Employee perspectives on mental health in the workplace

Publication

Employee perspectives on mental health in the workplace

Summary

Background

This is a crucial point in the development of mental health and employment policy in Scotland with the workplace identified as one of the four priorities for health improvement (Scottish Executive, 2003). Policy and practice has evolved in recent years from a focus on stress at work and rehabilitation to include the promotion of mental health and well-being in the workplace and job retention. A study commissioned by the Health Education Board for Scotland on employers'; views of mental health in the workplace identified ambiguity in definitions and a lack of practical guidance on of mental health in the workplace that was accessible and relevant to employers.Ã‚Â

Aim

The research reported here was commissioned in response to the above issues to examine the employees' perspective and inform the development of the mental health agenda in Scottish workplaces.

Approach

The main objective of the research was to gather the experiences of employees (with and without experience of mental health problems at work) of mental health at work and to understand what they would like employers and workplaces to do to improve these experiences.

Overseen by an Advisory Group comprising representatives from the employment and business community in Scotland, the research was conducted over six months, beginning in September 2002.

A brief literature review was followed by focus group discussions and one to one interviews with employees from small, medium and large companies and supported employment initiatives from across Scotland. Investigations focussed on four key areas:

Definitions and understandings
Promoting mental health and well-being in the workplace:
Addressing mental health problems in the workplace
How to look forward to change, to improve mental health and well-being in theÃ‚Â workplace

Data collection was completed with a Stakeholder Workshop with participants from a cross section of employees from different employer organisations and the research Advisory Group.

Difficulties were encountered by the research team in identifying employees to take part in the focus group element of the research; these have important implications for future work on mental health in the workplace. Approaches through employer organisations, firstly to secure agreement and access to employees and secondly, to recruit a group of employees in that workplace to take part in a group discussion hit against barriers. Employers reluctance to get involved was variously ascribed to pressures of work and time required to set up focus group or recent involvement in other HEBS activities. In some instances support from HR and from Occupational Health was not matched by support from management (and vice versa). Employee reluctance was also a problem on grounds of lack of interest, concerns about confidentiality of research findings and about talking on this topic with a peer group. In one instance, staff were advised by the employer that participation would have to be in their own time.

Key findings and discussion points

Perceptions and understandings: Employees' perceptions of the contribution of work to mental health and well-being reflected other research findings and demonstrated good insight into mental health problems and stress.

Work and mental health and well-being: Mental health and well-being at work hinged on relationships at work, a manageable workload and a good work / life balance. The impact of mental health on work performance and attendance was thought to be directly related to the response from employers in terms of the timing and type of support on offer for employees in the workplace.

Promoting mental health and well-being in the workplace: There was some scepticism amongst employees about the integrity of intention behind some workplace supports such as stress policies or counselling services. It was thought that such interventions were not helpful if the general workplace culture did not support mental well-being in the first place.

Getting help and support with mental health problems at work: Many mental health problems at work go unnoticed until they reach crisis. A supportive workplace culture was deemed key to engender employee expectations of a positive response to disclosure of a mental health problem. It was recognised that management require support to know how and when to deal with employees in such situations.Ã‚Â

A whole organisation approach to improving mental health and well-being in the workplace: Respondents emphasised the need for employer's awareness regarding the benefits they can gain from providing supports that will enhance workforce retention, reduce absence and gain them recognition as an employer of choice. The focus of mental health and well-being should filter through all levels of the organisation, including action and accountability for managers, human resources, occupational health and individual employees.

Inhibiting and facilitating factors: Barriers to employers acting on the mental health and well-being agenda included lack of awareness, low commitment, little interest and perceived lack of financial incentive. Key enablers were thought to be legislation and government guidance, financial incentives, awareness of the business argument for supporting employees.

Recommendations

Seven key recommendations were produced from the research including:

Making the case to employers for improving mental health and well-being at work using a business oriented model, supported through better co-ordination and communication of this message via bodies that work with employers.
The role of managers in promoting mental health and well-being in the workplace should be recognised and supported through skill development as part of a whole organisational approach.
Promoting job retention through stronger local and national employer networks that share knowledge and offer advice to employers.
Reward schemes should extend their remit more widely to increase the status ofÃ‚Â accreditation for attention to mental health and well-being in the workplace accreditation amongst employers.
Supports and resources for employers through provision of examples of good practice to indicate the range of actions that employers are already undertaking to contribute to mental health and well-being in the workplace.
Tackling stigma and negative attitudes to mental health in the workplace.
Future research needs to address the lack of commitment of mainstream employers and employees to participate in the mental health and well-being debate.

Context

The research reported here was carried out at a critical point in the development of mental health and employment policy in Scotland:

the Disability Discrimination Act 1995 includes people with mental disability and requires employers to make reasonable adjustments to the work environment to accommodate this
past emphasis on mental health at work has traditionally focused on the effects of stress in the workplace and on the workforce (HEBS 2001, HSE, 2001)
the regulations of the Employment Act 2003 contain provision for flexible working arrangements for parents of young or disabled children, in order to enable working parents to retain their job
there are early indications of a reorientation in practice in relation to employment development and employment support for people with mental health problems, to extend beyond models of intervention premised on rehabilitation supporting return to work (Butterworth, 2001). More recently in both policy and practice, awareness is emerging of the role of job retention strategies, which aim to facilitate early intervention and support to maintain in employment people who develop mental health problems (Department of Work and Pensions, 2003)
the workplace is one of the four priority areas for health improvement identified by the Scottish Executive (Scottish Executive, 2003). The National Programme to Improve Mental Health and Well-being in Scotland provides an important impetus to actions in a range of sectors and settings, including the workplace, to enhance mental health and well-being.

In 2002, the Health Education Board for Scotland (HEBS), commissioned research with employers on the availability of information on, and their views about mental well-being at work. This study also looked at employers' perceptions of barriers to action to promote mental well-being at work. The study indicated that, for employers, there is considerable ambiguity in the information available on mental health, mental illness and stress. It also suggested that employers require more practical guidance to indicate the business case to support action on mental heath improvement in the workplace and to highlight evidence of what works (Lee, 2002).

In view of these findings, HEBS and the Scottish Executive National Programme to Improve Mental Health and Well-being in Scotland commissioned a further research study. This second study set out to understand mental health at work from the perspective of employees and to consider in particular:

employee understanding of mental health and well-being in the workplace, stress at work and mental illness
employee experiences of actions designed to improve mental health in the workplace, including steps to promote mental well-being, to prevent or alleviate the development of mental health problems and to support and rehabilitate those with experience of mental health problems
actions that employees would like to see taken forward by employers to improve mental health in the workplace
perceptions of likely motivators/incentives and barriers to such action being taken by employers.

Mental health and employment policy is presented within the National Programme as comprising three distinctive, but intertwining strands, which have been explored in this research into employees' perspectives:

firstly, the promotion of mental health and well-being in the workplace for all employees
secondly, the steps that might be taken to support and retain in work those who develop mental health problems
thirdly, the responsibilities of and actions required by employers to facilitate the return to mainstream work of those affected by mental health problems or mental illness.

Study aims

The aim of the research reported here was to identify key issues from the employee's perspective that would inform the development of the mental health agenda in Scottish workplaces. The main themes that the research was asked to address were to examine employees' perspectives on mental health at work and what they would like employers/workplaces to do to improve these experiences, taking account of the three dimensions featured above: promotion, prevention and return to work. The research was carried out with two principal groups: employees with and employees without identified experience of mental health problems.

Introduction

Background

Aim

The research reported here was commissioned in response to the above issues to examine the employees' perspective and inform the development of the mental health agenda in Scottish workplaces.

Approach

Overseen by an Advisory Group comprising representatives from the employment and business community in Scotland, the research was conducted over six months, beginning in September 2002.

Definitions and understandings
Promoting mental health and well-being in the workplace:
Addressing mental health problems in the workplace
How to look forward to change, to improve mental health and well-being in theÃ‚Â workplace

Data collection was completed with a Stakeholder Workshop with participants from a cross section of employees from different employer organisations and the research Advisory Group.

Key findings and discussion points

Recommendations

Seven key recommendations were produced from the research including:

Making the case to employers for improving mental health and well-being at work using a business oriented model, supported through better co-ordination and communication of this message via bodies that work with employers.
The role of managers in promoting mental health and well-being in the workplace should be recognised and supported through skill development as part of a whole organisational approach.
Promoting job retention through stronger local and national employer networks that share knowledge and offer advice to employers.
Reward schemes should extend their remit more widely to increase the status ofÃ‚Â accreditation for attention to mental health and well-being in the workplace accreditation amongst employers.
Supports and resources for employers through provision of examples of good practice to indicate the range of actions that employers are already undertaking to contribute to mental health and well-being in the workplace.
Tackling stigma and negative attitudes to mental health in the workplace.
Future research needs to address the lack of commitment of mainstream employers and employees to participate in the mental health and well-being debate.

Context

The research reported here was carried out at a critical point in the development of mental health and employment policy in Scotland:

the Disability Discrimination Act 1995 includes people with mental disability and requires employers to make reasonable adjustments to the work environment to accommodate this
past emphasis on mental health at work has traditionally focused on the effects of stress in the workplace and on the workforce (HEBS 2001, HSE, 2001)
the regulations of the Employment Act 2003 contain provision for flexible working arrangements for parents of young or disabled children, in order to enable working parents to retain their job
there are early indications of a reorientation in practice in relation to employment development and employment support for people with mental health problems, to extend beyond models of intervention premised on rehabilitation supporting return to work (Butterworth, 2001). More recently in both policy and practice, awareness is emerging of the role of job retention strategies, which aim to facilitate early intervention and support to maintain in employment people who develop mental health problems (Department of Work and Pensions, 2003)
the workplace is one of the four priority areas for health improvement identified by the Scottish Executive (Scottish Executive, 2003). The National Programme to Improve Mental Health and Well-being in Scotland provides an important impetus to actions in a range of sectors and settings, including the workplace, to enhance mental health and well-being.

employee understanding of mental health and well-being in the workplace, stress at work and mental illness
employee experiences of actions designed to improve mental health in the workplace, including steps to promote mental well-being, to prevent or alleviate the development of mental health problems and to support and rehabilitate those with experience of mental health problems
actions that employees would like to see taken forward by employers to improve mental health in the workplace
perceptions of likely motivators/incentives and barriers to such action being taken by employers.

firstly, the promotion of mental health and well-being in the workplace for all employees
secondly, the steps that might be taken to support and retain in work those who develop mental health problems
thirdly, the responsibilities of and actions required by employers to facilitate the return to mainstream work of those affected by mental health problems or mental illness.

Study aims

Methodology

Research management

In order to oversee the direction of the research a short life Advisory Group was put in place. The group membership (see Appendix 1) comprised representation from a number of organisations to provide coverage of key stakeholders who could ensure that the research has relevance to current policy and practice agendas.

The Advisory Group met at an early stage in the planning of the research to assist with contacts for sample member recruitment and to guide the formulation of questions for discussion. The Group was later used as sounding board to assist the research team with interpretation of data and to comment on emerging themes.

Approach

To ensure that a sufficient depth and breadth of data was captured to meet the research objectives a number of qualitative techniques were used. These included a brief literature review, focus group discussions with employees, one to one interviews with employees and a stakeholder workshop.

The literature review was undertaken to provide an overview of what is known to date about employee's views on mental health with three key aims:

to provide clarity of focus in developing the topic guide and interview schedule for group and individual discussions
to ensure that the findings from this study could be set in context
to ensure that this work could add to rather than duplicate previous research.

Selecting and recruiting employees

The steps taken to recruit employees to the study are set out below in some detail, as the process and its outcomes may have implications for future work on this topic.

