JUNE 2002 STATE REPRESENTATIVE — 166TH DISTRICT DISTRICT OFFICE: CAPITOL OFFICE: Prescription assistance program for Medicare recipients Several pharmaceutical companies have created aindividuals and $38,000 for couples, and not be eligibleprescription drug assistance program for Medicarefor any other prescription assistance, includingrecipients who earn too much to
White paperRecognising and managing mental health issues at work
The rationale for training and evidence of effectiveness Introduction
This paper develops some of the rationale for the effectiveness of training employees in the recognition and management of mental health issues and then explores available evidence in this area.
This is not an academic paper, although references and further reading areprovided to facilitate a more detailed exploration of the issues if required.
The training approach discussed is that developed by Andrew Buckley, and colleagues, of Kipepeo. Kipepeo is a consultancy firm that offers training and consultancy to help organisations manage the mental well being of employ-ees. This approach is primarily aimed at the non-specialist manager both the line and support, such as HR. The focus of the training is on deciding what to do in a workplace setting rather than any attempt to decide what is wrongwith the employee showing signs of dis-stress. No prior knowledge is needed The issues arising from the mental health needs of employees is a topic that has only come to the forefront of thinking over relatively recent years. The knowledge base is continually growing. It is the intention of the author thatthis document will be periodically updated. This revision was completed in Background
The cost to the nation of mental ill health has become increasingly well docu-mented. The sum of many billions of pounds is quoted. For organisations,large and small, the costs include absenteeism, long-term sickness, earlyretirement, recruitment and the less tangible, or readily measurable, costs ofloss of productivity, poor decision-making and mistakes.
Thomas and Secker suggest a three-pronged approach to helping organisa-tions reduce the costs of mental ill health at work and, at the same time, ben-efit the individuals struggling with issues (Grove, Secker and Seebohm 2005:123).
Primary prevention – focuses on creating a healthy workplace and in-cludes stress reduction and awareness.
Secondary prevention – primarily about job retention and includes earlyrecognition of problems and prompt action. Key to this is the ability ofmanagers to recognise and manage possible problems as they arise.
Tertiary prevention – manages those employees who have become illand, usually, need the services of the health professional. Return towork, either in the employees’ previous role or in new employment, andemployment placements, sit here.
The training interventions, developed by Andrew Buckley and colleagues atKipepeo, have a primary focus on secondary prevention with overlap to bothprimary prevention and tertiary prevention.
Benefits of training in the recognition and management of mental
health issues in the workplace
The benefits that may result from training in the recognition and manage-ment of mental health issues in organisations sit in four categories: Tel: 01263 862286
Reducing retirement/redundancy on medical grounds Improving and maintaining productivity Overall increase in staff well being resulting in a more healthy and Helping people gain a realisticunderstanding of mental health It is at the team level that the effects of mental health problems are seen on a day-to-day basis. By helping managers and supervisors take a more activerole in the recognition and appropriate management of emerging issues the Accepting and compensating for the normal emotional ups and Knowing how to approach an employee appropriately to offer early help and accommodate with minor adjustments Understanding how to facilitate a referral to specialist support (in Supporting the rest of the team and creating a sense of caring for the Early intervention, which increases the likelihood of a speedy return Early intervention, which facilitates the involvement of the clinician at A sense of being cared for and understood A reduction in feelings associated with possible stigma and the fear Changes in perception of mental health within the culture of an individual or-ganisation with benefits of; Increased diversity in recruitment practice – it can be beneficial to employ someone with a history of mental health problems Changes in the relationship with psychological issues results in a more balanced and reasonable response to emotional issues at work,including work related stress, personal life issues etc.
An acceptance of the normality of life’s ups and downs (even when the “down” is very down) allows for a balanced response that meetseveryone’s needs, those of the organisation, team members and col-leagues, and the individual Taking a wider focus with training, incorporating the needs of the individual,their colleagues and the organisation as a whole, leads to a wide range ofbenefits that is not solely limited to helping a sufferer return to normal func-tioning, the most common focus.
cuses on helping the personsuffering.
Focusing training on all three areas leads to wide benefits,
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including benefits to society as a whole
Training can, broadly speaking, be approached by focusing on the medicalmodel of illness definitions or by taking a less formal psychosocial approach.
A brief summary of these two approaches follows.
The Medical Model
The medical model, or bio-medical model, of mental illness promotes the view that problems are an illness similar to any physical problem. At the core of the medical model are definitions and categories of disorders that can be used to link an individual with a named disorder. This is exemplified by theDSM IV (Diagnostic and statistical manual of mental disorders, fourth revi-sion, American Psychiatric Association 1994) and ICD 10 (World Health Or-ganization 1994) with lengthy and complex lists of diagnostic criteria. Thismodel of mental illness helps the clinician categorise and then choose treat-ment for patients who present with symptoms.
