Are we on the cusp of a mental health crisis?
Jenny Roper, April 23, 2018
A much more nuanced and well balanced article than the title led me to fear!
Read More Chris Morgan
April 24, 2018 12:56
As work grows more unstable and NHS provision falters, are we approaching a mental health perfect storm?
It was the end of last year when Angela O’Connor, CEO of The HR Lounge and former HRD at the National Policing Improvement Agency, started to notice a worrying shift among those she was coaching. People were articulating much higher levels of stress, and exhibiting more signs of anxiety and depression, than she’d ever witnessed. “Sometimes people didn’t have the words for it; but the issues were definitely there,” she reports.
A key theme emerged as O’Connor unpacked these feelings with her clients: Brexit. Her senior-level coachees were being affected by what mental health experts agree is one of the most significant causes of psychological ill-health: negotiating uncertainty.
“The world has become such a strange place in the last 18 months; no-one knows what to expect,” she says. “It’s confusing for people that the rules – which used to be ‘work hard, stay loyal to your organisation’ – are changing.”
Brexit is exacerbating for many a pressure that’s been building (courtesy of tech-fuelled ‘always on’ cultures and radically shifting working patterns) over the last few years: of never quite knowing when enough work is enough. In a climate where anything could suddenly happen to a business, where a completely unplanned-for strategy might be required – but could still prove the ‘wrong’ one – managers have no idea anymore how to get the job done.
The mental health fallout from this could be huge, feels O’Connor. Cary Cooper, 50th anniversary professor of organisational psychology and health at Manchester Business School, agrees.
“I’m hearing from a lot of people on Brexit and mental health, and it’s not positive,” he states, agreeing with O’Connor that: “It’s the uncertainty that’s the important factor. The most important cause of all common mental disorders – anxiety, depression and stress – is lack of control.”
Cooper agrees that these disorders are already, anecdotally, strongly manifesting among senior individuals. His and O’Connor’s observations concur with a recent survey by The Chartered Management Institute (CMI) of 1,037 managers, which found that 23% feel Brexit is affecting their morale and 22% their overall psychological wellbeing (14% directly attributed a rise in their working hours to Brexit).
“At a senior level it’s issues to do with how we manage a workforce at a time of great uncertainty,” says Cooper. “‘Do we get investments, do we sell products, where’s our market going to be?’ They’re thinking: ‘how do I manage my workforce if I can’t reassure them?’”
The pressure is no less great for junior colleagues. “For those people it’s: ‘will I have a job?’ Brexit has made job insecurity a lot worse,” says Cooper. “At middle management level it’s the same thing; they think they’ll be the first people to go.”
The trouble is that Brexit is by no means the only mental health pressure. The concern among many is that the present climate could represent something of a perfect storm, leading some to wonder if we might be on the cusp of a mental health crisis.
There’s evidence to suggest that, despite several years of encouraging awareness-raising on the topic, we (as a nation, and community of workplaces) still have a long way to go.
From a national perspective, a 2014 NHS study found that one in six (17%) people over the age of 16 had experienced a common mental health problem in the week prior to being interviewed – an increase from 16.2% in 2007. More long term, the proportion of people with severe symptoms of common mental disorders has risen from 6.9% in 1993 to 9.3% in 2014.
The government-commissioned Thriving at Work report, released in October and authored by Mind chief executive Paul Farmer and former HBOS chair Dennis Stevenson, revealed the implications for employers. It found that 300,000 people with a long-term mental health problem lose their jobs each year, with the annual cost to the UK economy of poor mental health standing at £99 billion; of which about £42 billion is borne by employers.
“That report highlights that the challenge we’re facing is much larger than we realised,” comments the CIPD’s employee relations and diversity advisor Rachel Suff, echoing the report’s authors’ sentiments upon releasing their findings.
Suff points out that the report also, however, contained some encouraging elements such as examples of best practice at companies, much greater awareness of mental health issues than 10 years or so ago, and the opportunity for dramatic, employer-led change over the next 10. The question for some is whether this will prove enough, given the scale of the challenge.
A nation in crisis
Skim recent mental health-related headlines and the key challenge facing the UK’s collective mental health (beyond Brexit) becomes apparent. Mental health services have undeniably borne the brunt of NHS cuts, with an analysis by health think tank the King’s Fund finding that 40% of mental health trusts in England had seen their budgets slashed from 2015-16.