Recruitment of appropriate employee participants depended on the early identification of employers and organisations that were willing to take part in the project and work with the research team to encourage employee participation in focus groups and interviews.

A range of sources were used to establish initial contacts, including the SDC Employment Programme' national database of mental health employment projects and related initiatives and working partnerships such as SHAW, the Federation of Small Businesses and Scottish Business in the Community to provide an inside track to voluntary, public and corporate employers and employees.

It was made clear to all employers and organisations that were approached to participate that their anonymity and confidentiality would be respected at all times.

All employees who agreed to participate in the research were provided with an information sheet summarising the aims, objectives and methods of the research and why they had been selected. Each employee was asked to sign a consent form that assured his or her confidentiality.

Sample 1: mainstream employee focus groups

The research team aimed to hold ten focus groups, involving employees from a cross section of employer organisations that was representative of the diversity of employer types in Scotland, in relation to the following criteria:

public, private and voluntary
small, medium and large
urban, rural
workplaces actively and not-actively working on improving mental health.

For the purposes of the research, businesses with less than 25 employees were deemed as 'small' and those with between 25 and 100 employees were deemed as 'medium'

In the first instance senior management in each of the employing organisation was approached formally by the SDC and their organisation invited to take part in the research. Link people were then nominated by each participating employer to assist the research team with identifying and recruiting employees to act as voluntary participants in the research. Briefing meetings were held with the link person and relevant colleagues to introduce the aims and methods of the research. Employers were encouraged to invite employees from all levels of role from manual workers to middle management, including representatives from Human Resources where possible.

Each focus group aimed to include a minimum of six and a maximum of ten participants.

Thirty-three employers were contacted over a period of three months. A total of six focus groups were undertaken including with employees from the following employer types:

large hotel (6 participants)
local Education Authority (4 participants)
large retailer (6 participants)
Student Union (4 participants)
small businesses (5 participants)
local NHS organisation (8 participants).

Focus groups were held across Scotland in Inverness, Coatbridge, Galashiels, Glasgow, Livingston and Edinburgh. At least six employees confirmed their intention of attending each group, but not all proved to be available to take part on the day.

The recruitment of employees for focus groups encountered many barriers and proved time-consuming, with many lengthy negotiations. Attempts were made to ascertain the reasons from those companies who were unable or unwilling to take part, but these were not forthcoming in most cases. However, the main reasons given for not taking part were:

employers were not able or willing to commit time to recruiting staff or releasing staff. People were already highly busy
employers were wary about the confidentiality of the project. There may be many reasons for this but some were particularly concerned that the company might be identifiable, despite reassurance in writing
there was perceived to be no obvious business incentive for employers to take part in the project
when management gave their agreement to participate, staff proved unwilling to take part. In some cases, being advised by their employer that participation would have to be in their own time may have contributed to a negative response from staff
staff felt that mental health was not an issue they wanted to discuss in front of colleagues.

Sample 2: mainstream employee interviews

From the 33 employers originally contacted when recruiting for focus group participants, a sample of twenty employees was identified. This sample included employees working at different levels, in a range of mainstream employer organisations of different types and sizes:

large accountancy firm
civil service
university
voluntary organisation
small businesses
umbrella organisation for businesses.
In some cases employers who could not arrange focus groups were able to recruit staff to take part in individual interviews.

Sample 3: employees with experience of mental health problems

A sample of twenty people who had experienced mental health problems at work was identified. This included people who were currently employed, unemployed individuals with a recent (within last 3 years) employment history, who could comment on what would have helped them remain at work and people in supported employment with a prior experience of mental health problems whilst in mainstream work settings.

Using the SDC Employment Programme database, organisations involved in mental health employment initiatives were invited to nominate link people to assist in identifying individuals linked to their organisation who would fit the sample criteria.

The organisations that helped to recruit were of the following types: supported employment services; local mental health user groups; national mental health support and lobbying groups; clubhouses and social firms; and advocacy organisations.

Link people approached the individuals in the first instance to seek consent to be interviewed. When this had been obtained, arrangements for face-to-face interviews were made directly between the SDC research team and the interviewees.

Twenty interviews were held across Scotland in Inverness, Ayr, Aberdeen, Fife, Dundee, Glasgow, Edinburgh and Lothian.

Sample 4: stakeholder workshop

Fifty individuals drawn from contacts developed in the recruitment stages for samples 1-3, and the research Advisory Group were invited to take part in a stakeholder workshop to consider themes and issues emerging from the early research findings and to explore the implications of these for employment practice and policy. Twelve individuals indicated their intention to attend and six individuals actually attended, of whom three were Advisory Group members.

Data collection

A summary of the structure and topics of the focus groups and interviews is provided in Appendix 2.

Findings

The main findings of the research are set out below, reporting on the main themes from the focus groups, mainstream and mental health employee interviews. The key issues raised at the stakeholder workshop are also reported here.

The brief review of current literature provided insight into recent research on attitudes to mental health at work, job retention, work life balance, well-being at work, what works, stress at work and the value of work. In addition Government publications concerning best practice in employment and the workplace, guidance packs for employers on stress at work and publications regarding the business case for mental health at work were reviewed. The themes from the brief literature review and from the findings below have been drawn on in the discussion and recommendations in Sections 4 and 5.

Experiences of mental health problems when employed

Mainstream employee interviewees perspective

Seven of the twenty mainstream respondents (sample 2) interviewed indicated that they had experienced a mental health problem at work, of whom two reported experience of longer-term depression. Each of the mainstream employee respondents reported experiencing difficulties coping at some point in their lives, usually for short periods of time and as a reaction to life stresses. This was considered to be normal.

"I guess we all have (felt unable to cope) from time to time, I'm no different from anyone else."

"...Everybody feels down at times, but unable to cope - not really..."

While mainstream respondents were comfortable with using the term stress to describe how they had felt at work on occasions, some of these interviewees were very wary about this being made known to colleagues.

"If I said I was stressed in my home life, that's one thing and you'd get support from friends and family there, but if I was to admit to being stressed in the workplace I would see that as being a threat to my career... the death knell of my career."

Employees with experience of mental health problems

Most of the sample of respondents with experience of mental health problems (sample 3) had had long-term mental health problems, ranging from depression to schizophrenia. They had experienced absences from work and periods out of the employment that ranged from relatively brief to long-term. Some reported that they had lost their jobs because of a mental health problem. Others were clear that, for them, work was a contributory factor in their experience of mental health problems:

"I'm hoping not to go back to the job because I think it had a lot to with it, I think there's too much stress in the job and people at work were not understanding about the situation."

Understandings of mental health problems

Focus group participant perspectives

Focus group participants offered definitions of key concepts (mental health, well-being, mental health problems and mental illness) which suggested capacity to draw important distinctions among the four concepts, as well as indicating differing understandings of each.

Mental health
Mental health was seen as a healthy state of mind, relating to both an individual's emotional state and psychological abilities to cope and to deal with things on a day-to-day basis. Some participants referred to motivation and optimism, for others mental health connoted 'equilibrium'

Well-being
There was considerable overlap between participants' interpretations of mental health and of well-being. The latter was considered to relate to a state of being healthy and happy, of being comfortable, at ease with yourself, contented and self-confident. One person developed the notion of equilibrium further, describing well-being as “a balance of home, work, diet, exercise”; another as “physically and mentally untroubled”. Rather then suggesting a definition, one participant put forward the view that well-being was subjective and contended that it was not advisable to go by other people’s definitions and try to conform.

Mental health problems
Participants appeared to regard mental health problems as the converse of mental health, as described above, referring to a spectrum of different problems which tended to entail problems with concentration, psychological difficulties and dysfunction. Difficulties coping were both a manifestation of mental health problems and an effect of experiencing mental health problems. It was common for participants to observe that experience of mental health problems interfered with someone's everyday life, overriding the individual's normal way of doing things.

Participants also identified potential consequences for relationships with other people: there might be problems of communication compounded by the fear and stigma associated with mental health problems was perceived to prevent people admitting they were experiencing problems. "It may sometimes be a problem for others and not for the person".

Mental illness
Participants tended to regard mental illness as considerably more serious and longer term than mental health problems and some indicated that mental illness implied a diagnosed condition that required clinical treatment with medication. One person considered that mental illness had frightening connotations. Another pointed out that people should realise that 'you can recover'.

Stress
There was considerable commonality among participants in their definitions of stress. This was generally described as pressure and anxiety, arising from the mismatch between someone's ability to cope and the demands placed on them you. Mention was made of 'the pace of work, pace of modern life' and of the 'tendency to try to do too much'.

Several people pointed out the fine line between the positive effects of stress (helps you gear up to cope with things; generates ('a challenging buzz') and the negative effects ('when you are going over and over things in your head'; 'when you can't cope and can't get assistance').

The mainstream employee interviewees had varied experiences of and exposure to mental health problems and these personal experiences and contact with other people with mental health problems had shaped people's understanding:

"I know someone that's been depressed and I used to get angry with her... I didn't have much sympathy... that's bad."

"My boyfriend had a breakdown... through his illness I have seen more into it... I didn't understand that it was a mental illness and had physical links."

Mainstream employee interviewees' perspectives

For some mainstream employees there was confusion between mental health problems and learning disabilities that people are born with or develop later in life. Generally, respondents described a continuum of mental health problems between two extremes of mild stresses or distress to serious psychiatric conditions such as schizophrenia. There was a common perception amongst these respondents that mental health problems could prevent you from functioning in your own life and from relating to the world around you in a satisfactory way. Many respondents described mental health problems as strongly linked to emotional responses to life stresses in work or in relationships, which could diminish someone's capacity to cope.

Employees with experience of mental health problems perspective

Respondents with experience of mental health problems (sample 3) tended to conceive of a spectrum of mental health problems ranging from mild to extreme. A distinction was drawn between reactive distress brought about by life events, including experiences relating to work, and longer term mental health problems that go deeper:

"Depression I see as a more as a deeper feeling rather than... stress at work. Yes, you have times of stress and anxiety but that's not constant but depression if you've got it it's a constant thing until you sort it out."

Those interviewed talked of the potentially disabling effects caused by emotional pain and of the need to cover up or hide feelings and behaviours that might prevent their functioning in a normal day to day manner, in their relationships and activities in the workplace and in other contexts.

The relationship between work and well-being, and the work/life balance

Mainstream employee interviewees perspective

For the mainstream employee interviewees, work was perceived to contribute to well-being in many ways, but chiefly by:

affording a sense of achievement and purpose
contributing to personal growth and development, providing stimulation and interest and helping to build confidence
ascribing a role, an identity and status within wider society. Work makes you feel involved and allows you to feel you are giving something back
providing a social outlet and overcoming isolation.

Striking an acceptable balance between work and life was a challenge for all mainstream employee interviewees. Each person had struggled with this and many confessed to finding it very difficult, often taking work home in the evenings and at the weekend. Those who did not, had made a conscious choice to set boundaries. The accounts provided indicated that employees were often torn between their emotional investment in their work and career and their emotional investment in home and family commitments.

Mainstream employees claimed that in some workplaces, there were unwritten expectations that assumed staff would work beyond five o'clock and in such a culture it was very difficult for individual employees to resist. Employees reported that the prospect of taking annual leave could generate huge levels of anxiety because of the feeling that they could not afford to take time away from work.

Employees with experience of mental health problems perspective

The respondents with experience of mental health problems described how they felt work can contribute to well-being:

an opportunity to contribute, to feel a useful member of society and to gain a sense of self worth, a sense of purpose, of being part of something
enjoyment and satisfaction: knowing you're meeting the goals you have been set
structure and stability
occupation, activity and stimulation (physical, mental and social): 'work keeps your life moving on'
material rewards and status.

