging openness about mental health. They should adopt a positive approach by developing strategies for managing mental health, underpinned by the fact that most people who experience mental ill health can stay in work if they are provided with the appropriate support. Further, employers should raise awareness of the support in place to deal with mental health problems, for example stress management practices and interventions available through their employee assistance programme.

Employees have a responsibility to maintain their own mental health and to access the organisational support that they need. Staff should be encouraged to raise concerns about issues such as excessive pressure or long hours, and to take up opportunities for support, such as stress management or resilience training, access to counselling and help from the employer's occupational health service.

Employers can promote awareness and understanding of mental health in a number of ways as part of a long-term strategy, for example by putting up posters around the workplace, providing training in mental health and illness for line managers (see Training line managers), holding talks and seminars, dedicating a section of their intranet to mental health and wellbeing, and encouraging discussion among employees.

There are several national campaigns and networks that aim to raise the profile of mental health at work. These include Time to Change, a campaign run by mental health charities Mind and Rethink Mental Illness that supports organisations to end mental health stigma and discrimination.

Employers can contact these organisations for advice and to build links with experts on mental health. They may also choose to become involved in national and local initiatives to promote good mental health at work, for example by signing a pledge to improve mental health at work under the Mindful Employer initiative. Where employers are proactive about mental health, this will send a positive message to employees that the subject is taken seriously and that employees who experience a mental health condition will receive support.

Mental health strategy and policy

A mental health strategy should be at the heart of organisations' approach to fostering good mental health at work. It will be most effective when written by a working group that includes "experts by experience", ie people who are or have been ill with a mental health problem, and staff from different levels within the organisation.

Senior managers should demonstrate that the organisation is serious about the mental health of staff, and publicly acknowledge that the workplace can have a negative effect on employees' mental health if the environmental risks within it are not controlled. Senior managers can demonstrate their commitment in a number of ways, for example by raising the issue with line managers in training sessions; by ensuring that HR and occupational health are well equipped to handle mental health issues; by influencing the development of policy statements that clearly state the organisation's commitment to promoting good mental health among the workforce; and by making budgetary provision for initiatives such as stress-management training and a mental wellbeing section of the intranet.

Employers should ensure that their mental health strategy does not exist in isolation, and that it is embedded in other HR and health and wellbeing policies including those on: health and safety, performance management, change management, redundancy and sickness absence.

Organisations need to adopt a zero tolerance approach to stigma, prejudice and discrimination by educating all employees and managers about mental ill health to normalise it and ensure it is viewed like any other kind of illness. Example initiatives include running regular awareness-raising sessions and participating in national employer-based programmes.

Employees who have a problem with their mental health must feel that the organisation will provide appropriate support if they choose to disclose this, for example through making reasonable adjustments. Organisations should adopt a positive position about the employment of people with mental health problems, for example by not assuming that this group is more vulnerable to work-related stress, or will take more days off sick. Employers should be explicit in their policies and practices that they will support employees who have a mental health condition. This information must be clear, transparent and easily accessed, for example be set out in the staff handbook and on the organisation's intranet and reinforced in the guidance that HR provides to line managers.

A mental health policy (either as a standalone document, or as part of a wider employee wellbeing policy) will help to deliver the strategy. Organisations could include the following in their mental health policy:

  • A vision statement. The policy's vision statement could read: "The organisation aims to promote a positive working environment where it collaborates with employees to achieve the goals of the organisation; promote the physical and mental health of all employees; and welcome diversity by providing opportunities for people with mental health problems to participate in the workplace."
  • Principles and values. The organisation's principles and values for mental wellbeing should reflect and be reflected in its corporate values and culture. The principles might refer to the business case for investing in the mental health of the workforce, for example: "Employees should have access to treatment and support for mental health problems because they matter as people, not just because it is cost effective for the organisation to ensure the early treatment of people with conditions such as depression."
  • Objectives. Objectives for mental health should translate the organisation's policy vision into concrete statements of what the organisation seeks to achieve in a given period. These will depend on the organisation's circumstances but could include: to raise employee awareness of mental health problems; to minimise the negative impact of stress on the mental health of employees; to support employees who disclose a mental health problem at work; and to reduce absence, whatever its given reason, by a certain level within a specified period (research shows that a high proportion of people will give another reason for absence related to mental ill health).
  • An explanation of the holistic approach taken. The mental health policy should explain how it links with other organisational policies, for example those covering sickness absence, substance misuse and stress. It should provide details of how the organisation will monitor employees' mental health, how senior managers and directors are performing in relation to the mental wellbeing of their staff, and the training that it will provide for all staff, starting at the top of the organisation, to implement the policy.

For an example wellbeing policy that incorporates mental health, see Policies and documents > Employee wellbeing policy.

The role of line managers in supporting mental wellbeing

Managers play a key role in supporting employees who experience poor mental health. Employers should develop guidance for managers covering the practical aspects of their mental health policy. The guidance should:

  • emphasise that the organisation does not expect line managers to make diagnoses, but that they should seek advice from HR or the occupational health service if they have any concerns about an employee's mental health;
  • state that managers should seek expert advice if they believe a change in an employee's behaviour might adversely affect safety-critical work; and
  • make clear that managers should approach all aspects of a person's mental health in the same way they would any other kind of health-related problem, seeking specialist input in relation to issues such as assessing fitness for work, dealing with sickness absence, considering workplace adjustments and managing performance.

The role of managers in supporting mental health includes:

  • being able to recognise the signs that an employee is struggling with poor mental health and addressing it before a crisis point is reached (see Signs and symptoms of stress or mental ill health);
  • fostering a workplace environment where employees feel comfortable talking about their mental health;
  • having a conversation with any employee they believe may have a mental health problem that is affecting performance at work or is a factor in sickness absence;
  • participating in organisational initiatives to tackle the stigma around mental ill health and encouraging the involvement of their team in such initiatives;
  • managing the potential sources of excess pressure in their team by ensuring that employees have the right training and equipment to do their job and by managing workloads effectively;
  • participating in training designed to educate and raise awareness of mental health issues at work;
  • helping individuals who disclose a mental health problem to access appropriate help, for example by signposting specialist sources of advice, making quick and effective referrals to occupational health, and encouraging them to contact the employee assistance programme or their GP;
  • helping manage absence due to mental ill health, by working as part of a multi-disciplinary team to support employees to remain in, or return to, work;
  • supporting employees returning to work following absence, for example by making adjustments to their work and/or the working environment; and
  • communicating with other managers about their experiences of managing mental health to help demystify and destigmatise the issue.

Providing effective support to employees experiencing poor mental health

Managers should be provided with resources to help prevent employees developing work-related stress and support employees with a mental health condition.

Primary prevention

This level of intervention covers the creation of a workplace environment that is conducive to good mental health, for example training for line managers in developing the soft skills necessary to encourage disclosure of a mental health problem, and job design to support the creation of work that is satisfying and does not exert excessive pressure on employees.

Resources for primary prevention could include guidance for line managers on designing jobs that do not cause excessive pressure and programmes to promote good individual mental health and resilience. Line managers also have a role to play in removing other risk factors, including bullying and harassment, and promoting good working relationships.

Secondary intervention

This level covers the provision of support to employees at a sufficiently early stage of their presenting symptoms to prevent mental health problems developing, for example stress management and resilience training.

Resources could include training to identify stress, anxiety and other common mental health problems, or a stress assessment and management tool. It is vitally important that employers help line managers to spot when a team member may be struggling, be it with stress or any other form of distress.

Tertiary-level support

This stage of support includes the services organisations operate to support employees to return to work if off sick with a mental health problem, or to remain in work with enduring mental ill health, for example an employee assistance programme (EAP).