The medical model fits most closely those patients whose symptoms areclear and unequivocal. Normally this is the more seriously affected individual,so the medical model fits best in those people seen by a psychiatrist, or oth-er clinician, in secondary mental health care. There is an argument that saysthat the place for the rigid and detailed classification is best left for the use ofresearchers who need the clarity offered to aid the investigation of mentalillness. General practitioner, Dr. Carole Buckley suggests “for practical andclinical purposes it is often most useful to use a descriptive approach andleave the formal classifications for research purposes (Buckley and Buckley,2006: 183).
The validity of the medical model decreases the further away that one goesfrom the medical treatment of the more severely affected individuals.
The Social Model
The social model of mental illness, sometimes called the bio-psycho-social model, emphasises a continuum of behaviours from “normal” through to “abnormal” (i.e. the mentally ill) and links the individual’s place in society with their physiology and individual psychology. The interplay of behaviours, feel- ings and changes in physiology, leads to dis-stress for the individual and,potentially, difficulties for those around him or her.
The often complex relationship between those that subscribe to the medicalmodel and those that do not, both within the medical profession and outside,is a subject in itself. There are those who take an anti-psychiatric view ofmental illness. Szasz, Glasser and Lynch, amongst others, take the view thatmental illness does not exist (Szasz 1974, Glasser 2003 and Lynch 2001).
There is some validity in this to the extent that mental illnesses are both so-cial constructs (Snyder and Lopez 2005: 15) and inventions to meet theneeds of diagnosis, even with modern methods of examining brain functionthere are few objective tests available for the clinician.
Every human being has a view of mental illness, not just the “experts” work-ing in the field. Often pejorative terms start to be used in the playground,films, TV, and the media all impact on the view that employees take of whatmental health and mental illness means to them.
The rare but horrific instances of murder being committed by a “so called”paranoid schizophrenic and reported instances of successful suicide by aworker “who had everything to live for” further impact on the views that manyhold of mental illness as a scary subject that is best avoided.
With such a complex territory providing an education programme that chang-es behaviour and benefits all is a challenge.
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Approaches used in mental health awareness training
Training under the umbrella term mental health awareness is called for bymany commentators to aid with the management of mental health issues inthe workplace.
“Mental Health in the Workplace” (The Mental Health Foundation 1999) calls for specific training for personnel managers and health education for the workforce. The Action on Stigma campaign has both training and aiding an understanding of mental health issues as two of the five workplace commit- ments being promoted (Dept. of Health 2006). Feedback to SHiFT after the initial consultation for the Action on Stigma campaign has awareness trainingfor employees as one of the requests for support.
Both the social model and the medical model of mental illness are used inmental health education programmes.
“How Can We Make Mental Health Education Work?” (Rethink 2004) de-scribes the two primary models used to explain mental health issues andhighlights the need for clarity of approach in any training.
Before signing up to any training initiative most people will want to havesome faith that the approach used is likely to be effective. “Evidence basedpractice” is a phrase that has moved out of the medical world into other are-as. When the evidence base is limited, as with mental health awarenesstraining at work, care needs to be taken to look under the surface of headlineresults for the detail before deciding on a suitable strategy.
Evidence to support training in how to support employees with clear or possi-ble mental health issues falls into two categories.
Evidence of changes in perceptions and behaviour The business case evidence;
An increasing number of primarily large organisations have the evidence thatthe costs of mental health support, wellness campaigns andprotocols/strategies that underpin this, is giving real financial benefit, andhelping achieve a variety of business objectives.
British Telecom, the Royal Mail Group and Astra Zeneca have all publishedthe benefits they have found from their programmes.
An outline of the programme and the results of the British Telecom pro-gramme “Mental Health at Work – A Business Issue” was presented to dele- gates at some of the regional consultation days for the Action on Stigma programme. The results of their approach include a reduction in mental health sickness by 30%, 70% of long term absentees returning to their own job and medical retirement rate for mental illness down by 80%. These im- pressive results show clearly the business benefits of tackling the issues ofmental health at work.
Central to their strategy are education (to dispel myths), concentrating on thecommon mental health problems and de-medicalising the issues. Mentalhealth issues are kept mainstream and practical tools are provided for peo-ple and managers.
Central to the BT approach is the line manager and their ability to proactivelysupport staff that show early signs of dis-stress.
Glaxo Smith Kline have a broadly similar programme across the companythat has demonstrated similarly impressive business benefits. To them thesuccessful inclusion of line management in the process of helping those em- ployees with mental health issues is central to success.