Additionally, while 23% of NHS activity is taken up by mental illness, mental health trusts have been receiving only about 11% of funding in recent years. An analysis of official statistics last year pointed to thousands of people being sent more than 30 miles for services like acute care, psychiatric intensive care or rehabilitation.
The good news is that extra money has been earmarked; meaning that by 2020-21 £1.28 billion more should be spent in real terms than in 2015-16. The bad news, explains NHS Providers’ policy advisor Cassandra Cameron, is that health funding isn’t always this straightforward.
“Policy decisions over the last few years are now attempting to address that imbalance between physical and mental health funding. But we know that those decisions aren’t always translating into investment that will keep up with rising demand,” she reports.
“One of the really difficult things about the way the NHS is structured is how the money flows from central government to frontline services… What that means is there are ways it gets siphoned off to compensate for cuts made to other parts of the service. We get told by our trusts that investment isn’t necessarily flowing through to expanding provision; it’s being used to shore up support they’re already commissioned to provide.”
On top of this concerning lack of provision, and quite aside from Brexit, we’re facing some of the most profound societal shifts in decades, points out Kathryn Austin, chief people and marketing officer at Pizza Hut Restaurants.
“If you take it up to a macro level are we in the midst of a collective existential crisis? Are our traditional values and support structures (family, religion, governments, community, environment) changing more rapidly than we can cope with?” she muses.
Automation, as a significant element of seismic, macro-level changes is a serious stressor for many, adds group HR director for engineering provider Costain, Sally Austin.
“Bearing in mind that we have an ageing workforce tending to work longer and unemployment at an all-time low, for certain parts of the workforce there’s a feeling that ‘if I don’t learn new skills I’m going to be out of a job, and I don’t know what the new skills are’,” she says.
For those ‘out of a full-time job’ there’s perhaps gig working. But, while many defences have been mounted for the more empowering end of gigging, the potential pressures for many others (as highlighted in Matthew Taylor’s Review) can’t be ignored in any debate on mental health.
“As we’ve moved towards flexibility and the gig economy, the nature of a lot of jobs is that people are on their own for longer periods of time; they don’t have the social connections of work,” highlights Dan Lucy, head of research at Roffey Park.
“Those people might also be insecure [workers]. So there’s something about the nature of jobs and the health implications.”
This insecurity is particularly affecting the younger generations, says Martyn Dicker, director of people and learning at The Prince’s Trust. He points to his organisation’s most recent annual Youth Index, which surveyed 2,200 16- to 25-year-olds.
“Young people’s happiness across every single area of their life has never been lower. One in four feel trapped in a job they don’t want, one in five believe they’ll never amount to anything no matter how hard they try, and 44% think there’ll be fewer job opportunities for their generation,” he reports, adding worries around getting on the housing ladder.
Then there’s the dreaded ‘e’ word, cited by pretty much everyone HR magazine spoke to for this piece. “The obvious candidate for me is people’s relationship with email,” asserts Craig Jackson, professor of occupational health psychology at Birmingham City University.
“If you trace it right back, the stress epidemic started pretty much when everyone started getting email in the mid-‘90s… Email is great but it means more people can give you more work more of the time.”
“It’s the pressure of tech,” agrees Business in the Community’s (BITC) wellbeing director Louise Aston. “It’s our 24/7 always-on culture, the global economy, working across time zones… We know that sleep is emerging as a massive topic for employers.”
A pretty gloomy picture then, spelling an urgent need for employers to plug NHS gaps but also contend with a maelstrom of ever-building macro-economic, societal and technological pressures.
But to this concerning outlook, many would sound a more optimistic note. Rates of reported mental health conditions have steadily increased. But a significant factor is greater awareness and willingness to self-identify and seek help, points out NHS Providers’ Cameron.
“We know that rates of depression and anxiety seem to be growing relative to population. We know that there are rising numbers of people in particular risk groups,” she says, highlighting that women are now much more likely to have a common mental illness; with one in five reporting they have, compared with one in eight men in England.
“But there’s also definitely increased openness. So it’s a combination of both social risk factors but also greater awareness.”
The more positive outlook is that although the number and intensity of pressures facing people at home and at work may have crescendoed recently, society and workplaces are hopefully doing a decent job of keeping pace.
“We are in a perfect storm but I genuinely believe, based on the evidence, business is waking up to the scale of the challenge,” comments Aston.