Employers should provide resources to support managers to identify and support employees with severe and enduring mental ill health, for example mental health first-aid training, guidance on using the management support part of their EAP, and training in making effective referrals to occupational health or other medical specialists.

Employees with a more serious long-term illness will often need a different management approach to those with a mild or moderate condition - particularly where the condition fluctuates, with relapses and remission periods. Most employees with enduring mental ill health will function well most of the time, and are best placed to identify the early warning signs that they are not well, making it vital for them to be involved in workplace support. Some organisations have developed a structured approach for engaging support quickly where an employee identifies problems with his or her own mental health. This approach empowers employees with mental ill health to manage their situation at work.

Mental health and recruitment

An individual with a mental health condition could be classified as having a disability, so rejecting a prospective employee on the basis of a mental health condition could amount to disability discrimination under the Equality Act 2010.

It is advisable for employers not to ask health-related questions during the recruitment process. If an employer asks health-related questions prior to making a decision about whom to appoint, and then fails to appoint a disabled candidate, in the event of a subsequent disability discrimination claim, it will have to prove that there were other reasons for its failure to appoint the candidate to the role that were not related to his or her disability. Employers should base recruitment decisions on whether or not candidates have the necessary qualifications and competence for the job, without making assumptions about health or disability.

Job candidates are increasingly likely to ask about the wellbeing strategies that organisations have in place and how they are actioned.

Employers may choose to take a proactive approach to recruitment, and encourage applications from individuals with a mental health condition, for example by liaising with mental health charities to broaden their pool of candidates.

Therapies available for people with a mental health condition

Employers should promote awareness of the range of support available for employees experiencing mental ill health through their employee assistance programme (EAP) or externally. They could use their health and wellbeing intranet pages to signpost employees to sources of expert advice and outline the range of therapies available. Occupational health could be involved in advising on the therapies available for common mental health problems.

The National Institute for Health and Care Excellence (NICE) recommends cognitive behavioural therapy (CBT) as an intervention for the most common types of mental ill health, including depression, anxiety disorders and post-traumatic stress disorder. CBT is well suited to a workplace setting and is at the heart of many workplace counselling services, including those provided through an EAP. Where an organisation refers employees to its EAP for counselling or CBT, it should first ensure that the EAP is equipped to handle employees with mental health issues.

CBT involves the individual working with a therapist in a collaborative way to develop solutions to deal with his or her mental health problem. This type of therapy is recognised as being effective in helping people back to work following a mental health problem. The collaborative nature of CBT means work-focused goals and strategies can be set, which employees often find empowering. Typically it is delivered in the form of six to eight sessions of counselling, which can be face to face, although many providers have developed e-therapy programmes that are delivered in an online interactive format.

The use of new technology to deliver counselling support has several advantages, for example:

  • counsellors can often get to the heart of the matter more quickly, because many employees feel less inhibited "talking" to an adviser electronically rather than face to face;
  • employees can access support wherever and whenever they wish and do not have to wait for the next session of face-to-face counselling to be scheduled; and
  • some individuals prefer the anonymity of an online counselling session.

An employee with a chronic or long-standing mental health problem may need a more holistic package of psychological therapies, and it is likely that a number of different specialist services will be involved in his or her treatment, in addition to the employer's occupational health service and EAP.

Building resilience

The business case for building employee resilience as part of an organisational approach to managing mental health is clear: resilient employees are better able to maintain their performance at work, even under pressure. However, it is important for employers to remember that in many instances stress and distress are symptomatic of much wider systems problems. Resilience training must not replace looking for and correcting these problems.

Resilience training can help employees to:

  • be more flexible about organisational change;
  • adopt a "can-do" attitude and be more optimistic about their future at work; and
  • remain calm under pressure and feel less anxious about work and home life.