"I would feel lost if I didn't have my work. It gives me a sense of purpose and a sense for getting up in the mornings, aims in my life and hopes and dreams, moving on and what I'll do."

For employees with experience of mental health problems, the benefits of work were often perceived to be finely balanced with the more negative aspects of being employed. From the accounts given, it appeared that characteristics of the work setting were key in determining whether employees were able to retain their job, characteristics that included the nature of the work, workplace relationships and the level and nature of support available. One person made the following observation:

"Until recently, it's always been the kind of job that as long as I was standing upright it didn't matter what I was doing or not doing. Now I've got a job where it does matter how I am. It's a good thing because I've got more motivation to look after myself... a lot more self-esteem and confidence."

Respondents with experience of mental health problems talked of their efforts to manage the balance between work and home life. It was noted that some people had found that they behaved differently at work and at home and tended to be more organised and in control at work. However, it was also recognised that these different dimensions of their lives were inter-related and inter-dependent. Families were affected by any work tensions brought home and did not always have the capacity to support the individual. Work could be physically tiring which could affect the quality of home life. Conversely, some of these respondents reported difficulty in leaving personal problems behind, when they went to work, where there can sometimes be no outlet.

Stakeholder workshop perspective

Workshop participants perceived that there was a connection between employee well-being and the health of businesses which is not always acknowledged by employers. They felt that key features of good practice examples of work places that focus on mental health and well-being should be drawn out so that they can be transferred to other workplaces. It was suggested that if employers were dealing with mental health, then they would be dealing with well-being therefore including mental health in a current general approach to well-being would help. It was noted however that stigma is a reality, even when there is an openness about mental health in a workplace there are still inhibitions and fears that need to be addressed.

Sources of stress at work

Mainstream employee interviewees perspective

The main sources of stress at work reported by mainstream employees were as follows:

workload: excessive workload; deadlines and tasks that are unreasonable and unrealistic, long hours
relationships: poor working relationships with colleagues, harassment and bullying; personal problems intrude at work; feeling you do not fit
performance: competitive pressures; feeling under-valued; lack of positive or constructive feedback
working environment: physical environment; job security/insecurity
role: lack of clarity about own responsibilities and boundaries; managing staff, especially dealing with disciplinary and other sensitive situations; lack of control over your work.

Employees with experience of mental health problems perspective

Three main sets of stressors reported by those with experience of mental health problems:

workload: deadlines; too fast a pace of work
relationships: personality clashes; lack of understanding or trust; not knowing who to confide in; bullying; harassment
performance / achievement: feeling you are not performing well enough; worry that something will go wrong; not understanding what is expected of you.

For this group, excessive stress was largely regarded as distinct from mental health problems but also likely to precipitate or exacerbate mental health problems:

"I'm thinking is it me that can't cope? Initially, it was probably the workload and not getting to grips with what I was supposed to be doing... I thought I'd actually been working really hard and no-one ever said to me that I wasn't. The manager didn't think I was doing the job the way he wanted but he never actually approached me to say that."

Coping mechanisms

Mainstream emplyee interviewees perspective

Mainstream employees used a variety of coping mechanisms, to some extent as a preventative measure against the build up of stress. These included:

healthy lifestyle: diet; exercise - "I've started going to the gym and hitting the punch bag", "a healthy social life"
relaxation and diversion: "having a hobby or pursuit that takes your mind away from work"
adjustments at work: planning ahead, good time management; taking a step back to rethink the problems that are causing you stress; maintaining emotional distance from work, detachment from office politics; listening to music at work to cut out other noises; working harder and faster
support: off-loading to family and friends to gain reassurance; going to GP and staying off work.

Employees with experience of mental health problems perspective

For employees who had experienced a mental health problem, coping mechanisms included:

Relaxation / diversion:

taking time out at lunch time to relax
yoga, aromatherapy, exercise
sleeping
hypnosis and relaxation tapes
music
alcohol
taking medication
organising thoughts to improve concentration.

Adjustments at work:

finding work that suits what you can cope with; taking part-time or temporary work
regular meetings with peers or boss to discuss issues. However, some people reported trying to talk to people at work about their problems as a way of coping and receiving a poor response.

In describing their coping mechanisms, respondents were aware that some of the strategies used such as alcohol, might be more damaging than helpful. Several people described how they had become more adept at managing their own mental health at work and were able to anticipate and prevent possible problems.

"Because I was aware that I had problems I was more in tune with what I was able to do and not able to do. So if there was a situation I didn't feel able to deal with when I was not well I would pass it on to another colleague."

Impact on work performance

Mainstream employee interviewees perspective

For mainstream employees, there was a perception that work is an integral, not a separate, part of someone's life and therefore the mental health of an employee will have an impact on the way they perform and on their attitudes and relationships at work:

"I realised I wasn't on top, I wasn't picking up cues as I should, I wasn't responding fast because of the depression, I was more sort of insular."

It was pointed out that many people have a strong emotional investment in their work. This was one reason why people might be reluctant or unable to acknowledge that their work was being affected by their mental health problems:

"I finally went to my boss and said, "Look I've got this problem, I can't deal with it. I need to take time off." His opening gambit was "I had no idea or else I would have done something about it." His comment was, I was very good at hiding these things."

Several employees referred to the fine line that separated work pressure that "drives you forward ... works as a motivator" from the degree of pressure that "will push you over the edge and be detrimental to the work performance."

"In the short term a degree of anxiety is probably no bad thing in terms of ... getting things done on time, but if it goes on and on, then it is de-motivating...leads people to take time off sick or leave... or to back off from aspects of their work".

Mental health problems could impact on work performance in both positive and negative ways. The main negative impacts were identified as:

loss of motivation and concentration
loss of self esteem and self belief
deterioration of relationships with colleagues and managers, loss of trust.
tendency to spend time worrying about work pressures rather than tackling them
lack of sleep leading to poor performance during the day
highs and lows in mood, leading to erratic performance and relationships.

On a positive note, it was pointed out that if someone has a mental health problem but is well looked after and supported through that, their workload and performance should reflect their ability.

Employees with experience of mental health problems perspective

Those interviewees with experience of mental health problems were of the view that people with long-term mental health problems can perform satisfactorily at work if the environment is flexible enough to accommodate and support them, when they are less well. Drawing on their own experiences of working life, respondents observed that their work performance had been affected in a variety of ways:

anger and frustration at their limitations
lack of confidence and low self-esteem in own ability
lack of motivation and low energy
poor concentration and memory
worry about employer's disapproval, and about coping with pressure from employer
withdrawal from social aspects of the work environment.

There were two key aspects here: employees with experience of mental health problems were concerned about the perceived diminution of their capability to perform their job, but also about how their employers and their peers would react. They often expressed concern about standing out as different from their peers and about having special allowances made for possible limitations:

"I didn't feel that was fair to the other workers when you turn and say I don't think I can cope with this. It would like me getting away with something they weren't."

In several instances, people with experience of mental health problems reported that they had lost their jobs because of a lack of recognition by themselves, their employers and the medical profession that they were experiencing a mental health problem.

Impact on work attendance

Mainstream employee interviewees perspective

Few mainstream employee respondents claimed that they had taken time off work due to a mental health problem, although some reported having taken time off for stress related problems that had reached crisis points and others had witnessed colleagues taking time off for stress related problems. Some of these interviewees declared that feelings of guilt prevented them taking time off, guilt that colleagues would have to cover their work or that their workload would further accumulate in their absence or guilt associated with being absent on grounds which were not wholly regarded as legitimate or valid:

"I feel I'd be letting people down ...the work would still be there...it's just postponing it."

"You know work is going to be sitting there waiting for you when you get back".

"You can't phone up and say I'm feeling particularly stressed today because so and so has happened. You can't do that, because people won't take you seriously."

It appeared that some mainstream employees would be more likely to cover up a short term absence for stress and it was only when there were long periods of absence that people seem to be more open if the cause were related to a mental health problem. The origin of the mental health problem or stress was also felt to affect absences, for example if the root of the problem was perceived to be at work, people might be more likely to take time off.

Many mainstream employee respondents felt that if their mental health was poor, they would not let this affect their work attendance because this was not perceived to be a constructive solution; alternatives such as "hiding away" at work or avoiding stressful meetings were suggested. Notwithstanding their own preferences and their own practices of maintaining attendance at work wherever possible, interviewees tended to be of the view that in general, people with mental health problems would have low motivation to attend work and would be prone to regular absences. It was acknowledged, however, that work could also provide structure and incentive to enable someone to cope with a mental health problem.

Employees with experience of mental health problems perspective

Most of the interviewees with experience of a mental health problem did not consider that work attendance would be affected by their mental health problems. Indeed, some reported that they would push themselves to go to work when they felt unwell, as a way of coping:

"That's my coping mechanism that I make myself come to work although it's bloody hard sometimes."

Where attendance had been a problem, this seemed more likely in the early stages of someone developing a mental health problem, when the person was less aware of what was happening to them and lacked the support and coping mechanisms they required. However, people who were constantly alert to the possibility of relapse / recurrence were considered by some respondents to be more likely to take time off work.

Responsibilities of employers to help employees with mental health problems

Mainstream employee interviewees perspective

"Employees that are happy and well cared for, that feel motivated, are going to be off their work far less through absence and through sickness. They're going to be better performers and going to feel more like coming in the morning and doing a good day's work."

"Absence rates can fall greatly if a company has proved to look after its employees properly, by recognising someone has a problem and (being) ... a bit more flexible about working hours or working conditions. If you are not looking after them, they are going to be off more."

Mainstream employees provided several strands of thought here: firstly the steps which employers could initiate across the whole company or organisation to create the culture and framework; secondly the policy and procedures that give shape to intentions; and thirdly, the working practices that impact on the individual working experience of employees. These were perceived to be inter-related and mutually reinforcing. Some of the difficulties described by mainstream employees arose where there were inconsistencies across these three levels, for example where policies existed but were not operationalised effectively. One of these interviewees stated that their workplace had a stress policy but thought that most employees in that workplace were probably unaware of the policy's existence.

Employees with experience of mental health problems perspective

Employees with experience of mental health problems considered that employers had responsibilities to help people with mental health problems in four main areas:

recruitment and retention of employment, to offer people jobs and to ensure that as far as possible staff were able to remain in employment
adequate arrangements for sick leave and sick pay so that employees could manage spells of poor mental health, confident of their entitlements and with the intention of returning to work
working conditions and practices that ensured people were supported and enabled to continue at work
better understanding among employers of mental health and mental health problems and how these affected their workforce.

"Employers need to wise up and educate themselves about the problems, learn how they can take the pressure off people. Don't say to them, you've to be back at work by such and such a date, or else you'll lose your job. That's just adds to people's pressure, which is going to knock them back instead of supporting them."

"In an ideal world, I think people with mental health problems can work and can work successfully, but there has to be a certain amount of give and take from the employer and a certain amount of flexibility as well."

"What makes a good employer is things that make them supportive to their staff."

Stakeholder workshop perspective

Accountability
Focus group participants perceived that there was a lack of accountability amongst managers for the well-being of their staff. They stressed that senior managers can find it difficult to be open about mental health as well as other staff. The group felt that when employees have a mental health problem, it involves all aspects of their lives, it can be difficult for managers to cope with addressing the problem fully when they are also busy and stressed themselves.

Participants felt that mental well-being at work shouldn't be a lottery that depends on your manger's personality, it is unlikely your physical well-being would be dependent on a personality. It can be the line manager who is the problem; it helps to have someone else to talk to e.g. a middle management policy that anyone is accessible.

