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Employee perspectives on mental health in the workplace

Contents:	Summary Introduction Methodology Findings Discussion Recommendations References Appendices

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.