Mental Health in the Workplace: Tackling the effects of stress

Written by Dr Penny Gray

We wish to acknowledge the help and assistance of the Health and Safety Executive in producing this publication

Contents

• Some facts
• Foreword
• The cost of mental ill-health
• What can give rise to stress at work?
• The early warning signs
  • Indicators of individual stress
  • Indicators of group level stress
• Creating a healthy workplace
  • Preventing or minimising the causes of stress
  • Helping people cope with unavoidable stress
  • Early intervention and support
• Developing a mental health policy
• Employing people with mental health problems
  • The Disability Discrimination Act
  • Equal opportunities
  • Returning to work after a stress-related absence
• References
• Further reading
• Voluntary organisations
• Government support services
• Publication details

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Foreword

Over 25 million people in the UK spend a large part of their lives at work. It stands to reason that a psychologically healthy workforce and a supportive work environment will benefit staff and employers alike. In a Confederation of British Industry (CBI)survey of over 800 companies, 98% of respondents said they thought that the mental health of employees should be a company concern. Similarly, the large majority (81%) considered that the mental health of staff should be part of company policy. Despite their concerns, however, less than 1 in 10 of these companies had an official policy on mental health.

The aims of this booklet are:

• First, to review the effects of stress at work, and those factors in the workplace that can cause or contribute to stress.
  
  
• Second, it will address the ways in which employers can help to create a psychologically healthy work environment, in which the effects of stress are minimised and managed, and employees are supported in using and developing their abilities and potential.
  
  
• Finally, the recruitment and retention of those experiencing mental health problems is addressed, and a list of useful contacts is provided for further information.

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The scale of the problem

Mental ill-health or distress is a major cause of sickness absence from work, reduced productivity and staff turnover. Stress is the root cause of a lot mental ill-health, especially anxiety and depression.

• Work-related stress is estimated to be the biggest occupational health problem in the UK, after musculoskeletal disorders such as back problems.

• Nearly 3 in every 10 employees will have a mental health problem in any one year – the great majority of which will be anxiety and depressive disorders.

• Mental health problems account for the loss of over 91 million working days each year.

• Half of all days lost through mental ill-health are due to anxiety and stress conditions.

Stress is a necessary part of everyday life. Indeed, some degree of stress or pressure is considered healthy. Underemployment can lead to boredom, apathy and a loss of energy and motivation. But conversely, excessive stress can lead to fatigue, impaired judgment and decision making, exhaustion and the onset of serious health problems – both mental and physical.

Physically, stress is implicated in the development of coronary heart disease, certain types of cancer, and a host of other ailments including stomach ulcers, skin rashes, migraine, asthma, and increased susceptibility to infections.

The psychological effects of stress can be just as damaging. Increased anxiety, irritability, disturbed sleep, poor concentration and aggressive behaviour can increase the risk of accidents and disrupt relationships both at work and at home. Individuals under stress are often inclined to smoke more, drink more alcohol, and consume excessive amounts of caffeine, thus increasing irritability, sleep impairment, etc., in a vicious circle. Exposure to prolonged stress will increase the risk of serious mental health problems, including depression and disabling anxiety conditions, as well as alcohol misuse.

Who is at risk?

Anyone can experience stress from their work, depending on the demands of their job, the conditions in which they work, and their individual susceptibility, which can be increased by problems outside of the workplace. In a recent research survey of 270 company line managers, 88% claimed a moderate or high level of stress in their work, which 39% claimed had got worse over the past year. >Just over three-quarters of those surveyed – 77% – thought stress in the workplace ‘will happen to everybody at some time’. Moreover, 52% said they knew someone who had suffered stress severe enough to stop them working and require long-term medical treatment.

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The cost of mental ill-health

Mental ill-health among the workforce exerts a substantial cost from British industry.

• Stress-related sickness absences cost an estimated £4 billion annually.

• Lost employment constitutes 37% of the total cost of mental ill-health in England (£11.8 billion).

• The CBI estimates that 30 times as many days are lost from mental ill-health as from industrial disputes.

There are many other costs in addition to those of sickness absence. Ineffective working and poor interpersonal relations can substantially reduce productivity. Increased staff turnover necessitates recruitment costs. Administrative as well as personal costs are involved in covering for absent employees. Additional costs are incurred when staff take early retirement or medical severance on health grounds.