It was suggested by participants that managers should be skilled up to be responsible for the well-being of their staff, and that this would not be any more daunting than other management responsibilities they deal with. Responsibility of staff well-being could be included in their performance review. The group stressed the importance of recognising that managers would need skills and support to do this well as well as any of their other tasks. This might include learning about listening and communication skills. Ignorance is no excuse, employers can end up with claims about stress which can be more costly than being responsible for the well-being of their staff.

Supporting employers to take responsibility for employee well-being
Workshop participants identified a need to move away from a blame culture for employers and suggested that alternative constructive advice should be available for employers to achieve the best from their employees.

It was noted that small and large businesses both have their share of good and not so good management, in large businesses there will be small pockets of good and bad practice. Similarly different jobs have different circumstances due to the construction the job itself but it was felt that good employer practice could be applied to any job no matter how mundane.

Participants noted that work is where people spend a large part of their lives and may be the only place where a developing mental health problem is noticed; meaning that if employers don't know much about mental health this can be a problem. It was suggested that some employers may know what supports are available but don't know how and when to use them. The group identified a need for better communication about what support is out there in the voluntary sector.

Retaining employees with mental health problems at work

Focus group participant perspectives

Focus group participants were asked to consider what reasonable adjustment in the workplace might be required to accommodate an employee with mental health problems. Several stated that it was particular difficult to specify in relation to mental health.

One group noted that the majority of issues that HR has to deal in the work setting are mental health related (stress, anxiety, depression), whereas previously it had been back problems. Suggestions included:

making adjustments to the workload
moving the person to new team / setting
reducing hours
easing people gradually into working with customers or the public.
allowing time off work when not well
providing confidential, outside support.

One discussion argued that it was important to "make things as normal as possible, to help (the person) feel good about themselves". The point was also made that the onus was on the employee to be open and honest and flag up their problems so that action could be taken to change work arrangements accordingly.

Recruitment and return to work

Focus group participant perspectives

Focus group participants were asked to consider issues regarding recruitment of people with mental health problems. One set of employees in a public sector organisation considered that someone with significant periods of absence from previous employment (for whatever reason) was less likely to be offered a job. Others were of the view that promoting recruitment had to be for the right reasons and that it was not in the interests of any of those concerned if a company was going through the motions of positive recruitment simply "to get brownie points".

One employee talked of the need for job applicants and those involved in recruitment to be clear from the outset about policy on disclosure of personal health information, including information on mental health, to clarify what would be made known to the interview panel and what would be known to occupational health.

The sorts of suggestions proposed for those with mental health problems returning to work were similar to the steps suggested to support and retain people with mental health problems in work:

phased return, for example a shorter working day / week
counselling
restriction of duties to facilitate gradual re-entry. It was noted, however, that once back at work, problems can be overlooked and support can tail off prematurely
return to work interview
on the job support from sympathetic colleagues.

Support from management was considered to be key to successful return. However, even in organisations which employees considered to be supportive, there was acknowledged to be stigma and ignorance about mental health problems.

Actions and supports provided by employers to improve mental health at work

Focus group participant perspectives

Focus group participants were able to identify a considerable range of initiatives that they considered indicative of their employers' efforts to improve workplace mental health.

Communication and information:

staff forum for people to raise issues, get information. Not used for personal issues but things that affect the way you work or affect customers
team briefings so that people can raise issues
staff handbooks that set out all personnel and equal opportunities policies
information, such as posters, on the signs of stress to look for in colleagues.

Identifying needs and priorities:

one HR department did a regular annual survey of job satisfaction. The results of these were shared with staff. The next stage was to follow this up with an action plan
a public sector employer had developed a set of tools for managers to carry out an audit of stress levels among their staff and to devise ways of addressing the findings.

Support resources:

a policy on stress at work that aimed to ensure people would know where to seek help
one public sector employer was in the process of opening up self referral to counselling, where previously this had been via the line manager
an educational institution had introduced a stress clinic, open to staff, who got 4 confidential sessions with a therapist - massage etc. Staff could also access counselling through this route if required
well-being day conferences were run for staff and students. These events were subsidised and offered sessions on mental and physical health
an employee assistance programme was available for the staff of a public sector organisation.

Policies and procedures:

flexible leave - "I asked for three months off unpaid in a family situation and this was agreed"
staff appraisal
induction and probationary procedures
procedures for when someone returns to work after sick leave, to provide opportunity to talk with line manager.

Working practices:

matching person and task: "I was taken off a project that was causing me stress"
open door policies so that HR and managers are accessible
social events and informal peer support networks.

Mainstream employee interviewees perspective

From the experiences described by the mainstream employee interviewees, they faced a number of obstacles in accessing support in the workplace. Firstly, was the issue of attitudes and awareness and the continuing negative associations relating to mental health including stigma.

"In our work environment, if someone is off sick ... with depression, higher up people might say "Why are you off work? It's not a real illness" and maybe people would not be accepted back".

Being able to ask for help was particularly difficult when employees were experiencing job insecurity and did not want to jeopardise their prospects. However asking for help was an essential first step:

"My boss is always saying to all the team, "If you have an issue, if you have a mental health problems or something is affecting you and your work... then come and talk and we'll sort something out. But if you don't talk about it, then well never know, how would we know?"

It was felt that much hinged on the line manager as the first resort for advice and support. Important here were both the employee's relationship with their line manager and the stance the latter took:

"If you have someone who doesn't have a caring perspective on things, then I'm afraid you are in trouble."

A senior employee, who managed and supported others had learned not to expect the same level of support for herself and tended to look to informal sources within the organisation for support and advice. It was not surprising therefore that employees noted how practices and approaches could vary within an organisation, from one department or one team to another. The sorts of supports described encompassed both formal and informal supports.

Formal supports
Those working for larger companies could list a number of formal supports that were in place such as:

counselling services
occupational health
mentoring schemes
listening service
union representatives
help line, also dealing with legal and financial issues, including debt
chaplain
stress policies

In some cases, steps to improve and support mental health were part of an organisation wide programme to promote well-being that included support on healthy eating and fitness. In this instance there was perceived to have been considerable gains in changing the culture, creating awareness and openness regarding stress and laying the foundations for stronger peer support. However, the withdrawal of counselling was said to have left a 'vacuum'.

Informal supports
Some respondents felt supported by a general socially supportive culture within their organisation in the absence of more formal supports. More informal types of support on offer include peer support, the line manager, open door policies. Peer support could take on a number of guises such as offering to help out with work tasks, socialising in and out of work hours, simply asking someone if they were okay.

One respondent made links between the wider shifts towards a more individualised society and the impact of this in the workplace, where people acted less as part of a social group at work and more for themselves, in the pursuit of performance targets. Reduced opportunity for face to face interaction and communications within the workplace was thought to be eroding the networks of informal support that were key for many employees.

In smaller businesses, it seems that the kinds of supports offered are highly dependent on the employers themselves, who are often under stress and may lack the skills and knowledge required. In small businesses, it is less likely that staff will have access to an independent source of support that is confidential from their employer.

Respondents were split on whether they felt supported or not: those who did feel supported emphasised that they had reliable peer support and knew who they could go to and trusted that person. When people did not feel supported, this was despite polices being in place with formal supports attached. It was also sometimes the case that the source or the individual offering formal support was not acceptable to the employee.

Lack of support seemed to be associated with a lack of recognition on the part of the individual, their managers and peers, of the causes, signs and symptoms of stress or mental health problems. Problems that are not noticed and acted upon early enough ultimately lead to a crisis situation which can often be followed by a long period of absence.

Employees with experience of mental health problems perspective

Timing of support
For employees with experience of mental health problems, individual accounts of working life contained a wide range of experiences, extending at one extreme from little or no support or understanding to extensive support and flexibility in employer responses at the other. For some, support was only offered when they reached a crisis and by then they felt that working relationships could have already been damaged. Where the employer had been supportive, this was perceived to have enabled people to continue in their jobs, despite periods of being unwell due to mental health problems:

"My employers offer me phenomenal support if I become unwell and that in itself takes the strain off you. Pressure ...just makes the problems worse but they alleviate that pressure which allows you to take a bit of time and you do come back."

"With the right kinds of supports in place the chances of me being ill or relapsing would be fairly slim. It's only because I'm not (well supported) ...that I have relapsed and I think ...that could have been avoided."

Types of support
Support assumed various forms: examples included a boss taking charge of an individual's medication, people being encouraged to have time off work, flexibility in the kinds of tasks staff have were assigned and the provision of extra supervision. Friends at work were perceived to be an important source of support.

Several of those interviewed had experience of returning to work via supported work schemes, which had the benefit of offering a graduated re-introduction to working:

"You start to go for a few weeks until you are comfortable, they (the support organisation) go with you until you have the confidence. It does take a wee while to get used to what you have to do."

Employee responsibility
It was evident that the availability of support for employees was not the only consideration. Firstly, to take up that support required willingness / ability to acknowledge that you were experiencing problems. And this could be an obstacle if, as was often perceived to be the case, people were wary of being stigmatised or as standing out as different and therefore avoided disclosing the fact that they had mental health problems. An indication of the effect of this was that some people had taken steps to hide their problem and to ensure that sick notes from their GP did not make overt reference to mental health problems. In such circumstances, where mental health problems remain a hidden issue, it was considered unreasonable to expect colleagues and employers to be able to offer support:

"I was told there would have to be an improvement in my performance at work or I would lose my job. There wasn't any recognition of the mental illness... That was my own fault because I didn't say I was suffering from a mental illness."

"If you've got a mental health problem who do you tell? Do you make it general knowledge or do you not, because you know people are going to treat you differently? Then again if you don't and you do become unwell, it's like a catch 22 situation."

Lack of awareness and understanding
Secondly, it was also perceived to be difficult for employers or colleagues to understand mental health problems and provide appropriate support if they had no personal experience or lacked awareness of mental health problems and might be wary or frightened as a consequence:

"They were frightened of mental health, frightened that I had presented myself as a person having a difficulty. I felt angry that they didn't understand my problem but now I feel that their lack of awareness was the reason. Maybe they did want to support me but didn't know how to."

Some had found their colleagues and managers very sensitive and responsive when they became unwell. However, in other instances the experiences had been less positive. Employees' motives for choosing or remaining in that area of work were sometimes challenged and the employees did not feel that managers or employers actively addressed their difficulties in the workplace.

In addition, managers' and colleagues' judgemental behaviour and their lack of understanding or insight into mental health problems could make it difficult for an individual to approach them. Managers could add to pressure by focusing on an individual employee's performance in ways that seemed harsh rather than supportive.

It could be especially difficult for employees with mental health problems in more senior positions, as there appeared to be an assumption among some employers that senior staff who were paid a higher salary were expected to be able to cope and to be invulnerable.

Supports required from colleagues, line managers, and employers to improve mental health and well-being at work

Focus group participant perspectives

Five key areas emerged from the focus group discussions with employees, highlighting what employees perceived to be important to improve mental health at work.

Ethos and culture
Employees indicated that the ethos and culture within the organisation set the tone for the way in which work was conducted, for the relationships between staff and for the experiences of individual employees:

"A lot of it comes down to the ethos and employment practices within a company - whether you kick people or pat them on the back to get them to work harder".

Others considered that what mattered was the commitment to respecting the individual employee. The lead given by those at the top of the tree was perceived to be critical in shaping behaviour and attitudes:

"It's the nature of the whole organisation (that makes it supportive), there are pressure points throughout the year and all staff pull together to do things. Everybody mucks in, we all know what it is like. Departments are not in competition, but interdependent".

Throughout the discussions, participants were alert to the need for companies and organisations to do their business or provide a service effectively and efficiently and mindful that these goals might be at odds with the interests of employee mental health. In some discussions, the point was made that the nature of the work meant that employees experienced it as stressful. Employees in a retail company found interactions with customers a major source of stress and felt that they were under pressure to perform in ways which lived up to the PR image of the company's advertising.