“We’ve had national awareness campaigns like Time to Change and royalty talking about their mental health,” she adds, citing Prince Harry’s recent disclosure that he sought counselling after struggling to come to terms with his mother’s death. “We’ve got things like the City Mental Health Alliance, the government’s Thrivng at Work review… More business leaders talking openly.”
Workplaces are on the whole now participating in being part of the solution, agrees Jaan Madan, head of Mental Health First Aid (MHFA) England’s client experience team. “I think it’s important not to confuse increased awareness of the problem with being at breaking point,” he cautions.
“Workplaces in a wide range of industries have been struggling or just about managing for some time when it comes to wellbeing. But growing awareness is now helping the workplace mental health agenda take root – something we’ve seen happening more and more over the past 18 months.”
“I know we have a perfect storm brewing but I think we’re in a much better place now than three years ago say, in terms of people’s personal awareness,” concludes Aston.
Lack of support
She adds though that “we’ve still a hell of a long way to go”.
For Mark Winwood, a counselling psychologist and director of psychological health at AXA PPP Healthcare, this means action to back up awareness-raising. What we’ve done an in some instances dangerously bad job of is backing up awareness-raising with support. Without this we could be exacerbating the perfect storm, warns Winwood.
“The crisis is going to be not having sufficient services to help individuals who identify as needing support,” he says, pointing back to the NHS mental health funding crisis.
This is playing out at an organisational as well as societal level, he adds. “The whole awareness and mental health first aiders thing is fantastic, because it’s helping people to help themselves and be better colleagues, friends and family members in supporting each other. But my concern is where do people who need professional, qualified help go?”
“There’s also a danger of some employees disclosing in an unsympathetic organisation,” points out Aston. “So [awareness-raising] could actually do more harm than good,” she says. “We know through our 2017 Mental Health at Work Report that 15% of employees who disclose are subsequently demoted, disciplined or even dismissed. That translates into about 1.2 million nationally.”
Birmingham City University’s Jackson cautions that there is a complex, tricky issue here around misidentification of ‘normal’ stress and challenge as poor mental health.
“I’ve been lecturing about the stress epidemic in the workplace since about ’97 and the subtext I always give is: is the world getting more stressful or are we just better at complaining about it?” he says. “I believe the more we talk about it, the more education you have, and the more stress awareness courses we have, it’s actually making the problem worse.
He adds: “I’m surrounded in my work by a [younger] generation who get a lot of their information online and from other people like them. It creates and perpetuates the belief that the world is a bad place and that ‘mental health’ is going to get them sooner or later.
“People talk about students ‘finding it a challenge’. Well it’s supposed to be. Like work, if it’s done properly it should be a good challenge,” says Jackson.
“The problem is that whenever something becomes very prominent you can fall into that thing of it becoming a bit like whiplash. Where rather than dealing with the problem we start to inadvertently foster victim- and dependent-type behaviours,” agrees Pizza Hut’s Austin.
“Stress is always bad but pressure in the right conditions, we thrive on,” adds Sally Hemming, associate director of ER and talent at EY and a PhD researcher and lecturer on chronic health and employability at Loughborough University.
Time for action
The next step for many employers, then, is to ensure they’re awareness-raising in the right way – by educating employees around what constitutes ‘good pressure’ and what’s a mental health issue. And crucially it’ll be about backing this awareness-raising up with action and concrete support.
Organisations need to put their money where their mouths are and invest in robust mental health counselling, employee assistance programmes (EAPs) and private healthcare support to help plug NHS gaps, feels Winwood.
“We’ve got a situation with mental health similar to where we got to with pensions; with employers having a strong role in terms of safeguarding the health and wellbeing of employees where the NHS is not fit for purpose,” agrees Aston.
“Some forward-thinking organisations have expanded their EAPs to include more long-term extensive intervention such as cognitive behavioural programmes,” reports Winwood. “Which evidence suggests are very effective for anxiety and depression, for example.
“Good mental healthcare costs money; good EAP services aren’t particularly cheap and cheap EAPs aren’t particularly good,” he says. He advises that making the case for strong support might be about highlighting, as HR would in any other risk management process, poor mental health as a serious risk factor (citing for example the £42 billion burden to employers figure in the Thriving at Work report).
“There’s so much evidence to demonstrate the ROI for putting this in place,” says Winwood. “If you frame mental health as you would any other risk then you can ask: what would you be willing to pay to mitigate or manage that risk more effectively?”