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What can give rise to stress at work? 

Work on the whole has a beneficial impact on mental health. It gives structure and purpose to the week, opportunities to meet people and make friends, and a means of increasing one’s sense of self-worth and of being valued by others.

In certain circumstances, however, work can cause or contribute to stress and subsequent problems of anxiety and depression. Research has highlighted a number of work-related factors that can negatively affect wellbeing.

• Lack of control over work

• Under-utilisation of skills

• Too high a workload, impossible deadlines

• Too low a workload, no or few challenges

• Low task variety

• High uncertainty, e.g. due to poorly defined roles and responsibilities, lack of clear priorities and targets, job insecurity

• Low pay

• Poor working conditions, e.g. noise, overcrowding, excessive heat, inadequate breaks

• Low interpersonal support, e.g. via inadequate or insensitive management, hostility from colleagues

• Undervalued social position.

No single factor alone is likely to be the cause of someone becoming stressed at work. Stress tends to build up over a period to time through a combination of circumstances, some of which may not be related to work at all. Problems in domestic relationships, money worries, even difficulties in travelling to work can contribute to reducing a person’s ability to cope with stress in the workplace.

If sufficient numbers of staff are affected by stress, however, the problem can become a serious organisational one, manifesting as absenteeism, reduced productivity, increased staff turnover and customer complaints. This becomes a particular risk during times of organisational change, such as restructuring or downsizing, which need to be anticipated and effectively managed if large numbers of staff are not to become disaffected.

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The early warning signs

Most people will experience aspects of stress at work sometimes, and no employer can totally prevent this. However, when an individual or group of employees becomes so chronically stressed that their health and functioning are affected, there will usually be characteristic signs and symptoms. Any of the following can provide clues that something is wrong and an employer needs to take appropriate action to help.

Indicators of individual stress

• Increase in unexplained absences or sick leave
• Poor performance
• Poor timekeeping
• Increased consumption of alcohol, tobacco or caffeine
• Frequent headaches or backaches
• Withdrawal from social contact
• Poor judgment/indecisiveness
• Constant tiredness or low energy
• Unusual displays of emotion e.g. frequent irritability or tearfulness.

Indicators of group level stress

• Disputes and disaffection
• Increased staff turnover
• Increased grievances and complaints.

These can all be signs that stress has built to such an extent that an individual may be in danger of developing more severe anxiety or depression. Effective help in the early stages can help to prevent long-term problems both for individuals and organisations. Clearly this needs to be sensitively handled or the intervention may exacerbate the problem. The emphasis should be providing reassurance and giving the individual the opportunity to talk about how they are feeling and to seek help.

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Creating a healthy workplace

Any employer who wishes to create a healthy work environment for their staff will need to develop policies and procedures to ensure that their approach is systematic and thorough, and its results are tangible. A specific policy relating to mental health at work is advisable. Effective stress prevention and management require tackling the problem at several levels simultaneously.

• Preventing problems by eliminating or minimising stress at source

• Minimising the negative effects of stress via education and management strategies

• Assisting individuals who are experiencing the effects of stress.

Preventing or minimising the causes of stress

Eliminating or reducing sources of stress may be achieved by improving physical working conditions, redesigning jobs, and/or allowing more flexible working arrangements, such as job sharing, job rotation, flexible working hours or the provision of crèche facilities. Changes in personnel policies, e.g. to improve communication, can also be helpful, as can strategic planning to allow more decision-making and autonomy among staff ‘on the ground’, e.g. by encouraging groups of workers to review and recommend changes to system practices to reduce stress.

Since the sources of stress will vary between and even within organisations, these must first be identified by some kind of ‘stress audit’. In larger companies, this might take the form of a self-report questionnaire administered to employees on an organisation-wide or site- or department-specific basis. The most widely used diagnostic tool of this type is the Occupational Stress Indicator (OSI), which includes scales to measure job satisfaction, mental and physical health, coping and support strategies, in addition to identifying sources of stress. Smaller companies may find it more appropriate to develop checklists, which can be administered on a more informal basis, or to organise discussion groups involving small numbers of staff. In either case, the agenda should cover the following issues.

• Work content and scheduling

• Physical working conditions

• Terms of employment and expectations of different employees within the organisation

• Working relationships

• Systems for communication and reporting.