Training individuals and teams to become more resilient as part of a programme to protect and promote mental wellbeing is an expanding area of work for HR departments. Many resilience training courses aim to foster employees' ability to adapt and be flexible during periods of organisational change and to recover quickly. Resilience programmes are particularly important where change has the potential to undermine confidence and morale in the wider workforce. Resilience training emphasises the importance of employees maintaining a sense of purpose at work and a positive outlook in the face of hurdles and setbacks.

Employee assistance programmes can offer a source of guidance and training in the resilience field and provide access to specialists from a number of disciplines who can deliver targeted support to the organisation and individuals. Some employers are developing coaching tools so that employees can self-manage aspects of mental health. For example, mindfulness therapy has emerged in recent years as a technique to help employees maintain mental wellbeing, particularly during periods of pressure and organisational change. Proponents argue that, if employees can be more mindful of their own emotional responses and reactions to workplace events, they will swap negative behaviours, for example resistance and fear, for more positive interpretations. Mindfulness is a way of helping employees accept that there are aspects of life and work - including potentially stressful ones - that they cannot change.

Encouraging disclosure about a mental health condition

Many people are reluctant to disclose that they have a mental health condition, so they may not give the real reason for a period of absence, particularly where the absence is short term and does not require a fit note. Mental ill health is always a sensitive issue for the individual concerned, but most employees welcome an open and honest approach from their manager. Managers should have regular catch-up sessions with all their staff. In discussing how employees are feeling, they should use simple non-judgmental questions to help them to spot signs of trouble early and make it easy for employees to talk openly. By building a good rapport with their staff, managers will make it easier for employees to disclose a mental health problem.

Mental health and employee performance

The relationship between staff performance and mental health is complex. It is often wrongly assumed that all mental health problems lead to underperformance, and at the same time health needs are often not properly explored when an employee is perceived to be underperforming. The management of the performance of any employee with a mental health problem must be conducted in a positive and supportive way.

If an employee's performance or behaviour is suffering as a result of poor mental health, this needs to be addressed at an early stage. The onus is on managers to make the first move in encouraging the disclosure of a problem if they suspect that an issue in relation to behaviour, performance or attendance could be related to mental ill health. Line managers should not try to diagnose conditions or assess how symptoms might affect job performance. Employees should have access to a GP or other medical expert who can diagnose and treat their condition. Line managers should work with HR, medical professionals and the occupational health department to provide support.

Making timely referrals to occupational health

Referrals by managers to the occupational health service are likely to be triggered in a number of circumstances, including where:

  • the manager is concerned that a change in the employee's behaviour may be related to an underlying mental health problem;
  • the manager is concerned that the employee's sickness absence relates to a mental health problem;
  • the employee is experiencing a mental health problem that may be work related; or
  • the manager is concerned that the employee is exposed to a situation at work that may be affecting his or her mental health, for example difficult relationships with colleagues.

Where an employee discloses a mental health problem to a line manager, the manager should, in the first instance, encourage the employee to consult his or her GP. The manager should also ensure that the employee is aware of any support available through work, for example from the employee assistance programme (EAP) or via a referral to the occupational health service.

Organisations that do not have their own occupational health service or EAP can access the free Fit for Work advice line and online resources for help in supporting employees when they experience mental ill health.

Early referral of individuals with a mental health problem to appropriate medical and/or other specialist services can help to prevent them taking sick leave. Therefore, it is vital for HR to ensure that managers have the right tools and guidance to make this process effective. Managers should be made aware of the following points:

  • Referrals should be made as early as possible and as soon as the manager becomes worried about an employee.
  • The manager should ask relevant questions of the occupational health team when making a referral, for example about the individual's fitness to carry out particular tasks or his or her prognosis for a return to work (if the employee is absent).
  • The manager should provide background information to the occupational health service to make the referral as effective as possible, including information on the employee's job role, any workplace adjustments already in place or attempted, whether or not a disciplinary or performance management process is under way, and whether or not there are any problems relating to the individual's relationships with colleagues at work.
  • The manager should discuss the advice received from occupational health with the employee, as a precursor to building an action plan to help them remain in work or return to work.