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Changes in perceptions and behaviours;
Other studies have focused on before and after measures of those beingtrained. They have looked for evidence that the training has had the desiredbenefit of changing the behaviour of the trainees.
The Kent Mental Health Awareness in Action programme used an approach based upon social model principles although using medical language to ac- knowledge the “labels” given to different “types” of mental health problems (Rethink 2004 for a summary, Pinfold et al 2005 for the complete results).
This study shows benefits in normalising, and hence reducing stigma, ofmental illness. Two of the many points made are: firstly that “the story” astold by service users is important and secondly that developing the skills andconfidence to work with people in distress is needed to have any lasting ben-efit.
Mental Health First Aid, a range of programmes developed in Australia, hascompleted a number of trials to assess the value of their work. This trainingtakes a medical model approach, focusing on four primary categories ofmental illness.
A randomised control trial of a study of their training in a workplace setting headlines with the benefits of the programmes in improving the mental health literacy of attendees. One benefit, though, seems to have been a marked increase in the ability of attendees to recognise the more serious problem of schizophrenia, whilst the ability to recognise depression increased only slightly from a high base level. The combined figures, however, for the rec-ognition of depression and schizophrenia, give an impressive result. The rec-ognition of depression was already very high before the training and in thecontrol group (Kitchener and Jorm, 2004).
It is worth mentioning that the approach taken by BT that has been influentialin showing the business benefit of training and the training developed byKipepeo focuses on non-medicalising the issues and emphasises the actionsneeded to help the majority of employees who present with the more minormental health issues (from a medical perspective) that are prevalent in theworkplace.
A further study assessed the training of a group of Scottish teachers aimed at helping them recognise students who are suffering from depression. This training seems to have a medical model approach and reports using medical language as one key message “it is important to note that the model of de- pression taught in the educational package was based on psychiatric con-cepts”. The headline results summary states “Systematic evaluation showedthat training teachers with this package did not improve their ability to recog-nise their depressed pupils.” (Moor et al 2007).
This training was very brief, 2 hours, and may point to the difficulty of balanc-ing the need to give enough training and evidence to allow those attending tobecome familiar with the terms, concepts and wider issue when medical lan-guage is used.
A study by Lam and Salkovskis found that using the biological (medical)model of mental illness resulted in a significantly more pessimistic individualthan those using a psychological explanation of the conditions of anxiety anddepression (Lam and Salkovskis 2007).
There is a further pointer to some potential difficulties, or lost opportunities,when the medical model is used to underpin the training. In a study called“Beliefs about essences and the reality of mental disorders” there were sig-nificant differences in the beliefs of experts and non-experts around mental illness and this highlights the implications when trying to offer explanations ofmental health conditions to the lay person (Ahn et al 2006).
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As yet there appears to be no specific research evidence published that ex-plores the benefits, or not, of a non-medical approach to training. The availa-ble evidence of the benefits gained by businesses, though, seems clear thata non-medical approach has the potential to provide substantial benefits tothe organisation and help those employees who are suffering.
Summary of benefits and evidence
There is a clear business need to address the issues of employees withmental health problems.
The ability of line management to actively and comfortably identify andtake action when an employee shows the early signs of mental ill healthis central to the organisational benefits.
Early recognition is key to helping the individual suffering.
A non-medical approach to training is central to the training offered aspart of “business case” evidence.
A medical approach to training shows benefit in some studies and nobenefit in others.
A medical approach to training has been shown to potentially complicatethe issues and possibly place barriers in the way of people approaching mental health issues in a positive and helpful way.
The overall philosophy of our approach to training is the message that men- tal health issues, psychological problems and mental illness are just a nor- mal part of everyone’s life. As with any illness or work related issue effective, early and appropriate interventions will benefit all, the organisation, the team their bit to support a swift re-covery and return to normal A lack of understanding or an unnecessarily complicated approach can present barriers to effective management. The key is to allow everyone in-volved to be able to take a balanced approach to any emerging issue. Wait-ing for a crisis and then hoping that the Doctor or other specialist can solvethe problem helps no one.
Every organisation, team and individual will be best served by a flexible andindividual approach.
Summary of training options:
Awareness raising seminars. Brief seminars to raise the awareness ofmental health issues at work and to enable those attending to under- stand that there are options that will benefit the organisation and the in-dividual.
Half-day training. Ideal for all managers and supervisors who need tohave straightforward guidelines on how to recognise possible problems, talk to the individual and manage the situation.
Full day training. A more in-depth training option for key personnel cov-ering the recognition and management of mental health problems. Ideal for those managers with specialist responsibility such as HR who aremore involved in case management and overall organisational benefit.
Team training - teams and work groups come together (not just manag-ers) to learn how to recognise when a colleague is struggling and whatto do. What to do to offer support and what to do when expert help isneeded.