Jackson agrees there’s often no cheap quick fix. “The problem we have is there’s the potential for more snake oil salesmen,” he says. “We’re already seeing internet counselling… Lots of people will make money but lots will suffer from iatrogenesis [where a health professional or therapy actually causes harm].”
The rebuttal from many will be that extensive EAPs, private healthcare services and the like are all well and good for larger organisations, but are unaffordable for small firms.
This is where larger businesses must again step into the breach, feels Manchester University’s Cooper. “It would be great if the government set up a challenge fund for SMEs for provision here… But that’s unlikely to happen with the government so preoccupied with Brexit,” he says.
“So instead of doing some of the things they do around CSR, why don’t large organisations actually provide their main suppliers and small companies in their area with access to their resources? Small companies could pay them a small amount; they could sell it really cheap.”
Others would point to cost-effective alternatives to EAPs. Jackson stresses the importance of employers simply being well-educated about where to refer employees: “There’s a lot of confusion among the general public on: if you have mental health problems, where you can go? But for most people it’s still the GP,” he says.
Workplaces “can do more than EAPs” anyway he says, citing “relaxation, yoga, mindfulness…” “It might sound gimmicky and silly but it’s still an attempt to do something and make the workplace more humane,” he says.
Pizza Hut’s Austin suggests partnering with a mental health organisation. “We partner with Rethink so if someone is struggling they know they can contact them,” she says. “We’ve got venues we can provide. We can help with some of their initiatives, and in return they’re a place for people to go. So mutual partnerships are great.”
She adds that rolling out comprehensive support as and when people need it can prove a robust yet affordable approach. “Depending on your scale, if you’re relatively medium-sized you try and deal with things on a case-by-case basis,” she says.
Kate Shaw, HR director for the UK and Ireland at pladis Global, advises enlisting the workforce to suggest what would make the biggest difference to them. “We put in place a working party [on this]. That created a platform where we got both fantastic senior management and grassroots involvement.”
Then it will be about tracking results. “How we measure things is important,” says Shaw. “For us that’s through the engagement survey and attendance.”
“It’s really important for employers to say: what effect do we want these things to have?” says EY’s Hemming. “When it comes to ROI it’s being clear about that and how you will know when you’ve achieved it.”
“People think less employees off sick because of mental health will be the indication you’re doing really well. But you might see an increase, or increased use of your EAP, because people now feel they can take that time out,” points out Faye McGuinness, head of workplace wellbeing programmes at Mind.
Corporate director at Bupa UK Patrick Watt adds though that small businesses, even if they can’t afford such provision, have a huge opportunity – potentially even more so than larger firms – to control one of the most important factors relating to mental health: the organisational element.
“Small organisations have a span of control over the whole workforce, which is much better than larger organisations,” Watt points out. “What the leader does, or what everyone does in that office of 20 can have a huge impact.”
Unfortunately many workplaces – big and small – are yet to fully recognise this organisational dimension. And while political macro-trends are certainly exerting new pressures, many factors creating poor mental health are directly attributable to, and caused by, bad workplace practices.
“Factors really do vary from one employee to another, but frequently-cited stressors include long working hours, excessive workloads, low pay, insecurity, poor relationships with managers and other colleagues, unrealistic targets… So we know there are a lot of organisational factors,” states McGuinness.
She cites a 2014 Mind/YouGov poll that found more than half of workers surveyed said they found work ‘fairly or very stressful’. “That was more than for financial problems or relationship breakdown,” she comments.
“The perfect storm is this,” says Cooper. “Number one is Brexit. Number two, even before Brexit, the recession changed the nature of work… The third reason [has] been there all the time. But it became more prominent because of the recession. It’s the line manager; we have the wrong kind and they’re causing enormous trouble.
“Before the recession we didn’t have many EQ-skilled managers but we didn’t need them. People just left when they had a rubbish boss. Now non-interpersonally-skilled line managers make insecurity from Brexit and recession 10 times worse.”
These organisational elements are harder to fix, meaning many have opted for superficial solutions, says Cooper.
“It’s a profound shift that’s needed. It’s easier to do massages at your desk, ping-pong tables and beanbags, to have EAPs and mental health first aiders – which are great, don’t get me wrong. But it’s not solving the problem. EAPs work up to a point. But they don’t get rid of a bullying management style or a long-hours culture or a glass ceiling for women; that’s structural change.”