Employers should encourage managers to seek expert advice if they feel unsure about a particular case or if it is particularly complex. Managers should be able to obtain helpful advice from internal sources such as occupational health and HR and external organisations such as mental health charities.

The feedback from the occupational health service following a referral tends to focus on recommendations and advice about whether or not the health problem is likely to have an impact on the employee's fitness to carry out his or her role. If the employee is absent from work, it should also give some idea about how long the absence is likely to last.

Line managers, HR and occupational health must ensure that personal data, including information about individuals' health, is handled in accordance with the organisation's data protection policy. In fulfilling its role, occupational health may need to liaise with employees' medical practitioners. The organisation should have a consistent approach for when a medical report will be requested and who will request it, and how. For more information see How to > How to obtain and use medical reports on employees.

Case management

Organisations should use a case management approach to support employees with a mental health problem to return to, or stay in, work. A case management approach involves key sections of the organisation, for example line managers, HR and occupational health, monitoring the employee's situation and requirements, and liaising with one another about appropriate actions. The employer will need to tailor its approach to the employee as each individual's experience of mental ill health and his or her coping mechanisms will be unique. Where possible, each case should be handled by a consistent group of people from within the organisation, for example a single case manager who will coordinate all actions, and the same HR contact and occupational health practitioner.

Maintaining contact with an absent employee

Keeping in contact with any employee who is off work on long-term absence is important, but is particularly vital in the case of an individual who is absent due to a mental health condition. Maintaining contact can help to prevent the individual feeling isolated.

The HR function should make clear to employees, through the organisation's sickness absence policy and procedures, that employees have a responsibility to stay in contact with the organisation while off sick. Employees should understand that, if they reject reasonable efforts by the employer to contact them, the organisation cannot be expected to be aware of a health condition, or to make adjustments on their return to work. However, there should be flexibility in the policy around the frequency of contact, as what is appropriate where an employee is absent due to a mental health problem may differ from what is appropriate where an employee is absent with a physical illness.

The HR function should encourage line managers to keep in touch with absent employees, setting out the rationale for the policy and emphasising that staying in contact with people who are off sick due to mental ill health can be a starting point for their eventual rehabilitation and return to work. Employees should have the opportunity to be contacted by the HR department or another nominated individual rather than by their line manager where appropriate, for example in cases where the employee perceives that the line manager is a contributing factor to his or her ill health. The organisation and employee should agree a method of communication; an employee who is absent due to a mental health problem may prefer to communicate via email rather than over the telephone or face to face. Home visits can be used, for example where occupational health need to assess the employee or the employee requests a visit, but a risk assessment should be carried out beforehand.

The line manager (or nominated individual) should open a dialogue with the absent employee as soon as possible following his or her absence from work. Contact should then be maintained throughout the employee's absence. The line manager should view this as an opportunity to tell the employee about work issues and to reassure the employee that the organisation will support them during the absence and return to work. The line manager should let the employee know about any support that is available, for example via an employee assistance programme or occupational health service, and gain the employee's permission for individuals involved in these services to get in contact. Employees should not be contacted by other colleagues about work-related issues during their absence, nor be expected to check work emails or voicemail. A record should be kept of all contact with the absent employee.

Employers may need to adopt a slightly different approach to maintaining contact with an employee who is experiencing a serious mental health problem. Electing to maintain contact with the employee through a representative may be the most effective approach.

Colleagues are often unsure if it is acceptable to ask how someone absent due to mental ill health is doing - however, just as with a physical health problem, most people in these circumstances appreciate enquiries about their wellbeing. The manager should take on board what the absent employee wishes the employer to convey about his or her sickness absence to colleagues.

Action plans

It is vital that an employee's return to work is managed well. A lack of support from the line manager, and poor communication between the manager and employee, are the most frequently cited barriers to an effective return to work.