All the training options can be personalised to the needs of the individual or- ganisation. Providing the training that meets the needs of the organisation,the culture, working environment and issues is vital to facilitating any long Tel: 01263 862286
term benefits for those individuals struggling and the wider needs of the or-ganisation.
Train the trainer courses are in development and it is hoped to be able toprovide an effective e-learning package in due course.
Course content; an overview of philosophy.
Whilst the ability of managers, and others, to take steps to help an employee showing signs that may indicate a mental health issues is important it is rare- ly central to management tasks. All managers will have more pressing busi- ness issues that remain the primary focus of their work.
Training needs to be simple, cost effective and focused on benefiting all Those issues called minor mental illnesses cover the vast majority ofcases faced at work.
Supporting staff through life’s ups and downs is the responsibility of eve-ryone, not just specialist or expert services.
Illness definitions and medical terms are best left to the clinician involvedin treatment.
The use of medical terminology by the non-clinician is best avoided.
Use of video case studies provides an understanding of the signs to beaware off and how to question.
The focus is on “What to do?” not “What is wrong?” What to do? As a goal means that terminology, diagnostics and complexprinciples are avoided.
Jargon free content and avoidance of medical terminology removes thepotential issue of training managers to be “amateur psychologists”.
“What to do” ranges from just supporting an employee through to urgentreferral to the medical profession.
Keep it simple, straightforward and pragmatic.
Take into account the needs of everyone before deciding what to do.
At Kipepeo we have developed a straightforward and memorable set of train-ing interventions that have the goal of actively promoting the abilities of man-agement to handle those times when an employee is struggling and to lookfor an outcome that benefits both the individual and the organisation.
We are all influenced by men-tal health problems.
Mental ill-health and mental illness affects everyone in one way or another.
Supporting all members of society through life’s ups and downs, whether this is a temporary or a more long lasting problem benefits the individual, their friends, family and colleagues, employers and the nation as a whole.
The workplace is an important focus for the majority of the adult population, so, investing in skills training for managers helps the organisation and the Organisations can see considerable rewards from supporting and managingmental health issues at work both to the effectiveness of the organisationand the benefit of the individual suffering.
Ahn W-K. Flanagan E.H. Marsh J.K. & Sanislow C.A. (2006). Beliefs aboutessences and the reality of mental disorders. Psychological Science, 17, Tel: 01263 862286
American Psychiatric Association. (1994). Diagnostic and Statistical manualof mental disorders (4th ed.). Washington, DC: American Psychiatric Associa-tion.
Buckley A. & Buckley C. (2006) A guide to coaching and mental health, therecognition and management of psychological issues. London, Routledge.
Department of Health (2006) Action on stigma. Promoting mental health,ending discrimination at work. London. Shift. Available online atwww.shift.org.uk (accessed 05/05/2007).
Glasser, W. (2003) Warning: psychiatry can be hazardous to your mentalhealth. New York. Harper Collins.
Grove B. Secker J. and Seebohm P. (2005) New thinking about mentalhealth and employment. Oxford. Radcliffe Publishing Ltd.
Kitchener B.A. & Jorm A.F. (2004) Mental health first aid in a workplace set-ting: A randomized controlled trial. BMC Psychiatry 2004 4:23.
Lam, D.C.K. & Salkovskis, P.M. (2006). An experimental investigation of theimpact of biological and psychological causal explanations on anxious anddepressed patients’ perception of a person with panic disorder. BehaviourResearch and Therapy, 45, 405-411.
Lynch. T. (2001) Beyond Prozac, healing mental health suffering withoutdrugs. London. Mercier Press.
Mental Health Foundation (1999) Mental health in the workplace. London.
The Mental health Foundation. Available online at www.mentalhealth.org.uk(accessed 05/04/2007) Moor S. Ann M. Hester M. Elisabeth W.J. Robert E. Robert W. & Caroline, B.
(2007). Improving the recognition of depression in adolescence: Can weteach the teachers? Journal of Adolescence, 30, 81-95.
Pinfold V. Thornicroft G. Huxley P. & Farmer P. (2005) Active ingredients inanti-stigma programmes in mental health. International Review of Psychiatry;17(2): 123-131 Rethink (2004). How can we make mental health education work? Rethink.
Available online at www.rethink.org.uk (accessed 05/05/2007) Snyder. C.R. & Lopez. S.J. (2005) Handbook of positive psychology. NewYork. Oxford University Press.
Szasz, T.J. (1974) The myth of mental illness. New York. Harper and Row.
World Health Organisation (1994) International statistical classification of dis-eases and related health problems, tenth revision, (ICD-10), 2nd edition. Ge-neva. World Health Organisation.
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