The issue isn’t principally one of cost, feels Cooper. But rather bravery. “HR is actually a source of the problem,” he says. “Because we think it’s too complicated and scary to take action. We would have to do an audit of all of our line managers to find out who’s untrainable and shouldn’t be there. But our survey [by Roberston Cooper and the CIPD, out soon] found it’s getting rid of people that causes [HR] the most stress. So HR doesn’t like doing it.
“Then you’ve got to find the budgets for training and you have to redesign your recruitment policy. That’s very doable but you have to be brave.”
Pizza Hut’s Austin agrees that the most powerful thing HR can do around mental health goes back to robust, carefully-considered HR practices. Such practices can go a long way to counteracting potentially mental health-compromising large-scale flux outside the workplace.
“In our business we have lots of young people from unstructured backgrounds… When they enter the world of work it’s the first time they’ve joined a social community and they have to learn the norms of that culture.
“So our primary way of supporting mental health is not through a charitable approach or intermittent events. It’s a behaviours approach. Our behaviours approach builds constructive behaviour, grit and resilience.”
Dicker points to his organisation’s newly-revamped appraisals process as something that will – in addition to EAP support and signing up to the Time to Change pledge and action plan – foster a strongly supportive culture.
“We’re moving to continuous review and development. The point is having the right conversation and more of a coaching culture.”
He adds a cautionary note to HR not to move so strongly to a strategic, profit-enhancing focus that attention on wellbeing is lost. “We now spend much of our time advising on organisational design and development, being strategic… But that shouldn’t take away from our critical role supporting workplace wellbeing,” he muses.
“You wouldn’t want to swing the pendulum too far. You wouldn’t want to go back to a tea and tissues type team. But we need to make sure we’re positive advocates for mental wellbeing.”
Mind’s McGuinness agrees that good strategic HR and preserving robust mental health among workers should be one and the same. HR must look to policies that currently sit in opposition to its mental health activities elsewhere, she says.
“We get feedback from employees that what the organisation is saying doesn’t necessarily match up to the policies,” she says. “In a programme I oversaw for the emergency services quite a few people fed back that when they’d been struggling with their mental health and their performance wasn’t up to scratch, rather than being supported they’d been put through formal performance management processes.”
The key is being able to flex provision and policies around individuals, says O’Connor. “There’s a bit of a one-size-fits-all approach to mental health but we’re all completely different,” she says. “I have this horrible nightmare of HR creating even more risk assessment processes to deal with stress, which are utterly irrelevant because people are so different.”
For this reason it’s crucial, says the CIPD’s Suff, that employers take a “holistic” approach. “No single initiative will be enough on its own,” she says.
Employers mustn’t lose sight of the huge range of mental health conditions that exist, says Hemming. Nor the fact many conditions will always exist irrespective of external stressors, while others are possible to prevent. “There’s a huge bucket of people with conditions other than stress, anxiety and depression not being focused on currently,” she worries.
For those with generally good mental health it’s about educating people to take ownership around their individual triggers.
“If people had a bit more attention for themselves and wouldn’t trade that for a job this would be easier,” she says. “We need to get people thinking: what are your pressure points and how do you know you’re there? Is it tears, sleeplessness, inaccuracies? And how do you know when you’re in a place of performance?”
The bottom line for many is that while long hours and intense, socially-unrewarding work can have an extremely detrimental impact, good work is invaluable to good mental health.
Brexit and other macro factors may be exerting pressure on employees as never before, but workplaces can still provide a place of sanctuary, believes MHFA England’s Madan.
“With added uncertainty at present, a focus on wellbeing is one thing we can do to ensure we’re as prepared as possible for the challenges the next decade will bring,” he says.
This will take considerable effort on HR’s part. Awareness-raising activities now urgently need to be backed up with concrete action and support and – crucially – investment. Employers will need to look to everything they do as an organisation, scrutinising the very HR practices that sit at its core.
As last year’s Thriving at Work report makes clear, the issue can no longer be ignored. There are huge costs attached to mental ill health, and a huge opportunity to not only meaningfully affect society, but also reap the commercial rewards of a healthy, happy, highly-productive workforce.
“As Aristotle said: all work distracts and absorbs the mind,” says Jackson. “Workplaces are still the best potential we have for improving people’s mental health. You’ve got people for 37 hours a week, seven-and-a-half hours a day.
“I’m still convinced work is the best route we have to get people happier and healthier.”