The development of an action plan, prior to the employee's return to work, should help reassure the employee that his or her needs will be met. This typically involves assembling a multi-disciplinary team, including the employee, his or her line manager and any specialist treatment agencies. Even where the discussion is with another nominated individual, the line manager will need to agree the action plan where they will be responsible for any adjustments agreed. The organisation should be guided by the employee on when they wish to return to work, and put in place any reasonable adjustments to support this. An early return to work can help in the rehabilitation of employees who are not yet 100% fit, and employers should seek to facilitate this through practices such as phased returns to work.

The action plan should address the employee's health needs both on their return to work and on an ongoing basis. It should include agreed steps for the employee and manager to take, for example return-to-work adjustments and ongoing support, and should be reviewed regularly. A clear action plan helps prevent misunderstandings by setting out expectations, for example a realistic timetable for a return to normal duties.

It is important that the action plan is flexible - mental health conditions can fluctuate, and recovery does not always follow a steady path. The line manager needs to be patient and, if necessary, adjust the employee's workload to help ease them back into work, for example by allocating fewer tasks or allowing longer deadlines. The manager should continue to support the employee well beyond the first couple of weeks after their return to work. HR and the occupational health service may need to provide advice and guidance to managers to support them in monitoring the health and wellbeing of returning employees (see Training line managers).

Adjustments at work

The action plan should cover any adjustments that the employer is prepared to make to facilitate the employee's return to work. This should be underpinned by an honest dialogue between the parties involved in building the action plan about what the organisation can and cannot change in terms of the employee's job and tasks.

Mental health problems can fluctuate, or be episodic, so it is important for the employer to be guided by the individual experiencing the problem. It should explore the employee's specific needs with them and be as creative as possible when thinking about how to address those needs. The employer should make clear to the employee if certain adjustments are being made to facilitate a return to work and will not be in place permanently.

Adjustments for employees with mental health problems are often simple, practical and cost effective. Adjustments to work organisation include:

  • flexible hours or different start/finish times (for a shift worker, not working nights or splitting up days off to break up the working week);
  • a change of workspace, for example a quieter or in some cases busier working environment;
  • working from home (although it is important to have regular phone catch-ups so the employee remains connected and does not feel isolated);
  • changes to break times;
  • provision of a quiet room;
  • a light-box or a desk with more natural light for someone with seasonal depression;
  • a phased return;
  • relaxing absence rules and limits around disability-related sickness absence; and
  • agreement to give the employee leave at short notice and time off for appointments related to his or her mental health, such as therapy and counselling.

Changes to the role itself include:

  • the reallocation of some tasks;
  • changes to the employee's job description and duties;
  • changes to targets or objectives; and
  • changes to aspects of work that may trigger a mental health problem, such as reducing the amount of time spent on public-facing activities.

If it does not prove possible to return the employee to his or her original role, it is vital to involve the employee in a discussion about practical alternatives, which may include a transfer to a different role or relocation within the organisation. Managers must use the organisation's agreed procedures to manage these more complex cases, drawing on HR and occupational health advice.

Practices to support employees returning to work include:

  • increased supervision or support from the manager, for example monitoring of workload to prevent overworking;
  • extra training, coaching or mentoring;
  • extra help with managing and negotiating workload;
  • more feedback;
  • debriefing sessions after handling difficult calls, customers or tasks;
  • a mentor or "buddy" system (formal or informal);
  • mediation, for example where there are difficulties between colleagues;
  • access to a mental health support group or disability network group;
  • information on internal support available for self-referral;
  • identifying a "safe space" in the workplace where they can have some time out, contact their buddy or other sources of support, and access self-help;
  • provision of self-help information and the sharing of approaches and adjustments that have been effective at supporting others;
  • encouragement to build up resilience and follow practices that support good mental health, such as taking exercise, meditating and eating healthily;
  • encouragement to be more aware of their mental state and reflect on the factors in the workplace that affect it; and
  • providing regular opportunities to discuss, review and reflect on their positive achievements to help build self-esteem.