Working relationships with peers and with managers
Supportive workplaces were perceived to be those which consulted with and listened to staff, where a climate of trust prevailed so that people felt able to take issues and concerns to supervisors or managers.

Participants considered that management practices were very important in supporting staff. Management practices perceived as supportive including the manager being approachable, willing to spend time resolving difficulties, being prepared to "muck in and roll your sleeves up".

Peer relationships were generally regarded as a key if not the main source of support for colleagues: "We all back each other up on a bad day".

One discussion suggested that social events were therefore extremely important as an opportunity for people to get to know and trust one another. Another group explored the theme of peer support further, based on experiences of some participants of being dominated by colleagues. It was felt that mutual respect and the valuing of contributions made by different sets of workers were critical for good peer relationships and for individual employees.

It was observed that at times it could be difficult for someone with problems or difficulties to take these to their line manager. Further, employees might not be comfortable about going to HR staff (gender and age differences were thought to create barriers here). It was suggested that it would be helpful to have access to an independent person, not associated with the organisation, to act as broker to help resolve specific issues.

Policies and procedures for mental health at work
Participants considered that organisations should have clear policies about support, made available to all employees when first appointed. There was also recognition that policies alone were insufficient and to be effective need to be seen as one part of the supportive ethos within an organisation:

"HR policies are no good if people are not prepared to disclose issues and problems with confidence that they will be dealt with fairly".

In another context, it was reported that the HR role within the company was not taken seriously but was made fun of and seen as the "fluffy bit at the end".

It was clear that policies and procedures were seen as a means of promoting consistency and equity across an organisation and formalising good practice. However, it was also noted that the there might be arguments for tolerating variance in the ways in which policies were absorbed within departments or work units. For example, employees in a public sector organisation noted that provision for flexible leave was interpreted and implemented in different ways in different departments, reflecting the distinctive cultures within departments.

The key functions of supportive policies and procedures were to:

identify early where people were under a lot of stress or were taking time off, to ensure that opportunity was provided to discuss this with a supervisor or manager
prepare and support people for changes at work, including identifying training needs and providing support and coaching to enable people to take on new demands
promote awareness so that people knew about provision for sickness, the availability of and access to support
gather feedback from employees on working practices
provide individual employees people with constructive feedback and review of performance (not only to list shortcomings).

Flexibility
Participants perceived that the pressures they experienced in trying to meet the demands of their work role could affect their mental health and well-being. In addition, their capacity to respond to the requirements of their work role was influenced by their state of mental health. Therefore flexibility to negotiate adjustments to the demands of work - volume, nature and timing - was considered essential for mental health and well-being. The most common example cited was that flexible working arrangements allowed employees to take leave for family or personal commitments. Mention was also made of instances where employees were able to enjoy considerable discretion and control over the pace of their work and to be self directed, to ensure that the work got done.

Managing transitions: new staff and staff returning to work
There were several points at which participants acknowledged that employees would benefit from particular support. These were points of transition: when first recruited, when returning to work after sick leave, or when taking on new responsibilities:

In one retail business, a probationary period had been instituted and new employees had a meeting every three months. This was thought useful but limited, insofar as it only related to the person's ability to do the job. "You don't get asked, "How are you doing?"

Mandatory return to work interviews after sickness absence were also thought to be potentially useful, but much depended on how this was implemented and the extent to which the process gave due attention to the well-being of the individual as well as to issue of work productivity and effectiveness.

Mainstream employee interviewees perspective

Mainstream employee interviewees were asked to consider the support that they would like for themselves at work, in relation to stress or mental health problems.

Accessible support
There was a sense that in many workplaces there is a lack of formalised routes to find someone to talk to and put actions in place, such as changing or reducing workloads and tasks. Several interviewees registered concern that the ways in which their employers tended to respond was to offer support after the event, when an issue or problem had manifested itself and that there was little capacity to foresee and pre-empt difficulties. In all, half of the mainstream employees interviewed would not have felt comfortable talking to their colleagues or line managers about mental health problems, giving as their main reasons:

lack of private space to chat informally about problems
feeling that it is your fault, shame
may prejudice your manager and peers against you because of stigma: "I don't want to show any chinks in my armour, that stigma could affect my career"
expectations of unsympathetic reaction from line manager:
"(line manager) would see my home life as nothing to do with work".
"It's my problem to deal with myself".

Others who did feel more comfortable talking about these things, felt this way because of the following reasons:

knowing that there will be a positive response and your concerns will be acted on, e.g. reduced work load
the need to explain why your behaviour changes
colleagues are regarded as friends
you know other people feel the same, "I don't think it's something to be embarrassed about".

It is important to note that some of those above only felt comfortable talking about stress and not mental health problems or more clinical conditions.

Types of support
Suggestions were made of the kind of supports people would like to be available at work. The main suggestions are listed below:

practical support: making sure that employees have the resources and skills necessary to do a good job; realistic expectations and clear deadlines and boundaries for work tasks; mentoring
access to external, confidential and non-judgemental support from an expert
knowledge of what support is available in the local area from community groups and organisations
approachability and accessibility of line managers
early identification: managers able to notice when people are not at their best and to offer non-threatening and non-confrontational support
good communication: consultation with and involvement or employees so that they do not feel isolated and feel valued
time out: a room away from the work station to have breaks, signalling a move away form the unspoken expectation that you work through your lunch and coffee breaks.
sensitivity: applying policies and procedures in ways that show people they are trusted and valued.

Supports in the workplace for people with mental health problems
When asked to consider the support required in the workplace by people with mental health problems in general, employees' responses covered much the same ground:

approachable managers who ensure workloads are manageable and who do not ask people to do impossible tasks
giving people a chance, being supportive and encouraging, giving regular feedback that reinforces the positive messages
structures and processes that do not bully people
ensuring that people coming back from sick leave are supported as they settle back into working
preparing people for their roles, particularly senior staff who have people management responsibilities
enabling all staff to gain a better understanding of stress at work and how to recognise it.

The features and attributes that employees want to see in their own workplace are also those which they consider would be supportive in general of people experiencing mental health problems.

Employees with experience of mental health problems perspective

Of those who have experience of a mental health problem, one person who was now employed as an employment support worker, but had herself experienced mental health problems in previous employment offered the following comment that sums up what others also suggested:

"I would like to have had the kind of support that I give my clients. I listen, look at areas they find difficult so I know where the problems are... Every time I went to say something I got interrupted and I never felt listened to."

Several employees observed that it was difficult to be prescriptive about what support might look like, given that each employee and each work setting is unique. However, from their experiences, both good and bad, of employment situations, interviewees were able to identify a set of core elements that were considered important in supporting people at work:

Sensitivity and responsiveness
Often employees expressed regret that their places of work had not maintained contact when they were off sick. This was regarded as source of reassurance that colleagues cared about them when they are at their lowest and was also valued as a way of keeping up to date with developments at work and with colleagues.

It was suggested that for some people it was important to have a physical space and the permission to work on your own when you needed to, in view of the difficulties that people experienced when less well in relating to others at work. Many of the employees' comments were about issues of choice and control and the degree to which it was possible to shape work requirements round what would best accommodate their individual needs. They suggested that for this to be possible the following conditions would be necessary:

employees being aware of the ways in which their mental health impacts on their capabilities
employees being able to articulate where they think their boundaries and limitations lie
aspects of the work setting should be able to be adapted to achieve a reasonable fit between ability and task
managers and employers should be prepared to support the implementation of such steps in practice:

"(Employers) have got to be aware that it can happen to anyone at any time. They should be educated as an organisation and have the support there for the workforce... no discrimination allowed, work positively with people who are unwell who are becoming unwell so you make the right decision for them."

Structuring and managing workload
Employees were looking to employers and managers to assist by monitoring and managing workloads, by encouraging regular, realistic goal setting at work, and by providing regular feedback on progress and performance:

"I would be looking at ... regular appraisal. I would want them to take things in stages, to put a certain amount of pressure on, see how I did and then build it up."

Flexibility of hours and tasks was also perceived to be important in enabling people to cope better.

Accessibility
In a supportive work setting employees expected to be able to approach their line manager in the knowledge that they would get an understanding response:

"If it all became too much, I'd want to be able to say so and then steps taken because it wouldn't necessarily mean going off sick, it might just mean less to do or more support to do it".

Several employees also mentioned that it would be desirable to have the option of accessing an independent, neutral source of advice and support, other than one's line manager or colleagues, to talk through issues and concerns.

Non intrusive and respectful
In view of the sensitivities associated with mental health, arising from the perceived lack of understanding and people's reluctance to be seen to be singled out as different, employees were keen to stress that employers behaviour and attitudes should be non-intrusive and respectful:

"I would be introduced as Helen on supported placement there was almost a label, I'd think this labels me and they didn't realise they were doing it."

"I'd have liked them to understand that I am not any different than anybody else."

"It's really looking at ways of relieving the pressure, also being supportive but not necessarily intrusive. Reinforcing, yes you are different from anybody else, but it's a case that if you have a good working environment then you are the same as everybody else."

Stakeholder workshop perspective

Workshop participants generated four key issues regarding the approach that employers could take towards providing a workplace that supports mental health and well-being, these are detailed below:

Building sustainable initiatives
Mental health related initiatives (e.g. HEBS stress at work pack) at work need to be sustainable i.e. have a lasting impact on the organisational culture. Cultures need to be nurtured, a starting point would be to ensure that management decisions reflect a culture of well-being. Changing culture is something that people need to learn about, it's not as simple as a providing a phone line.

Building and open and supportive workplace culture
If a work culture is open so that people can talk about it, this will be an organisation that supports people. Many supports that are offered by large employers such as counselling phone lines are confidential but this can lead to a feeling that they are 'hidden away' and therefore although there might be a policy in place there can also be a fear amongst staff to talk openly in case it is detrimental to their career prospects.

Giving employees a level of control
A good employer allows employees a level of control over their work and decisions whilst knowing that there is openness within the organisation to talk about problems, that there will be honesty and a sense of shared values. Employees need to know they have someone they can trust to speak to at all times, and speaking to someone should be regarded as routine and not an exception to be ashamed of. Peer support is often only forthcoming when the mental health problem is known about and is rarely there during the build up.

Providing access to support
Mental health and well-being should be included in inductions and employees should know who to go to and that they will be supported if they need to discuss a mental health matter at work. Employers should be able to identify teams and parts of the workplace where there are problems with access to support and work towards solutions. Staff forums can give feedback to employers on whether mental health and well-being polices are hitting the mark.

Addressing mental health and well-being in the workplace - rationale and motivation

Focus group participant perspectives

Focus group participants were presented with a scenario depicting an individual's experience of work-related mental health problems and asked to identify the incentives or motivating factors that would prompt employers to take action to improve well-being

The rationale for employers to address well-being
The principal reason that these employees considered employers should be acting on this agenda was to ensure the retention and effective functioning of their workforce, as key to the success of their business or service. Trained and experienced staff were seen as a core asset, which would be forfeited if staff had to take sick leave or give up their job. Employers stood to make longer-term savings (through reductions in sick leave and increased efficiency) by investing effort and resource in employee well-being.

A different reason for employers to act was the more negative one of risk avoidance to prevent litigation and to stop cases being taken to a tribunal.

It was also noted that organisations might wish to be seen as exemplar "caring" employers, but this could be hollow if companies were "just trying to look good" and were not committed to following this through into working practices: "Not enough to do it for the image rather than the effect".

Incentives and motivators
Focus group participants suggested a variety of mechanisms to prompt employers to take action:

funding to contribute to any costs associated with setting up support arrangements or developing more mentally healthy policies
support from the senior managers within an organisation: several people suggested that positive attitudes and working practices on mental health and well-being had to be seen as part of a company wide strategy "supported from the top"
access to an independent broker to give support and information. It was thought that an employer was more likely to be accommodating and make adjustments if s/he understood what was required and was able to access advice and information from a source that had the capacity to work with the concerns of the employer and the employee
awards and accreditation to recognise commitment to the mental health and well-being of the workforce
systems of governance and accountability that encompassed staff well-being and that ensured policies were followed through to implementation.

Barriers
Focus group participants identified a range of barriers which they considered stood in the way of employers' addressing mental health and well-being in the workplace more effectively:

time and costs associated with planning and taking action
lack of facilities in small companies which did not have a personnel department or occupational health unit
lack of interest, understanding and awareness about mental health
lack of legislative requirement to stop discrimination
stigma and fear: these resulted in employers and employees colluding in continuing to avoid mental health issues: "It would be difficult to own up to your employer, but if they don't, how can they help?"
attitudes and values: employees reported feeling that they were not valued when the primary concern of managers was on how personal difficulties or sickness impacted on the work performance, with little regard for the welfare and well-being of the person concerned. In addition it was reported that mental health problems were not given the same credence as physical health problems ("She looks fine to me").

Mainstream employee interviewees perspective

Employees offered the following analysis of the barriers that stood in the way of employers' taking action to improve mental health and well-being at work, and the incentives and facilitators that made such action more likely.

Perceived barriers that might prevent an employer from providing supports:

lack of time
lack of long term vision of the benefits of investing time and resource in well-being of staff
lack of awareness and understanding of the meaning and priority of mental health issues
fears that the perceived costs are not affordable
unwillingness to take on responsibility for employee well-being
fear and stigma associated with mental health
assumptions and prejudices that people with mental illness or mental health problems cannot work
values and beliefs about the best way to get results from a workforce: some think bullying is effective
the complexity of being able to be flexible enough to meet individual needs.

Incentives and motivators:

publicity, awards, recognition
recognising that mental health already affects the workplace and work performance: being more aware of mental health issues and how employers can respond
enhancing capacity to recruit and retain staff by treating them well
knowledge of and confidence in the right supports and where to find them
business arguments about costs to employers through absenteeism
evidence from research and case studies
legislation with government campaigns with guidance on the best approach
fear of litigation
a shift in mind set and culture that encourages discussion of mental health.

Employees with experience of mentalhealth problems perspective

This group of employees suggested the following set of barriers and incentives were likely to influence employers in taking action to improve mental health:

Perceived barriers that might prevent an employer from providing supports:

limited knowledge and awareness of mental health, well-being and mental health problems in general; failure to recognise when individuals employers might have mental health problems
fear and stigma that prevail in relation to mental health problems
assumptions that people with mental health problems are a bad risk and that employers will lose money through absenteeism or unreliable working patterns
business orientation towards performance targets breeds a culture where it is perceived to be too challenging to have time for people's problems and where employers cannot afford to care.

Incentives and motivators to encourage employers to take action:

an impartial intermediary or advocate to contact the employer and explain the individual's situation
educated and awareness raising about mental health to dispel the myths: meeting people with mental health problems; more positive messages in the media
making the case to illustrate the number of people employers already have in their employ who are likely to have a mental health problem
financial incentives, such as tax relief, to support people back to work and to stay in work
evidence and reassurance: people with mental health problems can perform well at work, are just as talented as anyone else.
use of measures such as the working times regulations to set boundaries to working hours and to ensure employees have regular breaks.

Stakeholder workshop perspective

Workshop participants discussed a number of motivators for employers to take action on mental health and well-being:

Investors in People seemed to grab attention of senior mangers, to put well-being on the map it must relate to what senior managers respect and want.
Initiatives need to be targeted to the language and needs of senior managers if they are to be successful.
Employers want to project a positive image to attract and retain new staff, maintain a low staff turnover and reduce recruitment costs. Being recognised as a good employer is good business, being recognised as an employer of choice is an incentive to treat staff well.

Discussion

The study has explored the perspectives of employees from a range of employment settings and backgrounds on mental health in the workplace. It has included the experiences of people who have identified mental health problems and had recently been in employment, as well as employees who were not known to have had mental health problems.

The difficulties encountered by the research team in identifying employees to take part in the focus group element of the research have important implications for future work on mental health in the workplace. Approaches through employer organisations, firstly to secure agreement and access to employees and secondly, to recruit a group of employees in that workplace to take part in a group discussion hit against several barriers:

employer reluctance to get involved, variously ascribed to pressures of work and time required to set up focus group or recent involvement in other HEBS activities. In some instances support from HR and from Occupational Health was not matched by support from management (and vice versa)
employee reluctance, on grounds of lack of interest, concerns about confidentiality of research findings and about talking on this topic with a peer group. In one instance, staff were advised by the employer that participation would have to be in their own time.

Taking an overview of the perspectives and experiences reported through the focus groups and the one to one interviews, a number of key points stand out for consideration.

Perceptions and understandings

Mental health and well-being
Employees in this study shared an understanding of mental health and well-being that echoed findings from other research on perceptions and understandings of mental health and well-being in general (SDC, 1999) and of mental health at work (MHF, 2002). Employee perceptions of mental health and well-being were largely consistent with those of employers according to the earlier study by Lee in 2002.

For employees, mental health was an internal state of emotional health and was also associated with the capacity to fulfil roles and expectations satisfactorily. Employees' understandings of the relationship between work and well-being ascribed value to the following: a sense of purpose; the opportunity to feel useful and valued; fulfilment and satisfaction; social contact and support; stimulation and activity; material benefits and status.

These views on work's contribution to well-being are strongly supported by the literature. It is well recognised that work offers a social identify, social contacts and relationships, a means of structuring time, a sense of purpose, meaning and involvement (Jahoda, 1933; Shepherd 1989; Grove, 1999).

Mental health problems
Employees tended to regard mental health problems as a spectrum of difficulties which extended from the relatively mild to more severe difficulties that manifested as mental illness. Mental health problems were thought to interfere with the capacity to undertake everyday roles, tasks and relationships. It was commonly held that mental health problems were linked to the emotional distress brought about by difficulties in personal relationships or in the workplace.

Stress
Stress was considered by employees to arise from the mismatch between perceived demands and expectations on the one hand and perceived capacity and ability to cope on the other. The main sources of stress identified by employees included: workload and control; role clarity; performance and feedback; relationships at work; working environment, including job security and continuity.

While stress was regarded as distinct from mental health problems, the factors that generated stress at work were regarded as contributing to or exacerbating mental health problems.

Finding a balance at work between a level of stress that is motivating and a level of stress that creates unhealthy anxiety was considered to be unique to each individual employee and their own life circumstances including their family and social life and career ambitions.

Work and mental health and well-being

Contribution of work to mental health and well-being
Employees considered that balancing the demands of work and home life was crucial to their sense of well-being at work. This supports the findings of a recent Mental Health Foundation survey (MHF, 2003) which suggested that, as a result of working long hours, employees may be neglecting those aspects of their lives which them make more "resistant or resilient to mental health problems".

The work life balance is not static, but can fluctuate with different jobs and life circumstances. From the accounts of employees, there was evidence that people can learn to establish a balance that suits them, insofar as the workplace provides the flexibility to accommodate this.

It was clear from the findings that relationships at work were perceived as key, both as a protective influence in the face of stress and to promote a sense of well-being at work. However relationships at work could also contribute to or exacerbate experiences of mental health problems.

Overall employees' accounts of the factors that influenced well-being in the workplace were largely consistent with other sources:

A TUC survey of 900 respondents identified workload as the most detrimental factor affecting mental well-being at work, followed by the scale of change and the pace of work (TUC, 1998)

The UK Whitehall II study showed that how work is designed can affect employee mental well-being and physical health. The key factors highlighted were control and communication; effort / reward balance; support and understanding from managers (Stansfield et al, 2000)

The HSE has core management standards on work related stress (HSE, 2001). These seven standards cover:

demands, including workload
control: how much say the person has in how they do their work
support from peers and line manager, and training to equip the person for their job
relationships, covering harassment and bullying
role, to ensure clarity and avoid role conflict
change, to ensure effective management and communication of change
culture, to address the organisation's overall approach to stress

The most recent CIPD sponsored annual survey (Guest and Conway, 2002) asked 1,000 employees about workplace stress and found evidence of several different effects. Firstly workload, working hours and job content were more likely to be perceived by employees as having harmful effects on their health and well-being. Secondly, the social context of work, including help support and relationships at work, tended to be experienced as beneficial. In addition control over work and opportunities to use skills tended to act as forces for positive well-being.

Impact of mental health on work performance
Employees considered that there was a link between people's mental health and their work performance; however, the nature of the impact on work was perceived to be contingent on whether the conditions and relationships in the workplace were such that it was possible for the person’s difficulties to be identified and for timely support to be provided. Employees with experience of mental health problems tended to attach more weight than other employees to feedback and support to manage anxieties about performance at work.

These observations concur with evidence from elsewhere that people with mental health problems can gain and retain work, if the right support is provided (Crowther et al, 2001). In a comparison of people with a mental illness who had retained employment with those who had not retained employment, the factors that distinguished the two groups were organisational climate and person-environment fit. There were not differences between the two groups in individual characteristics, including diagnosis and history of illness (Kirsch, 2000).

Impact of mental health on work attendance
There were some difference in views among the two groups of employees about work attendance. Employees with personal experience of mental health problems considered that work attendance would not be affected by their mental health, as they had a strong sense of needing to pull their weight with colleagues and because attending work was of direct therapeutic benefit. Other employees were tended to the view that mental health problems probably would lead to absence from work.

As with work performance, it appears that the availability of support is a crucial factor and can reduce prevent sickness. One NHS Trust with a well established vocational support service for employees with mental health problems reports lower rates of sickness absence among this set of staff, compared with the rate for all direct care staff within the Trust (Rinaldi and Perkins, 2003).

Promoting mental health and well-being in the workplace

Employees were able to describe a range of ways in which their employers had been contributing to mental health and well-being at work and supporting people with problems. Often these actions or activities were mainstream and were not designated as mental health or targeted specifically at employees with mental health problems. This may have important implications for future action.

Employees harboured some scepticism about the integrity of intention behind polices, regarding policies primarily as a veneer. Discussion at the stakeholder workshop suggested that formal policies in the workplace specific to well-being, such as flexi-time or stress policies, would be unlikely to promote well-being unless they were part of a wider organisational approach. To work, it was contended that such policies needed to be supported by the organisational culture with commitment from all levels of the organisation and with clear accountability for employee well-being. It was considered that employees feel supported despite the absence of any formal polices for mental well-being, when they perceive there to be a healthy and supportive workplace culture.

Both sets of employees - those with and without identified personal experience of mental health problems - shared similar views about the workplace features that were indicative of good and supportive employer practices in contributing to employee mental health and well-being:

ethos and culture within the organisation that set the tone for relationships and experiences at work
working practices that valued and fostered peer relationships
accessible and supportive management structures and relationships
policies and procedures to ensure that good practice was established
flexibility and adaptation of role and workload to accommodate individuals
management of transitions and changes to support people moving into new roles or returning after absence

The perceptions held by employees concerning the workplace features that are important for employee mental health and well-being illustrate the importance of a whole organisational approach. A recent review of the evidence on mental health improvement in the workplace concludes that many of the factors that influence both physical and mental health of staff are psycho-social and relate to style of management and working culture. For this reason, the review concludes that mental health needs to be addressed systematically at an organisational, rather than an individual, level (Mentality, 2003).

Getting help and support with mental health problems at work

Employees considered that attitudes amongst the general population regarding mental health and mental health problems and how to support people with mental health problems filtered through into the workplace. Of note here therefore is evidence of the ambivalence of public attitudes in relation to mental health problems (Scottish Executive, 2002) and the persisting stigma associated with mental health problems in the workplace (Blackwell et al, 2001).

From the findings of the employee study and the study on employer perspectives (Lee, 2002), the initial identification of situations where an employee may be developing a mental health problem remains problematic, for both employees and employers. There appears to be uncertainty about how and when to raise the issue in the first instance and how best to deal with it. Employees were alert to the ambiguities associated with intrusiveness on the one hand and respect for the individual employee on the other.

Employees felt that a supportive working culture would engender expectations of a positive response when someone discloses a mental health problem and also be sufficiently flexible to accommodate and support both the employee and their manager. There is an evident need for tools to enable managers to identify employees at risk, before a crisis occurs.

It is important to note that the strongest factor associated with successful job retention is support from and active involvement of management. There are strong indications that without support of the supervisor or manager, return to work after sickness absence and job retention is seriously jeopardised (Gates, 2000).

A whole organisation approach to improving mental health and well-being in the workplace

The experiences of employees who took part in the study and their recommendations to improve mental health at work point to the importance of an integrated approach. The findings reinforce the interconnections between strategies and efforts to:

improve the well-being of all employees
retain and support people in work when they develop or experience mental health problems
facilitate the return to work of people who have or have had experience of mental health problems.

Set out below are the components which the findings of this study suggest make up a whole organisation approach to promoting and improving mental health and well-being at work, by considering the implications for organisations, for management and Human Resources functions within organisations and for individual employees.

Organisation wide responsibilities
According to participants in this study, to gain employer attention and commitment, there is a need to heighten employer awareness that the mental health of their workforce is a key asset for business success and for effective, quality service delivery and that the costs of not addressing this are high. It was also considered that employers stand to gain from enhanced workforce retention and from being recognised as an employer of choice.

The experiences and views of employees suggest that resource packs and tool kits are only one element of what employers need, and should be accompanied by training, support and advice to utilise resources and tools and contacts and connections with local networks of services and resources that can provide support to employees.

Employers require recognition if they are to strive to be employers of choice and need plaudits for good practice relevant to mental health and well-being. This might include acknowledging that a great deal is happening already and this need not always entail new or special initiatives. There is opportunity to make use of Scotland’s Health at Work scheme (SHAW), Investors in People and other routes to draw attention to well-being and ensure it is on the agenda of items that senior managers attend to.

According to the views of participants in this study, core factors that have a bearing on employee well-being are:

ethos and culture within the organisation: peer support and informal networks are a crucial resource that flourish in supportive organisations
employer commitment to the values of diversity and non discrimination, both in combating stigma and achieving heightened awareness of mental health and mental health problems
respect for employees, manifested by commitment to consultation and communication with staff and by promotion of flexible working arrangements

Establishing a whole organisation approach sets a framework for improving mental health and well-being and supporting employees, within which individual teams, divisions and departments can develop appropriate policies, procedures and practices. It is important to ensure that focus is on well-being at all levels within organisation to achieve equity and synergy of effort. It is also important to ensure that promotion of well-being and support for staff extends to staff at all levels, including senior managers and executives. Responsibility for employee mental health and well-being needs to be woven into an organisation's structures of accountability.

Management functions
Line managers are a key resource for employers in promoting the mental health and well-being of the workforce. The line manager role is well placed to provide support to assist employees with the factors that may affect well-being. They also need to be alert to early indications that employees are experiencing difficulties in order to take timely action to stop situations reaching crisis point. This means that managers need competence and confidence in communication and listening skills. Managers' job descriptions can be used to reinforce responsibility for employee well-being, by building this in as a performance indicator.

Organisations need procedures to facilitate access to information, advice and support for employees and for their managers. Policies and practices with regard to induction, return to work, appraisal, support and supervision all provide opportunities to maximise mental health and well-being. Working practices that value and respect employees and that give employees choice and control over their work as far as possible, contribute to employee mental health and well-being and support people with mental health problems.

Human Resources and Occupational Health functions
Staff turnover is costly in terms both of the expense of recruitment and of the experience and skills lost when people leave. Employers stand to gain by investing effort in measures to promote retention in work of people who develop mental health problems. These can include effective policies for dealing with sickness absence and return to work for people with mental health problems.

Methods of auditing well-being and stress at work can be useful to track trends and to pinpoint where attention needs to be directed. Occupational Health have a key role in this.

Communication and consultation with staff remain central to encourage dialogue and create a climate where it becomes easier to discuss problems, including mental health problems that affect work. Until this is possible, problems associated with mental health will remain hidden, to emerge when a crisis is reached.

Working practices with individual employees
Employees need to be made aware from when they are first recruited that they can talk about mental health issues and need to know how to access this type of support. Open door policies encourage accessibility. It helps to have options in addition to the line manager. There will also be sources of help in the local community if these are signposted appropriately.

Where an employee with a mental health problem is experiencing difficulty coping at work, looking with them at what changes can be made is an important first step. This can mean agreeing a change to workload or hours, setting and reviewing goals and providing feedback, arranging for gradual return to work after sick leave, arranging mentoring or buddying.

Inhibiting and facilitating factors

Taking action in the areas identified by employees in this research has to be informed by the features of the employer's world that are likely to stand in the way of or facilitate the desired changes.

Barriers to overcome
Undoubtedly the main barrier remains that of awareness, interest and commitment. As in previous work, this study points to the need to convey to employers that mental health and well-being are areas which would repay their attention (Mindout for Mental Health, 2002). The employee research and the earlier study by Lee on employers concur that the lack of understanding of mental health and mental health problems stands in the way of both employers' and employees' addressing mental health problems at work.

The employee study suggests collusion in workplaces, where employees are very wary of talking about problems they may experience, even when these problems have a direct bearing on their work performance and attendance, and employers appear not to register the mental health consequences (both positive and negative) of their policies and practices.

In addition, the perspectives of many of the employees in this study would indicate that the prevailing culture in many workplaces sets up a tension between the employer's duty of care on the one hand and a business ethic on the other that judges success in terms of performance and output, rather than seeing these as inter-dependent. This contrasts starkly with the strong ethical, legal and economic arguments, supported by an evidence base, which the Health and Safety Executive presents for employer action to address work-related stress (HSE, 2001).

Enablers and opportunities
There is scope, utilising the arguments put forward by the HSE and others to bring renewed attention to workplace mental health and well-being, not least on the utilitarian grounds of workforce retention and the enhanced performance that may flow from contented and supported employees.

The legislative framework to tackle disability discrimination requires employers to make reasonable adjustment to accommodate employees with a disability (Disability Discrimination Act 1995, HMSO). It has been argued that employers need to recognise the diversity of people who have a long term illness and disability to develop a range of responses which reflect the workforce profile (McLean, 2001). From the evidence presented here, for people with mental health problems, reasonable adjustments would entail flexibility of working arrangements and the provision of support. Broadly, what is required is a consolidation of those features of employment which tend to be recognised as good practice. It can be contended that in making the reasonable adjustments required to accommodate people with mental health problems in the workplace, employers could not only help to prevent recurrence of ill-health for people with pre-existing mental health problems but also, through the same courses of action, promote mental health and well-being for all staff and thus improve retention (Carr, 2003).

The employer research by Lee indicated that these cumulative messages have not yet been transmitted forcefully enough to employers to make the case. Lee suggested that employers were looking for a clear unequivocal rationale and a robust framework to guide their actions and to acknowledge effort.

The employee study included employees from a range of employment sectors, working in a variety of workplaces across Scotland. The particular challenges for small employers are evident in seeking to address the agenda set out here. What may be encouraging is the conclusion that much of what employees are looking for in the way of supportive workplaces (ethos and culture, working practices and supportive relationships, management of change, flexibility and workload management) is indicative of good employment practice, rather than necessitating special initiatives.

Recommendations

The recommendations are based on the findings of the employee study reported above, further informed by other research and by the experience of SDC in promoting mental health employment development (SDC, forthcoming). The recommendations are intended to form a framework for an organisational approach to improve mental health and well-being in the workplace.

Making the case to employers - a business oriented model

Three key messages emerge from this study of employee perspectives that need to be communicated to employers:

To improve mental health and well-being in the workplace and to support people with mental health problems, employees are looking for organisational practices that value and respect them
Steps to promote mental health and well-being at work are consistent with good employment and management practices. Action to improve mental health and well-being at work need not require special initiatives or an additional burden of work. Good organisational and employment practices have a major contribution to make to workplace well-being
Taking such steps will benefit employers by enhancing retention and recruitment and by improving quality and productivity of the workforce

In view of the reported confusion among employers about where to turn for reliable advice, information and support (Lee, 2002), better co-ordination and communication is required at national and local level among bodies that work with employers to promote consistency and to maximise impact.

Promoting job retention

The study has helped illuminate those features of work places and working life that employees find detrimental to and supportive of their mental health and well-being. There is an urgent need to point to existing examples of good practice in recruitment and retention.

In view of recent findings reported by the Department of Work and Pensions (2003) on employment retention after the onset of sickness and disability, which indicated that the highest risk factor associated with the onset of sickness and disability was reporting of mental health problems, there are good grounds for taking action on job retention under the auspices of the National Programme to improve of Mental Health and Well-being.

Experience elsewhere provides valuable models of what is required to facilitate job retention of people with mental health problems. There are timely opportunities in Scotland to develop programmes that are informed by the Bristol job retention pilots (Butterworth, 2001) and by similar work in the Netherlands (SDC, unpublished). Further, job retention within the NHS as a public sector employer has been also been amply described and evaluated (Perkins, 2001).

This would require establishing stronger networks locally and nationally among employers, employment services and mental health providers. It would also require a programme of development and support to promote skills and knowledge, to share experiences and ideas and to provide information and advice to employers.

Reward schemes

Employees were able to identify a range of ways in which their employers were contributing to enhanced workplace mental health and well-being. There is an opportunity therefore to build on existing good practice and to raise awareness of what else might be required. It is recognised that there are already intentions to extend the coverage of SHAW. Consideration should be given to build on the SHAW scheme, to give more prominence to mental health in acknowledging and crediting good employment practices. A possible template to assess good practice in mental health in the workplace, based on the findings of this research and broader experience, is shown in Appendix 4.

SHAW should strengthen its accreditation of workplace mental health practices using these criteria as a basis. SHAW should also take an active role in communicating to employers the legal, ethical and business arguments for the active promotion of workplace mental health at an organisational level.

Supports and resources for employers

The research by Lee reviewed information for employers on mental health and well-being and made a series of recommendations relating to the development of a resource to provide practical information. The proposals made in that study were for a resource that would act as a guide, to:

enable and equip employers to raise awareness of mental health and well-being in their workplaces
make the case for employers to take action to improve mental health
set out the skills and competencies required
highlight the likely areas in which employers were already taking action on mental health at work.

The research reported here from the employee perspective largely bears out these earlier recommendations. This study goes a stage further in generating the proposition that actions to improve mental health and well-being at work are inextricably linked to actions to support and retain people with mental health problems in work. In this regard therefore it would be important to provide further evidence of good practice to indicate the range and types of actions that employers are already undertaking that contribute to these goals.

In view of the particular issues for and constraints on small employers, the multi-agency steering group on mental well-being in the workplace should ensure that attention is directed towards identifying features of good practice in improving mental health in this sector.

Tackling stigma

The effectiveness of the steps set out above rests on the assumption that current attitudes and perceptions about mental health and mental health problems can be changed. Tackling stigma and negative attitudes to mental health is therefore a prerequisite. There are prime opportunities to consider how best the Scottish anti-stigma campaign 'See Me' can be taken into the workplace. One of the valuable features of See Me is the emphasis on real people recounting their stories and experiences. This may be a powerful tool within the work setting, to demonstrate to employers, managers and employees what is possible at a personal level, as a complement to the evidence and arguments put forward as the business case. It is suggested that this should be explored further as part of the National Programme, linking also to developing work on Recovery (SDC, 2002).

Future research agenda

The difficulties encountered in recruiting work settings and employees to participate in the employee study give a clear indication of how mental health is perceived in the workplace. There is a need for further investigation and development, through a combination of awareness raising, campaigning and training along with research activity, to identify the factors that contribute to greater openness about mental health and well-being in the workplace. In addition future research design should take account of the sensitivities associated with group discussion on matters relating to mental health in the work setting.

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Appendices

The study has indicated that improving mental health and well-being of employees relies heavily on the skills, competence and confidence of managers in effectively handling relationships with and among staff. Managers need to be operating within a framework of good business and employment practice that supports them in this role, reinforced through the organisation's policies and procedures.

There are also implications for management education and professional development. The research points to the need to review the extent to which management training and development programmes are geared to creating managers that have skills and confidence to deal respectfully with people, to communicate effectively and to listen sensitively. Consideration should be given to the development of in-company mental health awareness raising.

Appendix 1 - Research Advisory Group

Iain Grieve, Edinburgh Chamber of Commerce

Sheila Durie, SDC Employment Programme

Andy Crawford, Scottish Association for Mental Health

Christine Taylor, Box of Delights

Rory McKail, Federation of Small Businesses

Ian Tasker, STUC

George Shand, Intowork

Fiona Ross, National Schizophrenia Fellowship (Scotland) Employment Support Service

Lynne Davidson, Scottish Health at Work

Matthew Farrow, Confederation of British Industry in Scotland

Leona McDermid, Social Firms Scotland

Miriam O’Connor, HEBS

Fiona Tyrrell, Scottish Executive Health Department

Appendix 2 - Data collection

1. Focus groups

The focus groups concentrated on issues that could be addressed safely and sensitively in an open setting by people who share the same workplace. Data collection for the focus groups took place in three stages.

Preparatory questionnaire: Members of sample were asked to complete a confidential, preparatory semi structured questionnaire on key workplace stressors as mental health risk factors in their work place prior to their focus group. In their publication "Tackling work-related stress", 2001, the Health and Safety Executive identified seven key stressors in the work place; culture, demands, control, relationships, change, role, support, training and factors unique to the individual. Participants were asked to describe how the key stressors might impact in the short and long term. The questionnaire acted primarily as a tool to give the SDC research team insight into employee's experiences prior to the focus groups.The findings from this questionnaire are given in Appendix 3

Focus group format:

The focus group discussions were designed to include the following topics:

definitions and understandings
promoting mental health and well-being in the workplace, including work/life balance
addressing mental health problems in the workplace
examples of and incentives to change in the workplace.

The following Framework and Topic Guide provides detail of the format of each focus groups.

Framework and Topic Guide for Focus Groups

The programme for each focus group will be:

Arrival - tea and coffee and labels with first names
Introductions and explanation of research, aims for focus group and any questions
'Dumping' question

1. Definitions

Give out sheet with 'mental health, well-being, mental health problems, mental illness, stress' and ask participants to briefly note what they think the words mean before looking at them together. 'There are no right and wrong meanings - perhaps different meanings for different people'. Allow couple of minutes and then open up using flipchart.

Vignette

Hand out copies of vignette to aid discussion. Vignettes to be size 14 fonts for easy reading but also read out in case anyone has undisclosed reading problems. Use each vignette in turn

2. Imagine an ideal workplace, what should happen for this person?

3. Are there any ways that it might have been prevented from happening?

4. What would be the wrong way to deal with this situation?

5. What might encourage employers to take positive action?

6. Would there need to be incentives for employers? What?

7. Would there be any barriers?

Promoting mental health and well-being in the workplace

Thinking now about your own workplace:

8. What official policies are in place that demonstrate a positive approach to mental health and well-being? (For instance, good recruitment policies, family-friendly policies, duvet days, sickness provision, return to work interviews, provision of counselling or other support services, supervision systems)

9. What unofficial things promote mental health and well-being? (E.g. values like respect for individuals; the way people relate to each other at work, physical aspects of the workplace etc)

10. Can you give me examples of actions within your workplace to reduce stress or promote mental health at work?

11. Can you identify any further changes that need to be made in your workplace to provide a more positive approach to mental health and well-being?

Work/life balance

12. How do you balance your work and life outside work?

Addressing mental health problems in the workplace

The Disability Discrimination Act requires employers to make "reasonable adjustments" to help people with disabilities stay in their jobs. This includes people with substantial or significant long-term mental health problems, for example, depression, that may affect their abilities in day to day life.

13. What does "reasonable adjustment" mean to you?

14. How supportive is / would your workplace be in recruiting people with mental health problems? Examples?

15. Would someone receive support to get back into work after a period of absence?

16. [Only if used vignette about John] What would be the wrong way to deal with someone with mental health problems at work?

17. If there were one thing you could change in your workplace to make the experience more positive, what would that be?

Mental Health in the Workplace: The Employees' Perspective
Focus Group Vignette 1

John: John is 54 and has worked for a large company as a middle manager for 10 years. The company has recently brought in a new computerised accounting system which has significantly impacted on the way John has to work.

John was not used to using computers, he received a half day's training on the new system at work which he found difficult to understand. John has started to fall behind with his work and has become very worried about this to the extent of losing sleep at night.

He has tried to approach his manager to discuss his concerns, however she didn't seem to have much time to talk to him. John is starting to feel that he cannot cope at work and in other areas of his life and this is disrupting his relationship with his wife and family. John knows that his colleagues are aware that his behaviour has changed.

Mental Health in the Workplace: The Employees' Perspective
Focus Group Vignette 2

Karen: Karen is 27, she began to suffer from depression whilst studying at university and was prescribed medication for this. Karen had great difficulty continuing her studies and decided to leave university and travel for a year. Karen returned from her travels to make a fresh start and found a job with a small company.

She did not disclose her previous mental health problem at her interview or to her colleagues. This was because she was worried about being stigmatised and was unsure of how her disclosure would be received and whether her employer and colleagues would support her.

Karen has been in her job for two years now and has recently been experiencing some 'bad days' when she has called in sick and put it down to migraines or stomach upsets. Karen feels that she may be becoming depressed again and that this may impact on her performance and attendance at work in the near future. However she doesn't know how or whether to broach the subject at work.

One to one interviews

The face-to-face interviews with members of samples 2 and 3, provided an opportunity to explore in detail individual experiences and perceived needs in relation to mental health in the workplace. The interviews were tape recorded to ensure accuracy of recording and to facilitate in-depth qualitative analysis.

The main areas that were addressed in the interviews are as follows:

individuals were asked to give a definition of mental health problems and were asked whether they had experienced mental health problems at work
how does mental health impact on work performance and attendance? What were the individuals' own experiences?
how supported do/did people feel at work and what support would they like / have liked from peers, colleagues and immediate line mangers?
what are the main stressors for people at work and what coping mechanisms do they employ?
what relative importance do home life and work life have in terms of individual's mental health? How does this balance change?
perceptions of mental health and well-being in the workplace. How does the workplace contribute to their own well-being? In what ways does work make people feel positive and good about themselves?
perceived barriers and enablers that influence employer readiness and capacity to promote mental health.
what could their employer do / have done to improve their mental health and well-being in their workplace?

Stakeholder workshop

A stakeholder workshop was held at the conclusion of the fieldwork. Material from the workshop was used as an additional source of data for the proposed study as well as acting as a sounding board for preliminary conclusions.

The workshop entailed facilitated discussion structured around the key themes and issues emerging from the interviews and focus groups. The workshop focused on developing ideas and priorities for action to address these themes and issues and on identifying strategies to support implementation by considering the drivers, incentives for change.

Analysis

Analysis of the qualitative data collected from the third part of the focus groups and from the one to one interviews developed the main themes of interest to the research aims. Both systemic organisational issues and solutions and those that require an approach to meet the needs of the individual were explored.

Data collected in the second part of the focus groups were used to identify features and conditions required to implement the key changes suggested to improve mental health in workplaces. The data from each source: the two sets of interviews and the focus groups were each analysed with reference to common themes and care was also taken to consider disparities or divergences of view among the three sets of participants. The stakeholder group produced insights into the how the main findings and themes of the research might realistically be applied either in policy or in guidance to employers.

Appendix 3 - Focus group participants questionnaire

Focus group participants were asked to complete a brief questionnaire regarding the main work-related issues that may have a bearing on how people might become stressed at work. Participants were asked to describe how each of the stressors affected them in their current job. Their responses are summarised below

Culture of the workplace, i.e. the general attitude in your work place towards work-related stress:

respondents who reported a positive attitude felt well supported by their peers and / or line managers and some were aware of formal stress policies
those with negative experiences felt that they were restricted by workplace procedures and by the stress on task completion and by expectations of more effort in less time.

Demands of the workload - for example, the size of your workload and/or risk of physical danger:

workloads that fluctuated and were unpredictable caused anxiety
excessive workloads have a detrimental effect on home life and relationships with managers
regular discussions with line managers help to keep workloads manageable.

Control - this is how much say you have in the way you do your work

nearly all respondents felt they had a satisfactory degree of control. Those who did not found this a cause of stress.

Relationships at work - for example relationships which involve bullying and / or harassment

most respondents had not experienced bullying or harassment at work although a few respondents felt that they were exposed to a bullying environment, which was difficult to address openly or formally.

Change - how changes at work are managed and communicated to you

most respondents felt well informed about changes at work. Those who were not well informed felt that a lack of communication caused uncertainty and resentment.

Role - this is whether you understand your role you have in the workplace

understanding their role gave some respondents confidence. Clear job descriptions and regular appraisals help, although some were uncertain of their role within the bigger picture
not knowing what is expected of you at work can lead to stress, although a degree of flexibility in role can provide added interest to a job.

Support from peers and line management

support from peers and managers was essential to the respondents feeling motivated, encouraged, listened to and valued. Support seems to depend on shared goals and values.

Training - for you to be able to undertake the core functions of your job

staff had mixed experiences of training, many felt that they needed more training and more choice in their training.

The workplace catering for individual differences in the way you do your work

respondents welcomed the chance to feel like an individual at work and to enjoy a degree of autonomy, knowing where the boundaries lie. Encouragement from management was considered important in this regard
respondents could feel constrained by organisational cultures and procedures. Some felt that their ideas were not taken on board.

Appendix 4 - Criteria for assessment of good practice in mental health in the workplace

A written mental health policy or a policy statement which recognises the mental health needs of employees.

A dedicated occupational health unit or staff, with mental health expertise.
An Employee Assistance Programme with specific mental health components or access to equivalent.
A risk assessment, stress audit or other process, which assesses the overall employee group’s risk of stress or mental health problems, and can identify individuals at risk.
A sickness management plan which establishes procedures for managing employee absence due to stress or mental ill heath.
A system for early detection and intervention when a person goes off sick for stress or mental health problems.
A system for return to work planning for those absent through stress or mental health problems.
Initiatives to encourage informal supports in the workplace for those with a recognised mental health issue.
Evidence of preparedness to make workplace adjustments as part of a return to work agreement, e.g. a modified work programme.
A recognised mediation service for teams within the organisation which are not functioning well, due to inter-personal difficulties.
A performance management/appraisal system which invests managers with responsibility for workplace mental health and well-being.
Achievement of standards relevant to workplace mental health, e.g. 'Positive about Disability' symbol user, 'Investors in People'.

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