The results can be used as a lever for organisational change and a guide to where resources need to be directed to achieve change in preventing stress. Regular auditing can also provide a means of monitoring stress levels and evaluating the effects of changes in policies and practices at work.

Stress prevention strategies should also involve the development of a supportive work ethos and climate, in which staff can feel free to be open about stress they are experiencing, in the knowledge that they will be helped and supported to deal with their issues. This may require setting up more open communication channels within an organisation, and actively discouraging behaviours that contribute to stress, such as routine late working, taking work home at weekends, and competitive behaviour.

Helping people cope with unavoidable stress

A number of interventions can help individuals to deal with sources of stress that cannot be changed, and thus avoid their negative effects. Such initiatives generally involve skills training and education.

• Stress education and stress management courses can help people to recognise signs of stress and develop their coping skills and resilience.

• There are a wide variety of skills training options under the stress management umbrella, including assertiveness training, leadership skills training, time management skills, interpersonal skills training, and relaxation techniques. These types of courses can be particularly valuable in training managers to recognise the early warning signs of stress in their staff and review their management style and its impact on the people they manage.

Another approach is the direct promotion of positive health behaviours which aim to keep staff fit to cope with the pressures of work. These may include provision of exercise and keep-fit programmes, and the introduction of healthy lifestyle management initiatives, such as health screening programmes, smoking and alcohol cessation programmes, and dietary advice.

Early intervention and support

Early recognition of the signs of stress, anxiety and depression is the crucial first step in dealing with such problems and preventing them from becoming more serious. Most people make a full recovery, often without needing to take any time off work. However, individuals should be encouraged to seek help as soon as possible, via their GP if no workplace programme or occupational health service is in place.

Attention should be given to removing or reducing further sources of stress at work, and supporting the individual through any short-term crisis.

Access to professional counselling services can be an invaluable help in assisting the recovery and rehabilitation of stressed employees, and the number of organisations providing such services is currently increasing. Such services are ideally provided either by an independent outside agency, or form part of a broader employee assistance programme (EAP), which may sometimes be sourced in-house. Counselling programmes such as that introduced by The Post Office have substantially reduced staff absenteeism and other indicators of mental ill-health. EAPs provide information and referral to appropriate support services, including counselling support, for employees and sometimes their family members. Other provisions may include a 24-hour telephone counselling/help line for staff support.

A particular advantage of EAPs is that they can be used to provide feedback to employers, on a confidential basis, about recurring problems within an organisation, thus helping to identify sources of stress and areas of intervention for stress management and prevention programmes.

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Developing a mental health policy 

The Health and Safety Executive recommends that a mental health policy should be an integral part of any organisation’s health and safety policy. Some large companies, such as Marks and Spencer, AstraZeneca and The Boots Company, have developed policies that successfully address the issue of mental health in the workplace. Analysis of such model policies has defined certain key elements of good practice in relation to promoting mental wellbeing at work. As a first step, it seems that organisations need to recognise and accept that mental health is an important issue. Introduction of a mental health policy embodies such an organisational commitment to mental health.

There are three key stages in establishing a mental health policy.

1 Audit

– to provide information on existing levels of stress and mental ill-health within an organisation, and in what ways organisational structure and function may be contributing to these, or otherwise. The process will identify areas for intervention via a mental health policy.

2 Development

– to produce a mental health policy tailored to the needs of an organisation. The policy document may include:

• An introduction, outlining the negative effects of mental ill-health on sickness absence and work performance, and defining the aims and objectives of the policy. Core aims might be to promote mental wellbeing, reduce the stigma associated with mental ill-health, and provide assistance to employees suffering from stress or more serious mental health problems.

• Health, safety and welfare policy of the organisation.

• Human resource policies e.g. on mental health and recruitment, sickness absence and rehabilitation, alcohol abuse.

• Organisational philosophy on health promotion and mental ill-health prevention.

• Draft strategies for stress prevention and management, based on identification of mental health needs via the process of audit.

• Details of staff training programmes, including management training and stress management courses, specific training for personnel managers on mental health, and health education of the workforce, e.g. mental health education within induction training programmes for new employees.

• Descriptions of the roles and responsibilities of employees at all levels of the organisation in respect of promoting mental health, including senior managers, line managers, personnel managers, occupational health services, staff associations and trades unions, and employees (for themselves and their colleagues).

• Details of the processes of auditing, monitoring and evaluation.

• Estimated costs and time schedule for implementation.

Crucial to the success of a mental health policy is that it should be developed by a working group that includes representatives from all levels and sections of the organisation, including personnel/human resource managers, health professionals such as occupational health nurses, physicians or psychologists, senior management, and employee representatives. It should also be applicable to all staff, regardless of age, sex, ethnic origin or grade.

3. Implementation

– to convert the policy into practice throughout the organisation. This relies on the commitment and co-operation of all employees, headed by management at the most senior level. Any mental health policy should be reinforced by regular monitoring and evaluation against performance indicators, such as reductions in sickness absence and improvements in staff satisfaction as demonstrated by regular auditing. Revision of the policy in line with review findings should permit its continual improvement, alongside a parallel improvement in the mental wellbeing of staff.

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Employing people with mental health problems 

There remains a great deal of stigma attached to mental ill-health despite the widespread prevalence of mental health problems. A survey carried out by Mind in 1996 found that of 778 people with mental health problems, 39% said they had been denied a job, 15% had been denied promotion, and 34% had been dismissed or forced to resign because of their illness. A further 38% reported being teased, harassed or intimidated at work, while 69% had been put off applying for jobs because of unfair treatment.

Apart from reducing the employment prospects of people with mental health problems, negative, stigmatising attitudes can be a significant stumbling block to the development and implementation of a mental health policy, and thus to improving the mental health of all employees. In a 1999 research survey of 270 company line managers, 69% said they thought that staff would either be hesitant to talk about feeling under stress, or would not talk about it or ask for help, so their work might suffer. A culture of openness and acceptance of mental distress as a normal part of all people’s lives at some time is thus an essential basis on which to build a workable strategy for improving mental wellbeing among the workforce.

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The Disability Discrimination Act 

The Disability Discrimination Act (1995) may contribute to improving the acceptance of mental health problems. The Act makes it unlawful for employers of 15 or more people to discriminate on the grounds of disability. Disability is defined as

‘a physical or mental impairment which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities’.

Mental impairment in this context refers to a clinically recognised illness such as schizophrenia, manic depression, panic disorder or a depressive condition, while long-term means having lasted, or likely to last, for at least a year.

The Disability Discrimination Act places a duty on employers to make ‘reasonable adjustments’ to prevent disabled job applicants and employees being placed at a substantial disadvantage in relation to others in respect of:

• the physical environment, e.g. buildings, fittings and equipment

• recruitment and selection procedures

• any other aspect of employment, including training, career development and retention.

Many people with mental health problems will not require any adjustments to be made. Often, however, the most difficult aspect of having a disability – physical or mental – is other people’s attitudes. Implementing an equal opportunities policy on disability to cover people with mental health problems, and raising staff awareness about issues of mental ill-health and distress by means of training and a management commitment to a mental health policy, can make a considerable impact on these. Other adjustments may include: opportunities for flexible hours and working arrangements, additional support and supervision, provision of a quiet room, use of e-mail if direct contact is a problem, and allowing a gradual return to work after illness. People with long-term mental health problems may be eligible for help with such adjustments under the Government’s Access to Work Scheme.

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Equal opportunities

An equal opportunities policy that seeks to overcome barriers to recruitment and retention of people with mental health problems is an excellent further step towards overcoming stigmatisation on the grounds of mental health. Job advertisements, application forms and company policy may be used to state and reinforce a commitment to equality of opportunity for those with mental health problems. South West London and St. George’s Mental Health NHS Trust established such a policy in 1997, in line with the Disability Discrimination Act, but including a number of further commitments by the Trust, as follows.

• To identify positions where personal experience of mental health problems actively enhanced a person’s ability to provide mental health care. In these posts, experience of mental health problems was a desirable part of the selection criteria.

• To identify positions where specific accommodation could be made or help given to support people with marked disabilities due to mental health problems to gain and sustain employment. For such posts, experience of mental health problems was an essential part of the selection criteria, and support was offered by a specifically funded user employment project team.

• To establish a system for monitoring the success in recruitment and retention of people who have experienced mental health problems, and progress towards a percentage target of the workforce being mental health service users.

• To include an equal opportunities statement on mental health in its advertisements for posts.

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Returning to work after stress-related absence

Returning to work after a stress-related absence requires careful thought and planning by all parties. Persistent sources of stress will need to be addressed via audit, prevention and management strategies. Ongoing support, particularly in the early stages, can be vital.

Rehabilitation to work after a longer term absence due to stress or other mental health problem will usually be more cost effective than early retirement and recruiting and training a replacement. A return-to-work interview will be useful in determining whether an employee is happy to resume all aspects of their job, or whether they want a phased re-introduction to it, or for some parts of their work to be changed. Follow-up interviews will help to monitor progress. Liaison between the employee, their line manager, and occupational health services, where these are available, will play an important role in the success of a person’s return to work and further years of productive service.

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References

Bird L. The Fundamental Facts... all the latest facts and figures on mental illness. London: The Mental Health Foundation, 1999.

Cooper C, Cartwright S. Mental Health and Stress in the Workplace: a guide for employers. London: HMSO, 1996.

Doherty N, Tyson S. Mental wellbeing in the Workplace. A resource pack for management training and development. Norwich: HMSO, 1998.

Floyd M, Povall M, Watson G (eds.). ‘Mental Health at Work’. In: Disability and Rehabilitation Series 5. London: Jessica Kingsley, 1994.

Grayling. VAR Spotcheck™. Project Feeling. (Mental health awards commissioned report), VA Research Ltd., 1998

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Further reading

Cartwright S, Cooper C. Managing Workplace Stress. London: Sage, 1997.

Doherty N, Tyson S. Mental wellbeing in the Workplace. A resource pack for management training and development. Norwich: HMSO, 1998.

Employers’ Forum on Disability.
A brief introduction to the Disability Discrimination Act, 1996.
Briefing papers: A practical guide to employment adjustments for people with mental health problems, 1998; A practical guide to health and safety and the DDA, 1999.

Kogan H (ed.) The Corporate Healthcare Handbook. London: Kogan Page, 1997.

The Industrial Society. ‘Stress Management’. In series: Managing Best Practice. London: The Industrial Society, 1995.

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Voluntary organisations

• Alcohol Concern

Waterbridge House
32-36 Loman Street
London
SE1 0EE

Tel: + 44 (0) 207 928 7377
Helpline: + 44 (0) 800 917 8282 (24 hours)
Website: www.alcoholconcern.org.uk

Alcohol Concern is the national agency on alcohol misuse, supplying information and details of local services.

• Alcoholics Anonymous 
  

PO Box 1
Stonebow House
Stonebow
York
YO1 2NJ

Tel: + 44 (0) 1904 644 026 (Office Mon-Thurs 9am-5pm. Fri 9am-4.30pm)
Helpline: + 44 (0) 845 769 7555
London helpline: + 44 (0) 20 7833 0022 (10am - 10pm daily)

A fellowship of men and women who share their experiences to stay sober and to help others recover from alcoholism.

• British Association for Counselling
  
  1 Regent Place
  Rugby
  Warwickshire
  CV21 2PJ
  
  Tel: 01788 578328 (24 hour information line)
  Website: www.bac.co.uk
  
  Provides information and advice on counselling and counsellors in the UK.

• CRUSE Bereavement Care
  
  Branches in all areas. Contact via the local telephone directory or Tel: + 44 (0) 208 940 4818. Helpline: + 44 (0) 20 8332 7227 (9.30-5pm Mon-Fri).
  
  CRUSE is a national voluntary organisation offering bereavement counselling and advice to all bereaved people.

• Depression Alliance
  
  35 Westminster Bridge Road
  London
  SE1 7JB
  
  Tel: + 44 (0) 207 633 0557
  Website: www.depressionalliance.org/
  
  Provides information, support and advice for those who suffer from clinical depression and their carers; also a network of self-help groups.

• Manic Depression Fellowship (MDF) 
  
  8-10 High Street
  Kingston-upon-Thames
  Surrey
  KT1 1EY
  
  Tel: + 44 (0) 208 974 6550
  Website: www.mdf.org.uk
  
  A national charity established by and for people whose lives are affected by manic depression. MDF provides a specialist advisory and information service, and has a network of self-help groups throughout the country.
  
  
• Mental Health Foundation
  
  The UK’s leading charity working for the needs of people with mental health problems and those with learning disabilities. We aim to improve people’s lives, reduce stigma surrounding the issues and to promote understanding. We fund research and help develop community services. We provide information for the general public and health and social care professionals. We aim to maximise expertise and resources by creating partnerships between ourselves and others including service users, Government, health and social services.

• Mind (The National Association for Mental Health) 
  provides information and publications on mental health issues and services. Over 200 local Mind associations offer a range of day-care and other services.
  
  Listed in the local telephone directory, or contact via:
  Granta House
  15-19 Broadway
  Stratford
  London E15 4BQ
  
  Tel: + 44 (0) 20 8519 2122
  Website: www.mind.org.uk
  
  
• National Schizophrenia Fellowship (NSF)
  provides information and services for people with a diagnosis of severe mental illness, especially schizophrenia, and their families and carers.
  
  28 Castle Street
  Kingston upon Thames
  Surrey
  KT1 1EY
  
  Tel: + 44 (0) 208 547 3937
  Website: www.nsf.org.uk
  
  
• Relate
  
  Herbert Gray College
  Little Church Street
  Rugby
  Warwickshire
  CV21 3AP
  
  Tel: + 44 (0) 1788 573241
  Website: www.relate.org.uk

  Provides couples counselling for breakdown within relationships. Local branches throughout the UK.
  

• Samaritans
  10 The Grove
  Slough
  Berks
  SL1 1QP
  
  National helpline: 08457 909090
  Website: www.samaritans.org.uk

  UK Helpline for anyone experiencing emotional distress. Someone to talk to in confidence 24 hours a day. Details of local branches can be found in a local telephone directory.

• Turning Point
  
  101 Backchurch Lane
  London
  E1 1LU
  
  Tel: + 44 (0) 207 702 2300
  Website: www.turning-point.co.uk
  
  Provides help and advice on problems with drink, drugs, mental health and learning disabilities.
  

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Government support services

• Disability employment helpline
  0800 528 0462
  
  
• Employers’ Forum on Disability
  
  Tel: + 44 (0) 20 7403 3020
  Minicom: 0207 403 3570
  Email: efd@employers-forum.co.uk
  
  The world’s leading employers’ organisation focused on disability. Funded and managed by their members, it aims to make it easier to recruit and retain disabled employees and to serve disabled customers. Members employ approximately 20% of the UK workforce.
  
  
• Employment Medical Advisory Service (EMAS), Health and Safety Executive
  
  Tel: + 44 (0) 1342 334200
  
  EMAS is staffed by doctors and nurses with occupational health qualifications located at Health and Safety Executive offices throughout the country. EMAS provides free advice and support to employers and employees regarding work-related medical problems, including mental health problems. 
  
  
• Employment Service Access to Work Scheme
  The Government’s Access to Work Scheme, which is administered through a network of Placing, Assessment and Counselling Teams (PACTs) throughout England, Scotland and Wales, provides help for people who are disabled to continue working. PACT advisory workers, called Disability Employment Advisers (DEAs), are attached to local job centres. They will discuss with employees and employers the possibilities of job transfer and reconstruction, and make grants towards the cost of special equipment if required.
  
  
• Health Education Authority (due to become the Health Development Agency in early 2000)
  offers a range of expertise on health issues, including mental health and wellbeing. Information on the NHS, small and medium-sized business enterprises, and the Health at Work Award, a national quality standard, can be obtained by writing to:
  
  Workplace Health
  Health Education Authority
  Trevelyan House
  30 Great Peter Street
  London
  SW1P 2HW
  
  or calling + 44 (0) 20 7413 1873
  
  
• Health and Safety Executive InfoLine
  0541 545500

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Mental Health Foundation

Published by the Mental Health Foundation

UK Office: 20/21 Cornwall Terrace, London NW1 4QL
Tel: 020 7535 7400
Fax: 020 7535 7474

Scotland Office: 24 George Square, Glasgow G2 1EG
Tel: 0141 572 0125
Fax: 0141 572 0246

E-mail: mhf@mhf.org.uk
Website: www.mentalhealth.org.uk

Registered Charity no. 801130

Copyright © 1999, 2000

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