Returning to work after mental health absence can be very difficult for employees; HR and managers should ensure that people in this situation feel comfortable and, in particular, do not face unrealistic demands or a huge backlog of work on their return. Managers need to ensure that there is plenty of time for informal conversations about progress; an "open door" approach should help employees to feel comfortable discussing their situation.

Example action plan for an employee's return to work following mental health related absence
Issue Employee commitment Manager action
Set date for return. Meet manager or nominated individual to agree date.

Ensure that the initial meeting with the employee is informal.
Ensure that HR is provided with a record of any discussions with the employee.
Liaise with other colleagues in a case management approach.
Suggest phased return to work with flexibility.

Hours of work. Consider alternative hours of work.

Agree start and finish times but retain flexibility.
Agree break times.

Supervision and support on return. Allow people to support me.
Attend supervision sessions.
Listen to my own advice.
Build the employee's confidence and trust through an "open door" communications approach.
Reassure the employee that there will not be too much pressure, and that support is available.
Workload. Learn to say "no" to work overload. Allocate achievable tasks and consider reallocating some of the employee's duties on a temporary basis.
Be flexible about what the employee will achieve initially and do not fix rigid deadlines for performance improvements immediately.
Training needs. Discuss training needs and participate in any agreed training provision. Seek guidance from HR if the employee is not able to return to normal duties.
With HR's support, identify any training needs for the employee to enable such a return.
Work-related excess pressure. Identify sources of excess pressure and stress and discuss with my line manager. Assess potential risks to the employee's mental health.
Talk to the employee about what generates stress at work.
Monitor and evaluate the return. Tell the manager about what parts of the action plan are working and any that are less successful.

Keep in touch informally with the employee through catch-ups.
Set aside specific supervision sessions to discuss the rehabilitation plan more formally.
Review adjustments and whether or not they need to continue.

Training line managers

Managers play an important role in supporting good mental health in the workplace, in particular helping employees with mental health problems to stay at work or return to work after absence.

Training should help line managers to spot the common signs of mental ill health and to identify employees who are struggling with their mental health. Training should cover how pressure can tip over into negative stress and other work-related problems, for example poor performance. It should guide managers on how, and at what point, to seek specialist help if they cannot deal with an individual with a mental health problem, or do not feel confident or comfortable in managing the issue.

Training line managers in mental health at work is likely to lead to:

  • greater confidence among managers in approaching employees to offer early support at work;
  • more effective and timely referrals to occupational health or other specialist services;
  • more effective management support for individuals who are absent with a mental health problem;
  • less stigma about mental ill health at work; and
  • a reduction in absence due to an increased ability to keep employees well at work.

The following areas should be covered in an employer's training provision:

  • Being aware of the potential triggers. Training managers to recognise mental health problems and support staff will help maintain employee wellbeing. Managers should be alert to the work-related factors that can adversely affect employee mental health, see Environmental risk factors.
  • Identifying mental ill health. Line managers who know their staff and regularly hold catch-ups or supervision meetings to monitor work and wellbeing are well placed to spot any signs of stress or mental ill health at an early stage. Often the key is a change in typical behaviour. Symptoms will vary, as each person's experience of mental ill health is different, but there are some potential indicators to look out for, as given in the table below. However, if one or more of these signs is observed, this does not automatically mean that the employee has a mental health problem - it could be a sign of another health issue or something else entirely. Training should stress that managers must always take care not to make assumptions, and talk to employees directly.
  • Mental health first-aid training. This is designed to help managers intervene to prevent or deal with a crisis situation at work involving an employee with a mental health problem, for example when an individual may be a danger to themselves or others. Mental health first-aid courses also cover dealing with panic attacks, acute stress reactions and medical conditions such as schizophrenia.
  • Absence management and referrals. Training managers to hold difficult or sensitive conversations with employees will help them to manage absence and specialist referrals in relation to employees experiencing poor mental health. This training needs to focus on making such discussions open and positive, so that both parties can explore issues freely. The training should emphasise that the employer does not expect managers to perform the functions of a doctor, but that they should understand at what point to involve HR or occupational health professionals.
  • Return to work. Managers need to understand the importance of keeping in contact with absent employees who are experiencing a mental health problem, the value of a well-designed action plan for return to work, the legal and practical issues around adjustments at work and the benefits of a case management approach to rehabilitation.
  • Supporting day-to-day wellbeing. Organisations need to equip line managers with the skills to support the wellbeing of employees, particularly during periods of significant organisational change, for example during a redundancy programme. Managers must have the tools to break unwelcome news sensitively and prepare for the possible psychological impact of this news on employees. Managing the wellbeing of team members should not be a separate activity but part of line managers' everyday responsibilities. HR should develop training to boost the management competencies that help to reduce psychological harm at work, for example managing emotions, communicating on work issues and managing difficult situations.
Signs and symptoms of stress or mental ill health
Physical Psychological Behavioural
  • Fatigue
  • Indigestion or upset stomach
  • Headaches
  • Appetite and weight changes
  • Joint and back pain
  • Changes in sleep patterns
  • Visible tension or trembling
  • Nervous trembling speech
  • Chest or throat pain
  • Sweating
  • Constantly feeling cold
  • Anxiety or distress
  • Tearfulness
  • Feeling low
  • Mood changes
  • Indecision
  • Loss of motivation
  • Loss of humour
  • Increased sensitivity
  • Distraction or confusion
  • Difficulty relaxing
  • Lapses in memory
  • Illogical or irrational thought processes
  • Difficulty taking information in
  • Responding to experiences, sensations or people not observable by others
  • Increased suicidal thoughts
  • Increased smoking and drinking
  • Using recreational drugs
  • Withdrawal
  • Resigned attitude
  • Irritability, anger or aggression
  • Over-excitement or euphoria
  • Restlessness
  • Lateness, leaving early or extended lunches
  • Working excessively long hours
  • Intense or obsessive activity
  • Repetitive speech or activity
  • Impaired or inconsistent performance
  • Uncharacteristic errors
  • Increased sickness absence
  • Uncharacteristic problems with colleagues
  • Over-reaction to problems
  • Risk-taking
  • Disruptive or anti-social behaviour

Case studies

Read about the mental health initiatives implemented by three organisations in our Case studies tool:

Key references

Promoting mental wellbeing at work, NICE public health guidance 22
Work and mental health, Royal College of Psychiatrists
Centre for Mental Health
Time to Change initiative
Mind
Business in the Community Workwell initiative
Managers' guide on supporting workplace mental health, NHS Employers
Thriving at Work, The Stevenson/Farmer review of mental health and employers, October 2017
Workplace Wellbeing Index, Mind
Employee Outlook, July 2016, Focus: Mental health in the workplace, CIPD

Trends in workplace wellbeing

In January 2017 the Prime Minister commissioned an independent review into how employers can better support the mental health of all people currently in employment, including those with mental health problems or poor wellbeing, so that they remain in and thrive at work. The Thriving at Work review into workplace mental health was led by Lord Dennis Stevenson and Mind CEO Paul Farmer CBE.

Drawing on the accounts of more than 200 employers, people with mental health problems and leading experts in mental health and work, Thriving at Work sets out core principles and standards to which all employers should commit. It highlights employers that are taking positive and innovative steps to support the mental health of their employees.

The reviewers are calling on all employers, regardless of size or industry, to adopt six "mental health core standards" that lay the basic foundations for an approach to workplace mental health. These cover mental health at work plans, mental health awareness for employees, line management responsibilities and routine monitoring of staff mental health and wellbeing. Large employers and the public sector are expected to go even further, demonstrating best practice through external reporting and designated leadership responsibility: