The management of mental health at work

This is an independent, evidence-based research paper produced by Dr Maria Hudson from the Centre for Work Organisation and Society at Essex Business School.

The views in this research paper are the author's own and do not necessarily reflect those of Acas or the Acas Council. Any errors or inaccuracies are the responsibility of the author alone.

This paper is not intended as guidance from Acas about how to manage mental health at work.

Background

Mental illness is the largest single cause of disability in the UK.  Workplaces are amongst the institutions that contribute to, and impact on, our mental health throughout our lives. There is a continuum of mental health needs (Acas, 2014) - see table 3.1.

The complexity, diversity and range of root causes of mental health conditions make management of mental health at work difficult and challenging, especially for line managers who are often on the frontline in supporting colleagues or signposting them to additional support.

In commissioning the research on which this report is based Acas was keen to develop qualitative case studies with employers, to:

• (a) provide valuable insights on their experiences
• (b) be a source of good practice to other employers that manage staff with mental health conditions
• (c) feed into and help shape Acas's ongoing programme on mental health at work

The report explores the management of mental health at work in a variety of workplace contexts in the public, private and voluntary sectors. 30 semi-structured interviews were undertaken, largely across 6 case study organisations. A small number of interviews were carried out with key stakeholders in each organisation.

Both the report and its recommendations are underpinned by a ‘soft’ biopsychosocial model of mental health which recognises mental illness, and the health care support needs that can arise from it. However, the soft model places much greater emphasis on the need to mobilise change in the broader structure of social arrangements, addressing the barriers that people with mental health conditions encounter in the workplace, labour markets and wider society.

Mental health at work: organisational challenges

A range of factors within and beyond the workplace were found to contribute to mental health problems in the workplace. Outside work, these included a variety of issues, for example: bereavement, relationship breakdowns and family problems; addiction; finance, debt and housing issues; and genetics.

In the vast majority of cases, such influences were acknowledged as being beyond the control and influence of employers. However research participants noted that as we see a growing awareness of mental health, there is increasing acknowledgement of the need for employers to be mindful of the circumstances and challenges facing individuals outside of the workplace.

Key challenges to positive mental health within the workplace were found to include organisational change (both in terms of how this is managed and how it is communicated to employees), downsizing and work intensification and the impact this has on stress levels and work-life balance, and line management capability to engage with staff when it comes to interpersonal interactions, including around performance management systems.

Organisational change, downsizing, increasing workloads and pressure at work can manifest themselves in potentially negative ways, including impacting negatively on mental health and staff leaving the organisation due to stress. In different ways and to varying degrees these issues were evident in the private, public and voluntary sectors and could be complicit in the generation of the ‘anxious organisation’.

The evidence base suggests that anxious organisations tend to experience an ongoing struggle to effectively manage change, an increasing pressure to perform better and a management culture that mirrors the anxiety rather than contains it. There were some signs of these dynamics in many of our case study organisations.

Mental health at work: organisational responses

Most organisations need a 'business case' for developing workplace interventions, but the evidence suggests that there is a much bigger ‘human case’ for prioritising mental health. Recognition of the challenges associated with mental health problems have led to a growing acceptance of the need to prioritise the management of mental health as part of the employment relationship. Participants in this research were driven by a range of factors in their desire to address the challenge. They particularly emphasised the role of business pressures and understanding and respect.

Mental health and wellbeing are increasingly being seen as core components of business strategy, linked to both staff retention and customer satisfaction. The potential benefits of this were recognised and monitored in terms of the operational impact of absence on the business, lowering morale and increasing staff turnover.

Examples of good practice in the case studies reflect the personal commitment from senior leaders to champion the promotion of positive mental health. Those employers in the charitable sector were particularly concerned to help those with mental health problems to perform to their best and to be able to stay in work.

Examples of actions organisations took to promote positive mental health at work were given. Potential solutions often conveyed the need for a multi-faceted approach to managing mental health and the complexity that needed to be addressed. This complexity is summarised in table 3.1.

Constructive employer actions included, for example:

• having strong leadership around mental health seemed to contribute to engagement with the wider landscape of advice on better practice in the management of mental health at work, as well as the implementation of innovative practice
• the larger organisations ran workplace campaigns to highlight the ongoing stigma surrounding mental health
• having an early warning system in place, so that staff who felt unwell would be asked to answer a range of questions on their sense of wellbeing, enabling managers to provide the right level of support their answers would then flag a green, amber or red categorisation of mental health - a red outcome alerted line managers to hold a one-to-one meeting with individuals within 7 days and provide support
• a supervision policy to support the development of a workplace culture where staff felt empowered
• using alternative therapies such as mindfulness to promote the development of emotional intelligence and resilience
• tailored help and advice for line managers and employees, for example: 
  • for line managers documenting health conditions and reasonable adjustments so that if there was a change of line manager, histories of health and support needs were not lost, and also using intranet systems as repositories of information
  • for employees, Employee Assistance Programmes that provided access to a range of support services, particularly advisory services and counselling
• line management training helping line managers to be a little more confident and self-reliant whilst recognising that they are not expected to be experts on mental health needs
• employer outreach activity helped to challenge the stigma that continues to surround mental health

Supporting employees with mental health issues: the experiences of line managers and employees

The report also considers how disclosure of mental health issues, the management of the process of returning to work and reasonable adjustments influenced how supported employees with mental health needs felt in relation to being at work.

Employees with experience of mental health issues felt that stigma was a key influence on their decision to disclose. All of the line managers interviewed felt that early detection of mental health issues was important but that stigma could fuel reluctance to disclose. Having or making time to get to know their work team aided the ability of line managers to observe that a colleague might be in need of support.

Employees with mental health issues repeatedly emphasised the importance of being able to communicate with line managers and that they should be approachable. It was also perceived to be important that line managers had the emotional intelligence to be aware that in some situations co-workers might be a more appropriate person for someone with mental health needs to talk to.

Employees with mental health issues who had taken a related leave of absence suggested that a range of factors helped them to return to work.

This included:

• being given time to access the help of health professionals, such as their own GPs and counsellors; they were also signposted to such help, for example via employee assistance programmes
• not being pressurised to return to work prematurely, but instead being given time, space and a sense of control over the pace of their return to work
• being given time to become re-orientated to the workplace
• reasonable adjustments being made, for example changes to hours of work and avoiding sources of stress that might trigger symptoms

Line managers recognised the importance of making reasonable adjustments for people with mental health issues and provided numerous examples of where this had worked well, helping to avoid absence or supporting a return to work.

Lessons and recommendations

Recommendation 1: supporting the role of line managers

Line managers play a crucial role in the promotion of positive mental health at work and need the right level of support and training. This is essential to promote early detection of mental health problems, encourage early disclosure, where appropriate, and facilitate and accommodate an early return to work following sickness absence.

Recommendation 2: a more joined-up approach

We need a joined-up organisational response to promoting positive mental health involving all organisational actors (senior managers, line managers, people with mental health conditions, their co-workers, human resource managers, trade unions, and others in roles providing specialist support).

Without this joined up working, barriers to the labour market and workplace participation facing people with mental health conditions cannot effectively be broken down. Without this there will be a gap between organisational policies on the management of mental health at work and what happens in practice.

Recommendation 3: avoiding the anxious organisation

Organisations need to recognise the factors that can cause them to become ‘anxious organisations’, such as ongoing disruptive change and lack of people management skills. Responses to any concerns need to be addressed with full management support, using some of the examples illustrated in this report – such as empowering staff and training line managers.

Recommendation 4: advice and guidance

Acas should work with relevant stakeholders to produce more specific/tailored advice for how to manage each of the four areas set out in the ‘mental health continuum’. This may help organisations engage with the full complexity of mental health and achieve a balance in their efforts to promote positive mental health, supporting a broad range of lived experiences and support needs.

Recommendation 5: tackling stigma through employer outreach activity

There is added value in supporting employer outreach activity, drawing on the experiences of people with mental health conditions, to challenge the persistent stigma that surrounds mental health. Having more outreach projects like those featured in this research around the country may make a real difference to more positive and constructive employer engagement with mental health issues and the promotion of positive mental health.

Recommendation 6: staff empowerment

Organisations should also explore how the empowerment of staff can help to promote positive mental health, helping to provide more control over working lives in the context of organisational uncertainty and change. This may help to foster a workplace culture where individuals feel more comfortable and a sense that there is trust in the workplace, helping to minimise anxiety.

Workplaces are among the institutions that contribute to, and impact on, our mental health throughout our lives. This research paper seeks to explore the management of mental health at work in a variety of workplace contexts. In addition, it aims to examine the sometimes complex realities that need to be engaged with in order to promote and foster positive mental health. These aims are set out in full below.

This introductory chapter also provides a summary of this study’s research design which was centred on a case study approach and presents findings of a brief literature review, in order to set out the subject context.

This review is structured in the following way:

• first it sets out a continuum of mental health (Acas, 2014), conveying the complexity of the topic
• second, it addresses the issue of individuals’ reluctance to disclose mental health conditions and the related persistence of stigma that influences experiences of labour market discrimination and disadvantage
• third, it considers the links between mental health and workplace effectiveness; and considers some solutions
• the chapter closes with an outline of the report structure

1.1 Research aims and design

1.1.1 Research objectives

The research sought to focus on enablers, achievements and organisational benefits in the management of mental health at work. In so doing it also aimed to draw out the challenges being encountered, including less visible issues and emerging issues that might reflect the changing nature of labour markets. Taking a qualitative, case study approach, the aim was to focus on particular health conditions, namely depression and anxiety, whilst engaging with other conditions when highlighted by participating organisations.

Key questions included:

• what are employer perceptions of mental health and the root causes shaping it within and beyond the workplace in the current employment landscape?
• how is mental health perceived to be influencing workplace effectiveness?
• what kind of challenges are employers encountering in trying to promote positive mental health at work, including issues around disclosure?
• what kinds of sources of guidance/standards are being drawn on by employers?
• are there gaps between formal policy and informal practice and if so why?
• how equipped are line managers to manage mental health conditions at work and what are employers doing to support them?
• what kind of interventions may be contributing to healthier workplaces, how and why?
• how do the experiences of people with mental health conditions contribute to understanding of good and bad practice?

The research sought to explore these questions via a discrete qualitative study. In commissioning the research, Acas was keen to develop qualitative case studies with employers to provide valuable insights to their experiences and to be a source of good practice to other employers managing staff with mental health conditions.

This was undertaken with a view to feeding into and helping to shape Acas's on-going programme of work on mental health, including training, advisory work and written guidance.

1.1.2 Research design

A multiple case study approach

This was a small-scale project seeking to build a picture of practice, issues and learning points relating to the management of mental health at work. A short search/review of academic and grey literature covered how poor/insufficient management of mental ill health adversely affects workplace effectiveness and good practice. This also fed into the design of research instruments, for example providing context to the interview topic guides.

A qualitative case study approach was adopted, involving interviews with organisational actors and, where available, collection of policy documentation. To maximise the relevance of the research, data was collected from a diverse range of sectors and organisations in England covering the public, private and voluntary sectors.

The case studies provided insight into experiences of organisational life, engaging with perceptions, experiences and practices at the individual, team and organisational levels where possible.

The project attracted some interest (publicity generated by Acas). It was therefore decided to undertake a small number of additional interviews with individuals who expressed interest in participating via social media channels who had relevant personal experience of mental health issues (workers in the charity sector, the NHS and a consultant working in the mental health area).

Case study sample

The main organisational case studies were sampled and recruited via 3 methods: literature search and reviewing of websites; Acas suggestions from adviser activity; and consultation with people and organisations undertaking work relating to mental health. Trade union advice was sought in the education sector. A brief overview of the case study organisations is provided in table 1.1.

Table 1.1: The case study sample

Qualitative research can lead to insightful examples (Alvesson and Deetz, 2000). A small number of semi-structured interviews were undertaken with key stakeholders in each organisation to build insights into the management of mental health at work (see table 1.1).

Interviewees included:

• human resource / diversity / general manager / head of wellbeing service (this was typically the first interview undertaken to provide an initial organisational overview)
• line managers
• a trade union representative where unions were recognised
• other specialists, such as occupational psychologists
• employees experiencing mental health conditions (particularly depression and anxiety) who had benefited from good practice

Ethical considerations

The research proposal went through a process of ethical approval by the University of Essex, which provided due consideration to issues of informed consent and confidentiality. All participants were provided with information sheets about the research to support the process of securing informed consent. It was emphasised that all information collected from or about staff would be anonymised and kept confidential.

On completion of the case study the researcher would discuss whether organisations might be willing to be named in the outputs. It was also emphasised that participation in the research was entirely voluntary and participants could withdraw at any time.

In this report the individual contributions of research participants are presented anonymously and, given the small number of interviews per case study, organisational pseudonyms are sometimes avoided where there is any risk that they might reveal identities.

Topic guides and data analysis

A range of themes were covered in the topic guides (see Appendix 1), including for example:

• employer perceptions of mental health, the factors shaping this and its influence on workplace effectiveness
• mental health policies, procedures, sources of guidance/standards
• development/experience of supportive practices
• line manager skills, mind-sets and experiences vis-a-vis mental health issues
• implementation challenges and how they have been/might be overcome
• the kinds of interventions that promoted positive mental health contributing to healthier workplaces
• the experiences of people with mental health conditions

A criticism often levelled at the case study method is that it provides fragile grounds for making generalisations. However, in relying on data collected from particular situations, they are useful for asking 'how' and 'why' questions, seeking explanations and illuminating key features of a phenomenon. The approach suited the exploratory and small scale nature of the research.

All interviews were digitally recorded and transcribed. Case study summaries were developed providing an overview of organisations’ policies, practices and experiences. Such individual case study reports support within-case analysis, providing an opportunity to explore unique patterns in a case as well as converging evidence (Eisenhardt, 1989) and helped in the early mapping of learning points from the organisations. A coding framework was developed and data analysis was undertaken with the assistance of Nvivo11, supporting thematic exploration.

The remainder of this report presents a thematic overview of the research findings, illustrated with case study examples. Information drawn from the case studies is presented anonymously.

1.2 Context and review of literature

1.2.1 Mental health, the continuum of mental health and the complexity of managing mental health at work

The UK’s Chief Medical Officer (CMO, 2013) reports that mental illness is the largest single cause of disability in the UK. Box 1.1 presents the CMO definition of public health and mental illness which indicates that common mental disorders affect around 25% of the UK population.

The most recent large-scale survey of adults living in England found that nearly one person in four (23%) had at least one psychiatric disorder (Health and Social Care Information Centre 2009 cited in CIPD, 2016a). Mental health exerts a strong influence on our everyday lives, including how we think, feel, behave and relate to other people. It involves our emotional, psychological, and social wellbeing. Mental health can be shaped by biological factors (for example, genes or brain chemistry), life experiences (for example, a traumatic event) and other environmental factors. Therefore an individual’s mental health can also change through the life course and affect their working lives and experiences.

Moreover, as people are living and working for longer, they are more likely to be affected by a mental health condition at some point in their working life.

In contemplating the range of scenarios that an employer might need to engage with in the management of mental health at work, it can be helpful to think of mental health as a continuum (Acas, 2014), covering 4 areas (see table 3.1 for more information):

• employees with positive mental health and no diagnosis of a mental health condition, for example, an individual encountering a moderate degree of stress at work and able to cope with this
• employees with poor mental health and no diagnosis of a mental health condition, for example, a bereaved individual experiencing symptoms of anxiety linked to loss who does not see themselves as having a mental health condition
• employees with poor mental health and a diagnosis of a mental health condition, for example an individual with a history of depression currently experiencing depression, the symptoms of which have been amplified by a stressful work environment
• employees with positive mental health and a diagnosis of a mental health condition, for example, an individual managing bipolar disorder through a combination of medication and psychotherapy

Throughout their lives, individuals can move between different parts of the mental health continuum and some people with a mental health condition will not necessarily realise this fact or think of it in those terms. The complexity and diversity of mental health conditions can make management of mental health at work difficult and challenging, particularly for line managers.

Mental health is influenced by social, economic and environmental factors. Workplace contexts are not static and economic pressures, organisational change and work restructuring add to the complexity of the management task. Some mental health conditions are longstanding and permanent while others are acquired and may be temporary. Thus employer efforts to promote positive mental health are likely to require reactive and preventative measures.

1.2.2 The persistence of stigma, labour market disadvantage and reluctance to disclose mental health conditions

The Chief Medical Officer (2013: 149) notes that mental health can involve:

"Distressing and disabling symptoms; chronicity if untreated; high rates of co-morbidity; effects on many aspects of individuals’ lives; spillover effects on families and communities; disrupted employment; associations with anti-social behaviour and crime; links to self-harm and suicide; widespread stigma, discrimination and victimisation; and interconnections with socio-economic disadvantage and inequalities."

As Thornicroft (2006: 50) argues, drawing on Warr (1987), work can potentially promote positive mental health in a variety of ways, through 'opportunities for control and using skills, externally generated goals, variety, physical security, interpersonal contact, and a valued social position'. However, people with a history of mental illness are over-represented amongst the unemployed and economically inactive and, those in work are at a greater risk of experiencing absenteeism or presenteeism (working while sick) (CMO, 2013).

While half of the respondents to the CIPD Absence Management Survey described their mental health as poor and had taken time off work for this reason the other half had never taken time off because of it (CIPD, 2015, cited in CIPD, 2016a).

The CIPD commissioned YouGov to undertake a survey in June 2016, surveying over 2,000 employees with a view to identifying their experiences and attitudes about mental health in the workplace (CIPD, 2016a). The survey found that the number of people in employment reporting experience of mental health issues had increased from a quarter to a third since 2011. Keeping work when you have a mental illness can be as big a challenge as finding work (Thornicroft, 2006).

Whether mental health conditions are longstanding and permanent or acquired and temporary, something they share in common is the stigma (relating to attitudes) and discrimination (relating to behaviours) that is both a consequence of mental illness and a barrier to provision of support (Shaw Trust, 2010; Thornicroft, 2006).

It has been argued that severity of the condition can help to shape the degree of stigma (Seymour and Grove, 2005). Perceptions are important here. Stigmatization (Link and Phelan, 2001) involves a process of people distinguishing and labelling human differences, dominant cultural beliefs about mental illness, linking ‘labelled’ persons to under-desirable characteristics and casting them as outsiders.

Stigmatization influences behaviours towards 'outsiders'. Discrimination and prejudice influence the access of people with mental health conditions to employment and within employment (Hudson et al, 2009; Thornicroft, 2006). Unfair discrimination is often based around stereotypes (Noon et al, 2013). Stereotypes are linked to conscious bias, for example reluctance to employ a person due to their mental health. They are also linked to unconscious bias, where assumptions are made when someone does not realise it. The dynamics are complex, with the unemployed conveying many anxieties about disclosing their mental health histories to potential employers.

A common thread running through some of the narratives of people with mental health conditions who are not in employment is concern that employers will see them as a risky appointment, hinting at the process of 'self-stigma' explored by Thornicroft (2006).

Drawing on research and the voices of service users, Thornicroft illustrates how people with mental health issues often encounter negative assumptions of others about what they are capable of (Thornicroft, 2006). His discussion conveys how people with mental health conditions often internalize these negative assumptions in a self-fulfilling prophecy. This can lead people to make choices not to pursue a particular avenue, for instance a particular job search, or decision not to disclose a mental health condition, because of fear of failure or rejection (Hudson et al, 2009, Thornicroft, 2006). As argued by the Mental Health Foundation (2016:2) "The fact that 41% of those choosing not to disclose cited shame as a reason shows that we need to take on self-stigma too."

Disclosure of a mental health condition can play an important role in both helping someone with a mental illness stay in work and also in improving the quality of their working life (Wakeling, 2014). Disclosure affords the 'potential' to be signposted to appropriate support.

Employees may have rights to reasonable adjustments when mental health conditions are considered a disability under the Equality Act 2010. Under the Health and Safety at Work Act, employers also have duties to ensure the health and wellbeing of their staff. Evidence of a paucity of disability practices in British workplaces and employer reluctance to engage in dialogue with disability equality stakeholders (Hoque and Bacon, 2014) fuels the imperative to raise employer awareness of good practice and how this can be achieved.

That only 46% of respondents in the CIPD/YouGov survey (CIPD, 2016a) reported that their organisation supported employees who experience mental health problems very well or fairly well (CIPD, 2016a), reinforces evidence of an ongoing workplace support gap (Thornicroft, 2006). Around two-fifths of respondents (42%) in the Deloitte Millennium Survey suggested that their employers were not fostering an inclusive working environment (CIPD, 2016a).

It has long been known that there are 'good' and 'bad' managers and line management practice (CIPD, 2016a; Collinson et al, 1990), and that poor line management can contribute to unfair treatment at work and lack of organisational compliance with the spirit of employment rights and protection. A recent quantitative study of the ill-treatment of employees with disabilities in British workplaces found that 10% of employees with a disability or a long-term illness were treated particularly badly, for example, experiencing insults or ridicule (Fevre et al, 2013). Employees with disabilities reported that managers and supervisors were amongst those responsible for their ill-treatment, as well as co-workers and customers.

In a qualitative study of employee experiences of disability and the negotiation of adjustments in the public sector workplace, it was found that managers lacked understanding of their legal obligations to employees and could bully and generate stress for them (Foster, 2007). Greater support and training for line managers may help (CIPD 2016b; Mental Health Foundation, 2016).

1.2.3 Mental health and workplace effectiveness

Addressing the workplace support gap is important for individuals with mental health conditions and their families, but also for workplace effectiveness.

Mental health problems are widely recognised as a major cause of ill-health and sickness absence in the UK (CMO, 2013; Layard, 2004, 2006; SEU, 2004; Grove et al, 2005). In 2007, they were responsible for 70 million sick days. The indirect costs of unemployment, absenteeism and presenteeism has been estimated to total £30.3 billion in England in 2009/2010 across all mental illnesses (CMO, 2013: 148). Lengthy periods of sickness absence can also adversely affect mental wellbeing (Nice and Thornton, 2004).

Engaging with empirical evidence pointing to a positive causal effect of subjective wellbeing on individuals' physical health, research by Bryson and colleagues (2014) has linked employer-employee data to investigate the relationship between employees’ subjective well-being and workplace performance in Britain. The analyses shows 'a clear, positive and statistically-significant relationship between the average level of job satisfaction at the workplace and workplace performance' (Bryson et al 2014: 66), perhaps implying that the loss of valued job features may adversely impact on subjective well-being and workplace effectiveness. The importance of job features is also emphasised in Warr’s discussion of the 'person-environment fit' (Warr, 2007).

The CIPD 2015 Absence Management survey, conducted in partnership with Simplyhealth, found that two-fifths (41%) of organisations claimed an increase in reported mental health problems in the past 12 months (CIPD, 2016a). They identified a worrying association with not only long working hours but also the extent to which operational demands are being prioritised over employee wellbeing.

In putting reactive and preventative measures to promote positive mental health into practice, managers may work in institutionally complex settings and have to grapple with contradictory logics and practices (Smets and Jarzabkowski, 2013). For example, they may be trying to support a colleague with a mental health condition, providing stability and insulating them from pressure, during a period of intense organisational change.

As research continues to show that the poor quality of workplace relationships and line management support is hampering both disclosure and access to support, this suggests an imperative to build the right workplace culture to help foster positive mental health at work. Leadership, people management and workplace cultures are all important, and inter-related, areas for focus (CIPD, 2016b).

Discussion of leadership as the 'extra-ordinarization of the mundane' (Alvesson and Sveningsson, 2003) reminds us that leadership needs to be seen as part of the role of managers at a number of levels in organisational hierarchies to support the promotion of positive wellbeing in workplaces. For example, by line managers placing greater value on talking and listening in everyday working relationships and this being seen as leadership activity.

1.2.4 Current initiatives to promote positive mental health

In part driven by the issues raised in the previous section, policy interest in supporting the management of people’s mental health has grown in recent years. This has spawned a variety of new initiatives tackling the issue of mental health, alongside ongoing work by mental health charities and campaigners. There are initiatives relating to changing attitudes and raising awareness as well as workplace change.

There have been projects such as Time to Change's 'Time to Talk Day'. Time to Change is a social movement formed in October 2007 to end mental health discrimination. It seeks to transform how society thinks and acts in relation to mental health problems. Time to Change has launched ‘Time to Talk Days’ to encourage conversations about mental health in schools, homes, workplaces, in the media and online.

There are signs of positive change. A survey commissioned by Time to Change found that overall community attitudes towards mental illness became more favourable between 2008 and 2013 (TNS BMRB, 2014), reinforcing previous evidence of an improvement in understanding (for example, see Shaw Trust, 2010).

As well as the government's broader 'disability employment gap' agenda, the issue of mental health is being tackled through many different schemes – including through a focus on improving the extent and quality of workplace support. For example, the long established HSE Stress Standards (2012) cover 6 key areas of work design that, if not properly managed, are associated with poor health and well-being, lower productivity and increased sickness absence.

More recent initiatives include Mind's 'Workplace Wellbeing Index' which provides a tool for identifying and assessing gaps between an organisation’s approach to workplace wellbeing and staff perceptions of this benchmark of best policy and practice.

A new 'Healthiest workplace' project was set up in 2016. This plans to provide the UK’s most comprehensive workplace wellness study involving a survey completed by both employers and employees. The aim is for participating employers to gain a better understanding of the health risks affecting their employees and to monitor how these, and related health and productivity impacts, change over time. The survey will also monitor workplace support for wellbeing and provide recommendations for improvement.

The government, the Economic and Social Research Council and Public Health England are funding a 'What Works' centre dedicated to understanding what national and local governments, along with voluntary and business partners, can do to increase wellbeing. There are sectoral initiatives such as the tripartite review into the health and deployment implications of teachers working longer as a result of the normal pension age increase.

This range of initiatives is to be welcomed, including the emphasis on research as there continue to be many gaps in the evidence base and a need for more rigorous, higher-quality evaluations conducted with more diverse samples of the working population (Hanisch et al, 2016; Seymour and Grove, 2005).

1.3 Report structure

This report builds a picture of the complexity of mental health and workplace life whilst encouraging a focus on practical solutions. The report is structured to facilitate this.

Chapter 2 builds a picture of organisational contexts and issues that form the backdrop to the management of mental health at work, and focuses on the main challenges faced by employers. It ends by presenting a diagnosis for 'anxious organisations' – those unable to cope with ongoing change, for example, where mental health is not given a high priority.

Chapter 3 begins by setting out why organisations are responding to the mental health agenda. It then uses the case studies to illustrate the wide range of good practices adopted by employers to help promote positive mental health, such as line management training, employee empowerment and early detection.

Chapter 4 takes a closer look at the perceptions and experiences of line managers and employees vis-à-vis support for employees with mental health issues. It considers factors influencing the disclosure of mental health issues, the enablers of a return to work and the importance of reasonable adjustments.

Chapter 5 considers a range of learning points that can be drawn from this case study research to promote positive mental health at work and highlights the key recommendations.

This chapter builds a picture of organisational contexts and issues that form the backdrop to the management of mental health at work. After setting the scene, it focuses on the 3 issues that were identified in our case studies as presenting the greatest challenge to positive mental health in the workplace: 

1. Organisational change: both in terms how this is managed and how it is communicated to employees.
2. Downsizing and work intensification and the impact this is having on stress levels and work-life balance.
3. Line management capability to engage with staff when it comes to inter-personal interactions, particularly around performance management systems. 

Taken together, and in the light of other persistent workplace challenges explored in the evidence base on ‘job’ insecurity and organisational change (Gallie et al, 2016; Burchell et al, 2002), in different ways and to varying degrees the case study evidence suggests that these factors can lead to the development of 'anxious organisations' – that is, environments in which positive mental health is unlikely to be a priority.  The theme of anxious organisations is explored further in section 2.5. 

2.1 Setting the scene 

There was a strong perception across research participants that mental health is influenced by a complexity of factors both inside and beyond the workplace. Outside work, these included a host of issues including:

• bereavement
• relationship breakdowns and family problems
• links to genetic history
• problems associated with addiction finance, debt and housing 

In the vast majority of cases, such influences were acknowledged as being beyond the control and influence of employers. However research participants noted that, as we see a growing awareness of mental health, there is increasing acknowledgement of the need for employers to be aware of the circumstances and challenges facing individuals outside of the workplace.

Indeed current socio-economic and demographic changes in the workforce, for instance the growth in older workers and the demands on carers, may mean that the interface between private lives and the workplace experience are increasingly interlinked.

Such linkages are implicitly recognised by the biopsychosocial model of disability, initially proposed by Engel (1977). This model is especially pertinent to mental health as it seeks to broaden the perspective on 'illness' by recognising its psychological, social and behavioural dimensions.

What might be described as a ‘hard’ biopsychosocial model of disability has been subject to considerable and cogent criticism from the disability rights movement (Jolly, 2012) for continuing to over-medicalise the experiences of disabled people.

The present report aims to draw on a ‘soft’ biopsychosocial model of mental health which places much greater emphasis on the need to mobilise change in the broader structure of social arrangements, addressing the barriers that people with mental health conditions encounter in the workplace, labour markets and wider society.    

The report will now provide more insight on each of the three issues that were identified in the case studies as presenting the greatest challenge to positive mental health in the workplace. 

2.2 Organisational change 

In this study, there was strong recognition that management and communication of organisational change was a critical issue in the management of mental health at work. For example, a call centre manager at PrivateCo noted how a range of changes had a potential influence on mental health in the workplace: 

"The relentless inbound call pressure, how people cope with that pressure. The way that they're managed. The way that they're coached. How people deal with change, because the business is constantly changing, especially at the moment. We've just acquired [a new organisation]. The centre manager's about to go off for 12 months maternity leave, so we've got another centre manager coming in. The equipment's changing all the time, such as the dual monitors that I've shown you. So dealing with change is a huge, huge part of [mental health] and that can really feed into mental health, because it creates uncertainty." (Line manager, PrivateCo)

Another PrivateCo respondent in a different part of the organisation expressed the view that employees needed to have the skills and abilities to retrain and have a future outside of the company.

There was a view that the organisation needed to achieve a ‘balance’ in change management. At one point downsizing had significantly reduced the number of HR staff who were supporting operational teams and this was perceived to have reduced the support available to these employees during a period of extensive workplace change.

Similarly, a research participant from the National Union of Teachers (NUT) was concerned about the wider financial constraints on schools accessing the expertise that is sometimes needed to manage mental health at work: 

"Schools are not the experts, and why should they be, in mental health and wellbeing policies and practices. If they need to engage external people then they need to have the resources to do that, and school budgets currently don't really permit that. So unless you're a very well-resourced school, you're going to have so many competing interests that you're going to struggle to access that expertise." (Principal officer, NUT) 

For EducationEst, part of the change management issue was the frequency of change affecting the education sector, which was felt to increase the imperative for the management of mental health at work. Issues outside the control of an organisation and manager were felt to be very hard to deal with, amplifying the sense that managing mental health was a struggle. 

Staff working out of office or in dispersed virtual teams can also pose a challenge to the management of mental health at work. For example an employee in this position noted: 

"I'm not physically based in the same building as any of my co-workers which kind of makes it a bit harder to find what’s going on with people." (Employee) 

At PrivateCo there was management recognition that care needs to be taken to engage homeworkers. With an increase in homeworking in recent years, there was concern that these workers be properly engaged in the promotion of positive mental health.

There was a related move to bring some people back into an office environment. While there have been mixed feelings about this amongst homeworkers, they were seeing the benefits of 'coming in and seeing, and working with the rest of the team' and they had been given some flexibility to continue to do some work from home as well.

These issues are also important in the context of the significant growth in self-employment that has taken place in recent years (Hatfield, 2015), which has increased the number of people working in isolation. The Acas Homeworking study (Beauregard et al., 2013) found that moderate-level homeworking yields the best outcomes for staff in terms of stress, wellbeing and job satisfaction, relative to ‘dedicated’ homeworking staff, who may experience isolation and work-life boundary-related pressures. 

2.3 Downsizing and workplace intensification 

Organisational downsizing has been a prominent feature of the employment landscape and organisational change for the last 30 years and its influence on the intensification of work has long been recognised (for example, see Burchell et al, 1999).

Work intensification dynamics were evident in the case study organisations, albeit taking different forms. For example PrivateCo had responded to competitive pressures through new ways of working, restructuring and growth. Organisational change has generated uncertainty across the workforce. Downsizing exercises, linked to cost reduction, had been taking place since the 1990s and were still evident in the organisation’s response to economic pressures, reducing the number of job roles.

At the same time customer demands were changing for PrivateCo, in some parts of the business, giving rise to what one call centre manager described as both a challenging and rewarding environment:

"We work in a very challenging and rewarding environment. There's pretty much unlimited overtime and there is opportunity to sell through service. So there's good money-making opportunities out there, but at the same time, it's a difficult job. It's difficult. Customers are demanding. In the modern world, they want more and more. So our advisers have to adapt to that and so do managers." (PrivateCo, line manager)

In this context the manager’s role was very busy and included HR-related responsibilities, reporting sickness absence, and managing disciplinary proceedings around performance and absence. On top of this, they had to be a leader that staff could look up to, as well as dealing with the customer complaints linked to calls received by the team.

A worker discussing her experiences of working in the NHS explained how, for her personally, triggers of negative mental health beyond the workplace (a young family member with anxiety and anger issues) interacted with several experiences of job loss and job insecurity:

"And the waves of losing your job and having job insecurity does bring interpersonal problems and difficulties in families. It can’t not interfere across the board. From my own experience when my family support wobbled then I wobbled twice as much at work because of the ongoing stress at work that was affecting family life. I think the two are very much interwoven and I guess I’ve just learnt to love the NHS less and love my job as a job, not as a passion." (NHS worker)

She was taking more personal responsibility for her mental health in a context where she perceived that budget cuts and cost-savings were ongoing. The NHS was also encouraging staff to take more responsibility for their own health and wellbeing, including their mental health, though there were opportunities to access occupational health and counselling (and she had done so during a stressful period of reorganisation).

In EducationEst, participants reported that the scale of their responsibilities had escalated as a result of growing demands associated with curriculum changes and related administrative tasks. This was resulting in greater challenges in managing work and life balance, and placing strain on mental wellbeing. Pressure was perceived by the research participants to be in part a result of demands from the funding chain, with pressure exerted from government being felt at the local level and then exerted through the school.

Respondents at the school noted how it was impossible for staff to get their work done during working hours. As a result many teachers were taking work home to do in the evenings, working 60 to 70 hours per week. This was putting pressure on family time as well as the mental health of staff because there was so little opportunity to switch off.

One of the union officials interviewed put forward their own view on the nature of these pressures: 

"The government are putting pressure on the local authorities (or academies) now and the local authorities are putting pressure on headteachers and headteachers are then reciprocating by asking too much of their staff at times." (National Association of Head Teachers official) 

2.4 Line management  

Mental health can be very complex when it comes to diagnosis. This poses challenges for line managers who, in the absence of disclosure, may often need to base their judgements and interactions on 'perception'.

Some managers may be aided by having natural management skills, some might be trainable and some managers may show signs of a lack of capability for people management.

Within the context of this critical relationship between employees and their line managers, performance management systems present an ongoing organisational and personal challenge and one that poses particular issues for the management of mental health at work. These themes are explored further below.

2.4.1 Natural managers, trainable managers and bad managers

A recurring theme across the case study organisations was the need to change line manager mindsets to support a more positive approach to the management of mental health at work.

As will be explored further below, there were examples of training initiatives that were perceived to be a helpful vehicle in developing line manager understandings of mental health issues and their knowledge of supportive practice.

One organisation reported on a particularly difficult challenge in one section of its business, where first line managers, who tended to be middle-aged men, were largely managing other men. A certain 'mindset' prevailed, which made it hard to foster better people management skills.

Similarly, another senior manager reflected how some managers would never be good at people management as their focus is often on technical skills:

"In the UK we look at people management as an extension of technical skills. For some staff this comes naturally, while for others it comes with training and time. For others they will never be people managers." (senior manager) 

HR and line managers from the same organisation conveyed how some managers struggled to manage staff with mental health issues through poor people skills, a lack of time and confidence:

"So I would anticipate that any manager, all of our managers, should be having regular one-to-ones with each of our people. And it's not just [staff member], are you meeting your targets. It's [staff member], how are you doing? How are you feeling? You know, what's going on with you? Who are you? What are you doing with your life? And it's not a counsellor kind of exchange. It is an opportunity for a manager to get to know the individual and vice versa. And so many times managers either don't have the time, or they don't have the skills, or they're, you know they're nervous about causing offence." (HR manager, PrivateCo) 

"Never assume just because somebody has been promoted to a manager role that they are people people. Because lots of the time people have been promoted because they're good at their job. So some line managers might need a little bit more help." (HR manager, PrivateCo) 

"I think it's fair to say, from my own experience as an adviser as well, I've been poorly managed in the past, and that's drastically affected my mental health, especially with my anxiety." (line manager) 

A worker in the charity sector (not at CharityOrg) who had experienced mental ill health described the poor management style as complicit in an ensuing period of negative mental health related absence. He reached a point where he could no longer manage workplace stress after trying to cope with a mix of clinical depression, anxiety and stress:  

"[The managers] were very old school. They shouted at people. That was their way of managing. I would walk into trustee meetings and it was one attack after another . . . I had very severe depression and my manager never talked to me." (charity worker)

On seeking external specialist support, a counsellor who was a registered mental health nurse advised him: "in my opinion, the fundamental issue’s a management not a medical one." Reflecting concerns about the ill-treatment of disabled employees discussed in chapter 1 (again see Fevre et al, 2013), several members of staff at this charity had been diagnosed as having depression, secondary to work-related stress and felt that a culture of bullying and harassment was complicit.

These examples illustrate that mental health is greatly influenced by the nature of the relationship with managers, particularly when coping strategies are compromised by that relationship (see section 4.3 for an example of this concerning a manager’s lack of awareness of the need for reasonable adjustments).

A consultant engaging with this research project via social media emphasised the potential value of motivational maps as a mechanism for individuals to think about the fit between their current job and work orientations. Motivational maps may be a constructive tool for having difficult conversations with ‘bad’ managers about their fit in a particular role.

Sometimes the challenge could be one of holding on to good managers, as an NHS worker explained, hinting at a role for senior management in trying to create a workplace climate that will attract good managers to stay:

"Different managers work in different ways. I’ve been managed by managers who had no interest at all in health and wellbeing and just an interest in throughput and statistics and I’ve been managed by managers who really have the heart and soul in the wellbeing of the staff, but they all left in the reorganisation. There were several managers who were very much in it for the wellbeing of their staff and protecting their staff and stresses, but they all left for other posts and other areas of work. I think these things are cyclical and the patterns change depending on senior management and where the pressure is coming from. The loss of continuity of management change is massive." (NHS worker)

2.4.2 Performance management systems and mental health

While this research did not have a specific focus on performance management systems, as implied earlier in this chapter research participant accounts suggested that performance management cultures could be complicit in generating negative mental health.

At FinanceCo there were reports that targets were helping to fuel stress and anxiety in the workplace, implying that there needed to be greater sensitivity to the contexts in which targets were being set:

"But I think in the performance management culture that we have here, sometimes you need to do a brilliant job of something in order to get the rating that you want to get for your appraisal. But it can be difficult to get that done when you’ve got the next thing coming in that you’ve got to react to." (Line manager, FinanceCo)

In one organisation there were several accounts that conveyed an impression of line managers' perceived insensitivity or lack of awareness of the potential negative impact of poor feedback on staff struggling with their mental health. For example, the following experience was conveyed by an employee coping with family illness and bereavement:

"Well I think what happened was I got a marking which was 'development needed', which is unacceptable, and usually kind of results in some form of performance plan. And that came as a shock to me because you are never supposed to get that at the end of a quarter without having been warned. And I wasn’t the only one, you know, as I say, 60% of the team got that. But because I’d been so stressed with everything else, I’d reacted more than most of the other people did. If I hadn’t been given a 'development needed' then I might not have gone off sick with stress. I was struggling, definitely." (Employee)

One case study picked up on an overlooked area of performance management which has potentially significant implications for mental health, which relates to the menopause. PrivateCo is beginning to work with the (recognised union in their workplace to promote greater awareness of the impact the menopause can have on wellbeing. This work has come about in response to legal challenges, supported by the union, centring on how women experiencing menopausal symptoms have been treated at work.

The experience has been that as the menopause starts and a woman’s body starts to change, they may have several weeks’ sickness absence and find it difficult to cope with hormone changes affecting their body. This can make a return to work difficult.

One manager had encountered how the menopause can adversely affect mental health:

"I’ve witnessed people that have been on their menopause that have been really depressed, to the point that they’ve said that they don’t want to be here anymore, in the sense they're potentially wanting to end their life." (Line manager, PrivateCo)

Some managers were reported to have been putting women on performance plans that last 12 weeks, broken down into 4-week sections, and using this performance management framework to pressurise them to leave the organisation.

"And what they’ve been doing is they’ve been phoning these women up 8 weeks in and telling them that they’re not bothered about what’s up with them. They’ve just been telling them their performance is down, the company’s going to dismiss them in 4 weeks and [the manager] can offer them a dignified exit from the company if they take . . . basically a compromise deal if they leave. And a lot of these women, their minds are in disarray and they just want help to get out of the situation they’re in. They take 3 months’ wages, 6 months if they appeal against it and they’ve gone. And these women, in a lot of cases, have been about 53, 54 and have years left of work in them. And that’s what we’re trying to stop and I think PrivateCo has recognised this." (Union official)

2.5 Creation of the anxious workplace

Organisational change, downsizing, growing workloads and pressure at work can manifest in potentially negative ways, including impacting negatively on mental health and staff leaving the organisation through stress. There were signs of these issues to varying degrees and in different ways in the private, public and voluntary sectors and there is evidence that this could be complicit in the generation of the anxious organisation.

Anxious organisations may show signs of the following characteristics:

• an ongoing struggle to effectively manage change – this may be change imposed by external drivers but can be compounded by a sense of 'what’s happening next?' and an uncertainty about the wider environment
• an increasing pressure to perform better – this goes beyond positive stress that energises people and leads employees to feel constantly under pressure and unable to cope
• management culture that mirrors the anxiety rather than contains it – senior and line managers do not have the soft management skills to respond to organisational pressures effectively

For example, in the voluntary sector, a difficult funding climate can provide an ongoing challenge and structural constraint. At CharityOrg, projects were often of 1 to 3 years duration and there was a constant process of trying to generate new income to sustain services as well as the employment of staff. Austerity had amplified the financial insecurity and this in turn generated job insecurity and its associated stresses:

"Staff are in a constant state of anxiety or uncertainty about their role. There’s very little funding that we have that is ongoing and regular. Our core funding, our regular grant from the council, was cut by 50% last year. As an organisation, you can imagine the effect on people’s health and wellbeing, of that kind of pressure all the time. It’s a very stressful environment." (Senior manager, CharityOrg)

At CharityOrg, performance targets were often linked to project targets and a project’s success. This contributed to the stress:

"Targets can be a stressful factor in itself, but I think if it’s linked to funding… There’s the feeling that if people haven’t met their targets or haven’t evidence for the success of their project, then possibly funding won’t be renewed. And then that would have an impact on their client base, and also on themselves and their colleagues who work on the project." (Line manager, mental health charity)

There had been instances of individuals walking out of their job with the charity without giving notice, linked to a sense of pressure to perform. For example, one individual in a new role and on probation had felt a sense of pressure to prove themselves. With hindsight the individual did not seem sure enough of their workplace relationships and seemed concerned that it would be seen as an individual weakness to ask for help. They did not feel established enough to say that they needed support or that the job was very difficult.

Research participants in PrivateCo discussed how, alongside an intensification of workplace change, there was an emphasis on staff needing to perform well, all of which had fed into mental health needs at work.  Individuals responded very differently to new ways of working and there were reports of some staff leaving the organisation through work-related stress, while others had been pressured to leave the company through efforts to reconfigure the composition of the workforce: 

"The other side [of mental health] are the work-related factors, whether people are struggling with performance, they struggle with the managers sometimes, and the perception of how they’re managed, if they are a poor performer particularly. And then also people who are undergoing change at work, they find it difficult to adapt to new ways of working. Or the impact of cost reduction in the company, and the impact in reducing the number of roles that we have." (HR Manager, PrivateCo)

"I do know quite a few people who’ve left because they’ve been managed out of the business, and a few people who’ve left because of stress." (PrivateCo respondent). 

With the removal of a default retirement age (it was previously 60), PrivateCo had begun to employ staff who were in their 70s. PrivateCo was constantly changing and some older workers were perceived by management as struggling to keep up with the pace of change.

The union reported having received cases suggesting that organisational performance expectations, and experiences of the performance management system, were generating symptoms of depression and anxiety amongst older workers whose capability was questioned. Based on these cases, the union was concerned that some managers may be using the performance management system to place unreasonable pressure on some older workers to leave the organisation.   

Anxiety appeared to also manifest itself in the times that employees communicated with their colleagues via email. For example, in FinanceCo there was concern that managers did not always lead by example, sending emails late at night and thus adding to a sense of organisational expectations to perform in this way: 

"And you see emails sent by people ridiculously late at night. I’ve seen one this morning that was sent at 10 to 11 at night by somebody very senior, and it’s possibly their choice and maybe that works for them, you know? But you do kind of think, wow, I was asleep at 10 to 11. I think if you see that someone else is doing that, then you feel like oh, I’ve got to do that, you know, that’s what’s expected. Yes, and it drives it in, doesn’t it? Leading by example." (Line manager, FinanceCo). 

It is useful to dwell on these examples as such reported developments reinforce the need for managers to try to avoid the development of the 'anxious organisation'.

In managing mental health at work there are some things that are beyond a manager’s control, for example the introduction of new curriculum developments in the education sector. However, there is a need to identify practical ways to intervene and support individuals, whist accepting that there is perhaps a lack of power and influence to change broader structural constraints.

This viewpoint was evident in the accounts of most research participants who discussed their approach to the management of mental health at work. For example, it was clearly conveyed by a research participant in the education sector: 

"For myself, it’s about knowing the person, knowing where the pressures are coming from, and if I can manage the pressures within the school to alleviate things, all well and good. But there are certain things that are out of my control." (Research participant, EducationEst) 

The next chapter shows how employers have responded to these challenges and developed ways to avoid becoming an anxious organisation and, where possible, promoting positive mental health.  

Most organisations need a 'business case' for developing workplace interventions, but the evidence suggests that there is a much bigger 'human case' for prioritising mental health. Recognition of the challenges associated with mental health problems had led to a growing acceptance of the need to prioritise the management of mental health as part of the employment relationship.

Research participants were driven by a range of factors in their desire to address the challenge. These included: 

• Business pressures: Mental health and wellbeing are increasingly being seen as core components of business strategy, linked to both staff retention and customer satisfaction. The potential benefits of this were recognised and monitored in terms of the operational impact of absence on the business, lowering morale and increasing staff turnover. 
• Understanding and respect: There were examples of good practice in the case studies that reflect the personal commitment from senior leaders to champion the promotion of positive mental health. Those employers in the charitable sector were particularly concerned to help those with mental health problems to perform to their best and to be able to stay in work.  
• Legal obligations: Less mentioned by employers was that under health and safety law employers have a duty to protect the health, safety and welfare of their employees and are required to assess and address all risks that might cause harm. Employers must consult with their employees on any risks and instruct and train their workforce on how to deal with them.  

3.1 Leadership and the mobilisation of change

Having strong leadership around mental health seemed to contribute to engagement with the wider landscape of advice on better practice in the management of mental health at work, as well as the implementation of innovative practice. This might include appointing a head of wellbeing at a senior manager level (as was the case in PrivateCo), or a human resource manager to champion wellbeing (as found in FinanceCo).

At PublicOrg a senior manager encouraged an audit of activities to see how it could improve its policy and practice and was instrumental in ensuring that the organisation signed up to a range of wellbeing initiatives.

The style of leadership at CharityOrg had been significant in the direction of mental health policies and practices. It was strongly influenced by the Chief Executive, who first entered the charity via a volunteer route and drew on his lived experience of mental health in his day-to-day management of the organisation.

As will be explored further below, organisations were also keen to encourage line managers to show day-to-day leadership in the management of mental health at work, as pivotal players in the mobilisation of change.

3.2 Tackling stigma through awareness raising

The larger organisations ran workplace campaigns to highlight the ongoing stigma surrounding mental health. For example, several organisations were engaging with the national Time to Change initiative. As noted in chapter one, Time to Talk Days were first launched in 2014, to encourage conversations about mental health in schools, homes, workplaces, in the media and online. The organisations ran campaigns where they encouraged people to talk to colleagues and find out more about them.

These organisations were keen to use campaign activity to foster a climate where co-workers could pick up on early indicators that a colleague was struggling at work. Awareness-raising activity was felt to have scope to make a difference, though some felt that there was an ongoing need to communicate messages about policies, practices and procedures: 

"The way that those policies, practices, procedures get interpreted by managers and by our people can lead to a poor lived experience." (HR manager, PrivateCo)

At FinanceCo, which as will be seen below had a major focus on mindfulness alternative therapies, there were plans to run a campaign to raise awareness of mindfulness training opportunities and its potential benefits, for example displaying posters around the workplace and using a weekly e-letter.

3.3 Early detection

All the organisations were keen to foster early detection of mental health issues in order to be able to facilitate support. Some line managers discussed examples of team members who openly discussed mental health issues, for example disclosing anxieties that stemmed from a childhood event. However, many gave examples of colleagues who were more closed and guarded about their mental health. Further discussion of issues around disclosure are presented in chapter 4.

A good example of the kind of support that can be provided to line managers came from PrivateCo which had developed an online assessment system that involved staff who felt unwell answering a range of questions on their sense of wellbeing. Their answers would then flag a green, amber or red categorisation of mental health. A red outcome alerted line managers to hold a one-to-one meeting with individuals within 7 days and provide support. As an HR manager noted:

"Quite often you will find people will complete that assessment, and the manager may not even be aware that there was some concern in that area. Until they receive something to say somebody’s completed an assessment." (HR Manager, PrivateCo). 

In large organisations a further challenge could be the difficulty in reaching and influencing the practice of all managers with awareness raising on a more positive approach around mental health. Relatedly, creating a climate of openness and mutual support, likely to be important for early detection, can be more difficult.

At PrivateCo, staff turnover had intensified the effort needed and the degree of line management awareness of and engagement with the mental health agenda varied across different parts of the organisation. This reinforced the need for awareness raising, as well as the training of line managers, to be ongoing:  

"In PrivateCo it does seem to depend on which area you are, how well looked-after you are. And I'm very lucky with my present boss and my present line management’ (Employee, PrivateCo). 

The case study organisations with a smaller workforce (the school, charity and community interest company), were in a setting where everyone tended to know each other, and so broadly speaking they did not have to grapple with this issue: 

"The staff that have been here a while, we obviously know each other quite well and if I'm being completely honest with you, if you turn up in the morning, once you get to work with somebody quite often you will know if they're having a good day, bad day, if something is going on." (Line manager, Brentwood Community Print) 

3.4 Employee empowerment 

There were also signs from the case study organisations that employee empowerment can support positive mental health.

In particular, the charity had introduced a supervision policy (see box 3.1) to support the development of a workplace culture where staff felt empowered. This placed an emphasis on joint working and autonomy ensuring that staff did not have a 'non-necessary interfering kind of line management experience'. Rather the focus was on staff being able to make their own decisions and be able to have as much control and say as possible in their role and how they delivered their work.

These themes are not particularly new but what is interesting is the way in which they are linked to mental health. The supervision policy was quite explicit about the kind of support the organisation expected line managers to give to people if they had additional emotional needs.

The supervision policy reinforced messages around the importance of supportive practice and reasonable adjustments, working within a social model of disability:

"What matters to us is how people’s mental health affects them in either their daily living or in the workplace in their capacity to do their role. That's what matters to us, not the diagnosis - how it impacts their capacity to cope and live. That’s what we are about: helping with and supporting." (senior manager, CharityOrg)

3.5 Using 'alternative therapies'

In recent years there has been growing interest in mindfulness, a therapeutic practice which essentially engages with the development of emotional intelligence. It was a practice being engaged with, to varying degrees, in four of the case study organisations.

There was some concern about the growing popularity of mindfulness. These often centred around misunderstandings of what it is - for example, assumptions being made that it is simply a relaxation technique, rather than encompassing a wider range of practices and ideas (see Appendix 2 for further information on mindfulness as a therapeutic practice).

Almost two-fifths of the FinanceCo workforce have participated in an introductory mindfulness workshop. Mindfulness training had been well received and the company was trying to roll it out so that it was available to all staff. Mindfulness was reported to have made a significant difference to mental wellbeing, with feedback from course participants indicating reduced perceived stress within work and home lives (see box 3.2 for more information on the development of mindfulness in FinanceCo).

However, several research participants, though acknowledging the potential contribution of mindfulness to emotional intelligence, were concerned that it should not be seen as a substitute for a broader approach to mental health.

There was some concern that a focus on mindfulness (and links to the language of mental wellbeing and prevention) might detract from individual and organisational management of ongoing health conditions. For those managing an ongoing mental health condition, such as depression, how that condition is labelled by the organisation can be important:

"I had a mental illness and I recognise now that mental illness is an illness not a weakness - it’s not something that you might get for a little while and then come back out of. But I think we can dance around it a little bit by calling it wellbeing instead of saying, do you know what? You need to look after your mental health." (employee).

3.5.1 Line management training 

A recurring theme in discussions around training initiatives for line managers was the need to make it clear that they are not expected to be experts in mental health issues. The emphasis was rather on helping line managers to be a little more confident and self-reliant. For example, it was felt that they should be able to sense that a colleague was in need of support if they were frequently working late, looking tired or being irritable.

An HR manager at FinanceCo conveyed this approach:

"I just think we’d like to sort of, elevate our managers to be able to deal with that more themselves, rather than having to come to HR. So really just give the managers all the information they need to identify when somebody is struggling, and then enable them to have good conversations with themselves. We don’t ever want them to be therapists and we’re very clear with our managers to say if you need to support your person you need to talk to them, open a good rapport, good relationship but if in doubt you need to refer. And that’s when they refer on because we don’t want the managers, the leaders to step into this, trying to be a pseudo-counsellor. That’s not their job and they might say the wrong thing. So they refer." (HR manager, FinanceCo) 

FinanceCo had supported line manager participation in a course on 'knowing your team peers'. It aimed to help managers identify a change in staff behaviour – for example, if someone began coming to work smelling of alcohol. A manager here commented that it could sometimes do you good to have the obvious pointed out, as it helped to make you feel empowered to help someone.

At PrivateCo Call centre team managers spoke favourably of an off-site management team training day where they explored the warning signs of mental health issues. There was also a desire to have repeat training. Not all managers were aware that they could request this and there was interest in more detailed training around different conditions:

"We've actually had, as a management team, an away day in which they took us through how to see the warning signs of mental health issues. And we all went, including the centre manager, and it was quite good. Yes, so I think that helped us a bit. It was about spotting the early signs amongst your team, really." (Line manager, PrivateCo)

"I remember us all saying [the training] was really helpful. I'm sure we all took something away from it. But it would be nice to have a refresh and it would be nice to have some specific training, actually, on the different conditions. The problem is with these things, I guess it's in this environment we're in, not just in PrivateCo, across businesses, is that things are so fast paced. Sometimes you can go on a course where you come away from it feeling brilliant, but actually what are you doing 2 years down the line? What are you putting into practice?’ (Line manager, PrivateCo)

EducationEst had bought in the services of an in-house educational psychologist who had worked on wellbeing awareness with most staff as well as pupils. With sensitivity to the school environment, she had led training sessions on staff-to-staff wellbeing and staff-to-child wellbeing and child-to-child wellbeing. This had increased awareness, generally, around the school. The research participants (both in leadership roles) agreed that it had been a real advantage to have someone with this expertise located in the school who they, and staff, could approach for advice or talk to in confidence.

While training increased awareness and understanding, some respondents in the case studies suggested that real confidence in supporting people with mental health issues came with experience, for example encountering anxiety for the first time:  

"And I've never seen anybody with anxiety like that in my life. When people say they have anxiety, I just think they are just really nervous about a situation or they’re not comfortable in that situation and they just kind of want to get away from there. I’ve never seen it to the extent that they’d work themselves up that much, that they’re having to go to the toilet and be sick, because the anxiety levels had got that high. So that's the first time I had ever seen anxiety in that form. If I hadn’t seen that, I wouldn’t have even realised that anxiety could affect you in that way. See, that’s another thing that opened my eyes." (Line manager, PrivateCo).

There were several noteworthy challenges. The intensity of work could act as a constraint on putting training into practice. For example, a call centre team leader recalled how over the course of the previous year his team's workload has been so intense that there was little time to engage with his colleagues, making it difficult to spot early on whether they had potential mental health issues:

"Until last week, we couldn't get time with our people because we're that busy. And I don't mean as in, I can't spend time with you. What I mean is they can't come off their inbound role at all, apart from their lunch and their breaks. We don't get what we call investment time, because the customer demand was so high, we needed everyone to be bums on seats. And that went on for 12 months. We haven't had one-to-ones. We haven't had coaching sessions. We haven't had group team meetings. And it's just now being reinstated. So if you want to have a conversation with someone, it's literally 30 seconds here and there, you know. You can't have a proper chat." (Line manager, PrivateCo)

The problem was generated by a high rate of staff leaving who had been on an early leavers' package as well as other issues leading to a high number of customer calls. Recruitment activity subsequently addressed the issue.

A similar issue arose in EducationEst:

"Time is an issue, time to sit and talk to people can be an issue, you know, because sometimes things arise, and people need you there and then, to deal with that. And that can be difficult. And sometimes I feel a bit guilty about that, that, you know, they need to talk, and I haven’t always got the time at the moment." (Manager, EducationEst) 

Work pressures also influenced the duration and content of training courses in one of the case study organisations. During the early period of development of mindfulness training in PublicOrg, the services of a mindfulness trainer were employed. So that staff would not need to take too much time out of their working day in order to participate, the training was held at the workplace and short courses were run, the latter limiting the scope of the training. Given the scope of mindfulness practice and ideas, the trainer had some difficult choices to make about what to cover in 8 weekly 90-minute sessions.

While people who attended the classes were said to have got a lot out of the course, poor attendance was also an issue and this was again linked to work pressures: 

"Another one of the problems about working in the work situation is absenteeism. And, so, I just had to work with that, and work with people sometimes not being there and catching them up the following week. Sometimes missing 2 weeks, and then when they miss 2 weeks, and if they miss 3, they kind of miss so much of the course, that it's, they can't really catch up.  So, there was quite a lot of that actually.  And quite a lot of people turning up late, and having to leave early.  That was another problem.  And I knew that would happen because I'd worked in workplaces before, so I was prepared for that and I didn't let it bother me, but it was a bit disruptive." (Mindfulness trainer)  

This trainer also noted that when he and his colleagues went into companies they stressed that it was really important that people do the practice rather than just turn up to the class. They are told that they need to do 30 minutes of practice a day and that it is better for them not to attend if they are unable to commit to that. However, when courses are run at workplaces, individuals that do attend do not practice very much, limiting the benefits of the course.

Reinforcing this picture, in FinanceCo, staff reported that finding time to practice mindfulness could sometimes be difficult, with mindfulness practice being deprioritised during periods when it might be most beneficial:

"It's often the first thing that goes when you're busy, very busy. But it's probably the thing at that time that you need the most." (Line manager, FinanceCo)

3.7 Providing ongoing sources of help and advice

The examples of action organisations took to promote positive mental health at work often conveyed the need for a multi-faceted approach to managing mental health and the complexity that needed to be addressed. These are summarised in the table 3.1 below.

Table 3.1: Mapping of some organisational aims under the continuum of mental health

The organisations sought help to develop policies and practical tools to support the promotion of positive mental health at work. Several organisations had drawn on multiple sources of guidance. Some policies had been developed through consultation with public bodies.

FinanceCo reported that it had drawn on Acas guidance on mental health at work in the development of its policies, consulting the Acas website and drawing on booklets and occasionally using the Acas helpline if unsure about an issue. However, what was most striking was the role of the advice provided by an occupational psychologist, working closely with the mental wellbeing champion in human resources to develop practice in a number of areas.

This included practices that could foster a supported return to work for staff experiencing depression and also a focus on developing individual 'resilience’ through the introduction of mindfulness training. Developing a close working relationship with the mental wellbeing champion in human resources, the occupational psychologist was being drawn on as a critical friend, and her knowledge of mental health and the company were valued.

Similarly, while the local authority had a formal policy on mental wellbeing governing EducationEst, in response to mental health issues amongst both pupils and staff, the school had bought in the services of an in-house educational psychologist. She too had led on practical interventions running wellbeing awareness training sessions with most of the staff as well as pupils, focused on staff-to-staff wellbeing and staff-to-child wellbeing and child-to-child wellbeing.

CharityOrg had drawn on the Health and Safety Executive guidance in developing both formal guidelines and practice on the management of mental health at work. As it had grown it had searched for guidance that complemented its ethos and supported it in developing additional support to meet the full range of potential support needs of its staff.

The influence of Health and Safety Executive Management Standards for work related stress was evident in the charity’s Staff Wellbeing at Work policy (see box 3.3) and was drawn on to help minimise workplace stress and its potential to inhibit the promotion of positive mental health.

3.7.2 Help and advice provided for line managers

Once particular concern for the management of mental health is establishing a continuity of support. Staff turnover and movement is normal but if a line manager leaves or changes roles, it can disrupt the positive support being provided to a person with mental health conditions.

PrivateCo introduced a tool in order to address this. This allowed experiences of health conditions to be documented so that if there was a change of line manager, histories of health and support needs were not lost. There was also a similar practice for carers, for example detailing someone's need to take time off to take a parent to hospital appointments.

While the benefits of the tool will be further explored in chapter 5, it is worth noting that one HR manager commented on its potential benefits in helping to alert line managers to the need to insulate employees with mental health issues from the potential harmful effects of organisational change on mental health:

"And I just wonder whether that system provides, for example, in the case of [a section of the business that has been undergoing major changes] and some of the challenges that have been experienced, whether that [system] has provided a mechanism for kind of red flagging those individuals who might have a history, for example, of clinical depression to kind of just try and insulate them from some of those challenges that the business is grappling with." (HR manager, PrivateCo) 

The larger organisations had placed a lot of emphasis on making guidance on the management of mental health at work readily accessible. One vehicle for this was the development of intranet systems as repositories of information, alongside raising awareness of the information available.  

"I would say most managers in my position don't have the awareness of the intricacies of mental health problems, unless they've dealt with them. And therefore, we rely solely on the policies, rather than being able to spot it early and put the reasonable things in place, it would usually be as a reactive approach." (Line manager, PrivateCo) 

An HR manager at FinanceCo had placed a guide on the company intranet, called 'Managing the emotional wellbeing of your team'. Written by her in conjunction with an occupational psychologist, it contained suggested actions for the manager if they were worried that a colleague might be feeling suicidal and links to further sources of support and information such as the Samaritans.  

3.7.3 Help and advice for employees 

The larger case study organisations had developed Employee Assistance Programmes that provided access to a range of support services, particularly advisory services and counselling (for an example of this, see Box 3.4 above). The smaller employers did not have in-house employee assistance programmes but instead signposted staff to further support that might be needed, such as counselling.

3.8 Employer outreach activity

While the case study organisations reflect innovative activity, there is potential for many more employers to engage in the promotion of positive mental health at work.  A recent DWP DOH Green Paper (2016) has proposed that there will be greater use of Work Coaches in Jobcentres.

There is also recognition of the value of bringing external expertise into job centres and the contribution that the voluntary sector can make in the design and delivery of support (Department for Work and Pensions and Department for Health, 2016). Employer outreach activity provides a direct way in which more employers can be engaged in the mental health agenda, helping to challenge the stigma that continues to surround mental health.

Two case study organisations, those working in the mental health field, provided innovative examples of how this employer engagement could take place. Their work is also indicative of the kind of expertise and knowledge that Jobcentres might be drawing on in the design and delivery of support.

The charity was working to promote wider societal change and a project, 'Head for Work', aimed to raise awareness of mental health amongst employers. This innovative project involved 30 volunteer trainers who had lived experiences of mental illness. They were all long-term unemployed, living in the local area and in secondary healthcare, in the mental health service.

'Train the trainer' courses have allowed the volunteers to gain a qualification from a university as accredited mental health awareness trainers, qualifying them to become paid training ambassadors for the charity. The project manager had supported them in delivering mental health awareness training to employers in the clinical sector, educational sector and the corporate world, both in and outside of the local area.

Outreach activity was tailored to employers. Sometimes initial visits lasted 90 minutes to provide an introductory session, while in other instances the visits could be longer.

A perceived challenge was that some could be reluctant to engage in this kind of activity, unless they had experienced a 'crisis point', whereby an issue with the mental health of an employee arose in the organisation and they needed help to deal with it. However, the project’s engagement with employers had been very positive, as will be explored further in chapter 5.

Drawing on its own staff experiences of managing mental health, BCP visited local businesses to educate them on mental health, for example raising awareness of signs of mental illness and how to support someone who may be going through difficulties. The main initial focus had been on existing customers who purchase BCP services and the engagement had been broadened out to business networking groups, a borough council, job centre and a local funeral director. The visits were tailored, for example using an interactive PowerPoint presentation or roundtable discussion. Again, the benefits of this activity are presented in chapter 5.

This chapter takes a closer look at the experiences of line managers and employees vis-à-vis support for employees with mental health issues.

It considers the following 3 factors that influence how supported employees with mental health issues feel in relation to being at work: 

• disclosure of mental health issues 
• returning to work 
• the importance of reasonable adjustments

The research gives in an insight into some of the perceptions, issues and associated challenges faced by employees with mental health issues, and their line managers in dealing with these factors. 

4.1 Supporting the disclosure of mental health conditions 

Disclosure of a mental health condition is a key issue because it has the power to build bridges between individual experiences and workplace realities via family, GPs, occupational health specialists and, critically, line managers (Wakeling, 2014). In the CIPD commissioned YouGov survey (CIPD, 2016a) among the 101 employees who described their mental health as poor, only 43% had disclosed their stress or mental health problems to their employer or manager.

Individuals respond differently to the challenge of disclosure. Some people choose to hide that they are struggling, or would rather not acknowledge it, while others are more open. For example, the following quotations from FinanceCo employees, both managing depression, illustrate this.

"I'm quite open, I'm just that kind of person, I wear my heart on my sleeve. If I’m over the moon, everybody will know about it without me saying anything. If I’m under the weather by the same token, everybody will know about it. People that work closely with me tend to realise this quite quickly because it is just a large part of who I am, I just... I emote.  I don’t see the point in hiding how I’m feeling and biting my lip and if I’ve got to beat them up on it  I will usually shout up and if I’m not feeling great then people will pick up on that." (Employee). 

"And part of my problem historically has been putting this mask on coming to work, I come in and you know, you’re professional and you’re fun.  And you try and keep everybody else up and actually that’s not what’s going on for you." (Employee)

Employees with experience of mental health issues felt that stigma was a key influence on their decision to disclose. Some employees spoke of previous negative experiences that reinforced their reluctance to talk about their mental health issues. For example an apprentice at BCP described how her friends as well as previous employer had lacked understanding of her anxiety:

"People, like my friends, don’t really understand my anxiety and that’s quite off putting sometimes. So being in the work environment with a bunch of people that you don’t know at all, who don’t have any concept of anxiety, haven’t understood it, or think they know of it… Like, because you can know of anxiety but I think you’ve got to have some kind of experience or know someone who has suffered to have that compassion." (Employee). 

As noted in the previous chapter, all the case study organisations were keen to foster early detection of mental health issues, whether that be staff struggling to manage ongoing conditions, such as clinical depression, or issues that might be more temporary such as anxiety linked to bereavement.

All of the line managers interviewed felt that early detection of mental health issues was important but that stigma could fuel reluctance to disclose. For example, one line manager noted: 

"I think if companies could spot these things early, it would be better for everyone. But I know it's difficult. Sometimes, with mental health issues it comes to a head before anything can be done, doesn't it, because someone doesn't want to, for instance, talk about it to their manager or the business, or even to friends sometimes, because there's a bit of a stigma probably around it. But if you could have a crystal ball and know that someone was struggling mentally, you could put that support in at a stage where it wouldn't lead to absence and it wouldn't lead to their being unwell, or maybe help them as well." (Line manager, PrivateCo). 

At BCP and CharityOrg (the organisations employing and working with people with mental health conditions), there was a strong emphasis on developing a workplace culture characterised by openness and mutual trust. In these organisations line managers emphasised that this helped to increase the likelihood of employees disclosing mental health conditions. 

In the context of employee reluctance to disclose, having or making time to get to know their work team aided the ability of line managers to observe that a colleague might be in need of support. As one line manager noted:  

"You’re actually having to know the people that you work with day in and day out . . . They don’t walk around with Post-It notes on their head, saying I’m depressed." (Line manager, PrivateCo).  

Having agency staff seemed to give rise to particular challenges in one area of PrivateCo. Several staff had left with anxiety and it transpired that these were pre-existing conditions. In another example, an individual had disclosed this to the employment agency (which had not conveyed this to PrivateCo) and another had not disclosed it at all. Both had entered a pressurised environment and become overwhelmed.  

Employees with mental health issues repeatedly emphasised the importance of being able to communicate with line managers and that they should be approachable.  

"And so if you don’t feel that you have that relationship with your manager to be able to open communication then it’s just inevitably going to lead to problems for the employee. So yes, it’s absolutely integral that a line manager is approachable … is open and approachable so that you can speak to them … Calling in sick used to absolutely send me into panic attacks, it was horrible, I absolutely hated it." (Employee). 

A further skill, linked to emotional intelligence as well as people management, included appreciating that in some situations employees might prefer to disclose their mental health issues to co-workers. For example the young manager managing a woman experiencing the menopause and related mental health issues, discussed in the previous chapter, tried to be attentive by checking that she was all right. Other members of the team would also alert him if they noticed that she was struggling and they would find a space to talk about it. He was conscious that he was a new manager to her and that it would take a while for her to build her confidence in him.

"But I had always set the scene with her that, look, I’m your manager, it’s my job. If you need to talk, then you need to come to me. If you have any problems, come to me. I said, no matter how uncomfortable it is, or if it’s something that you’d rather talk to a mature female about, there’s plenty of mature female managers that she could go to. So it wasn’t just me that she had there for support; there were more experienced people, as well, and more women that she could speak to if she felt she needed to talk about that. And I think because it was all triggered from the menopause, I think she felt a bit uncomfortable talking to a younger male about it. But as time went on, she did open up, and in the end she loved me." (Line manager, PrivateCo).  

4.2 Enablers of a return to work following mental health related absence

Employees with mental health issues who had taken a related leave of absence suggested that a range of factors helped them to return to work. This included: 

• being given the time to access the help of health professionals, such as their own GPs and counsellors; they were also signposted to such help, for example via Employee Assistance Programmes 
• not being pressurised to return to work prematurely, but instead being given time, space and a sense of control over the pace of their return to work 
• being given time to become re-orientated to the workplace
• reasonable adjustments being made, for example changes to hours of work and avoiding sources of stress that might trigger symptoms 

An example of one employee’s experience of a positive return to work, conveying these enablers, is presented in case study 4.1 below.  

4.3 The importance of reasonable adjustments in the promotion of positive mental health 

The social model of disability recognises that the structure of social arrangements can form a barrier to the labour market participation of disabled people. Under the Equality Act 2010 employers have a duty to make reasonable adjustments for a person with a disability if it has 'a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities'.  The right to request flexible working may also help employees stay in work while managing a health condition. 

The line managers interviewed for this study recognised the importance of making reasonable adjustments for people with mental health issues and provided numerous examples of where this had worked well, helping to avoid absence or supporting a return to work. For example, while the charity has operational priorities in delivering its services, there is typically scope to make reasonable adjustments according to staff needs, for example in relation to working hours.

Line managers at the charity emphasised that making reasonable adjustments was often not a challenge: 

"If you’ve got a service to run, that's running between 9 to 5, not everyone can do them 8 to 4 … it kind of equals itself out. So I think if people don’t make lots of pressure points and don’t make it over bureaucratic and actually just work with the team …I’ve got a team of 10 that I manage and I’ve got some who say yes I love working evenings, some say they love doing mornings, and there’s some who say I’m quite happy to do the bog standard 9 to 5. So without me having to dictate and say no you’re going to do this, you’re going to do that, it manages itself." (Line manager, charity) 

"I think when people talk about reasonable adjustment they think it’s going to be something massive, and actually sometimes it’s the really, really little thing and it is just about asking." (Line manager, charity) 

Line managers at PrivateCo also discussed the difference that could be made to the quality of working lives by making reasonable adjustments: 

"I've managed people with depressive bipolar, schizoaffective disorder, depression and anxiety. And I can see how once you've got the guidance from all the services we've got available to us, once you've put those adjustments in place, you've seen how much happier and better supported the individuals are." (Line manager, PrivateCo) 

The line manager working with a woman on his team experiencing mental health problems related to menopausal symptoms noted that, as he got to know her, he learnt to see the signs that she was under pressure and needed to take a break, encouraging her to do so despite pressure of work. And an older worker coping with the ill health of parents conveyed how flexibility in working time and time off for hospital appointments helped her to manage a difficult period in her personal life that had led to stress related absence. 

A related theme emerged from some employees with experiences of mental health issues who had previously received constructive support from their organisations. They reflected on the fact that they became more self-aware and assertive in their engagement with line managers following feedback and asked for reasonable adjustments.

For example, a research participant managing stress at work noted that a key enabler for her to access support was being more aware of the risk of stress related absence and being pro-active in her engagement with her line manager in the performance management process and having the confidence that her line manager would listen: 

"You know, proactively going to my line manager and saying, look, I know we’re supposed to be writing objectives, but if we start writing objectives it’s just one more thing to add to my massive amount of stress which isn’t great at the moment. …And so it was realising that if I did try to do too much, then I would just end up worse, and I needed to kind of say, look, I have a little amount of control. We can write objectives if we want, but it’s just going to tip me over the edge probably." (Employee, PrivateCo). 

The research also came across examples of poor practice, reinforcing the concerns of Foster (2007) outlined in chapter 1. One provided insight into how chains of line management, and not only the immediate line manager, may need to be engaged in reasonable adjustments. An employee experiencing acute stress felt that the root source of this was in having to manage the care of her elderly parents through illness, but that the stress was accentuated by poor management. The employee noted: "I didn’t know whether to hit someone or burst into tears or do both."

While her co-workers were supportive and their support became part of her coping strategy, the manager above her line manager was very unsupportive and added to her stress through the performance target-setting process. She explained that once she took sickness absence, there was a supportive organisational response, but a more supportive approach at the outset might have avoided that absence: 

"They picked up the pieces quite well, but if they hadn’t knocked me off the wall that would have been better." (Employee). 

To take a second example, the NUT respondent described the experience of a member where a physical impairment then became a mental impairment because reasonable adjustments were not being made or were not being made competently. The problem seemed to stem from a lack of understanding about reasonable adjustments: 

"And that was really, there was nothing malicious about it, it wasn't deliberate, there was clearly a lack of understanding or knowledge about, about reasonable adjustments. There wasn't even any consultation with the member, changes were made to her work without any consultation with her, and not surprisingly that meant that things were actually, when implemented, they made her position worse not better." (Principal Officer, NUT). 

The report will now turn to the key learning points and recommendations from the research which can promote positive mental health at work.

A range of learning points can be drawn from this research, in particular from the case studies which provide a detailed insight on how employers can promote positive mental health at work. This chapter outlines lessons that relate to 4 areas:

• supporting the role of line managers
• promoting strong organisational leadership
• tackling stigma through employer outreach activity
• empowering staff with mental health conditions

5.1. Supporting the role of line managers through training

The research has highlighted some positive feedback from the case study organisations on the benefits of training, which appears to have contributed to increased line management awareness of mental health issues for those accessing courses, particularly in the larger organisations.

Line manager training is not about creating experts, as one HR manager noted: "There is no silver bullet, mental health is so much more complicated than that."

However, relevant training can raise awareness of the signs of negative mental health and this in turn can help line managers to take a more active role in early detection and signposting to appropriate support. As a manager from PrivateCo emphasised: "Your policies are only as good as the people who are implementing them."

Line management training on the management of mental health at work needs to be rolled out across organisations to minimise gaps in awareness and skill in managing difficult situations. Refresher courses may be needed rather than just one-off training courses. Without such measures, the effective signposting of employees to appropriate support is likely to be patchy across the organisation, again particularly in larger organisations.

Organisations need to identify gaps in training content. For example, this research study shows a need to develop line management understanding of less common mental health conditions. Addressing this gap would strengthen line management capabilities in early detection.

Line managers have a pivotal role in managing staff performance and need to be sensitised to the potential adverse impact of negative performance appraisals on staff trying to manage mental health issues. While this research has largely focused on positive examples of reasonable adjustments, it also highlighted negative employee experiences suggestive of line management training needs around reasonable adjustments. Greater line manager training in this area can support an organisational approach which recognises that reasonable adjustments to mental health conditions are a part of everyday working life and embeds them in workplace cultures.

Making reasonable adjustments, for example to working hours, can often be easier than employers think. Reasonable adjustments are also pivotal in supporting a sustainable return to work after a period of absence.

Line manager comments on their training experiences and needs suggests that it is helpful to consult them on their support needs. For example, a line manager in FinanceCo noted that a lesson for other employers was the value of general coaching techniques and understanding how mental health needs (depending on the issues being managed) can sometimes change, implying some recognition of a dynamic continuum of mental health:

"And equip your line managers with… I mean, it's general coaching techniques. So I think make sure the managers are equipped with open questioning. And also that they feel empowered to help somebody who’s perhaps got those kind of problems at a particular point in time. And I think as well, it’s really important to realise that people can get over it as well. I think sometimes, people go through a stressful period because of a particular thing, but then actually, a year later they can be absolutely fine because that thing is solved or gone away … and whilst that person may have been having some trouble coping then, that doesn’t mean they can’t cope now." (Line manager, FinanceCo).

There is also a need to acknowledge that some people are ill-suited to management and should not be in these roles.

5.1.2 Management and supervisee expectations / performance management cultures

As illustrated by CharityOrg, joint problem-solving and effective performance management can form part of a broader approach to promoting mental health. Perceived pressure to perform and meet targets can have a negative impact on mental health. This can be generated by external funding pressures that feed into individual targets, as well as the pressure that individuals can put themselves under in trying to prove themselves in a new role and/or on probation.

Line managers need to be mindful that it takes confidence for members of their team to negotiate these pressures, particularly if they have previously worked in an environment where voicing concerns about workloads has been discouraged.

Line managers need to be observant around staff who may be struggling and communicate with them, opening up a dialogue to avoid regrettable turnover.

5.2 Promoting strong organisational leadership

5.2.1 Key players in the workplace

Strong leadership is also important. In trying to minimise the scope for the development of anxious institutions, the management and communication of organisational change is a critical task for those leading on change management in context where there may be anxiety around job loss and the loss of valued job features.

Having a senior manager responsible for overseeing the development of policy and practice in the management of mental health at work can help in the journey of prioritising mental health and driving changing practice across the organisation. Leadership that draws on a strong understanding of mental health can help to foster an approach that encourages openness and support for people to talk about their mental health and emotional wellbeing in the workplace.

There was also a suggestion from research participants that organisations that developed good practice should show leadership in sharing those practices. For example, EducationEst felt that positive experiences and impacts of training should be evaluated and shared, for example at workshops and conferences to promote wider engagement across the sector.

In other case study organisations, some of this evaluation of initiatives was already taking place with a view to supporting the promotion of better practice.

The response of co-workers was also important. Research participants noted that people had friends at work who also seemed to provide a source of social support. An HR manager at FinanceCo suggested that supporting co-workers was a 'team-working competency' against which staff were being measured, which might be encouraging supportive behaviours.

There was also some perception that co-workers might also benefit from some training, rather than it being seen as the preserve of line managers, though this report has provided reasons why line managers should be a particular target. However, the difficulties that EducationEst encountered in providing dinner ladies, cleaners and supervisors with time to access training, suggest that there may be structural constraints.

Trade unions also have a role to play in promoting positive mental health. For example, this report has shown how they can bring more hidden issues to the fore. The NUT was developing a Wellbeing at Work Charter started by its Health and Safety Working Group in an effort to support the promotion of positive mental health across the sector.

5.2.2 Advice and guidance

As implied in chapter 1, there is quite a crowded marketplace for advice and guidance in the mental health field and organisations are drawing on advice from a range of sources. At various junctures this report has noted the value of recognising the continuum of mental health, conveying a complex configuration of mental health states and needs that managers may encounter in the workplace.

There seems to be a gap in that marketplace in terms of guidance around the continuum. It may be that the addressing of this gap is something that advice organisations can collaborate on in addressing, providing a clear steer to organisations on how the variety of mental health needs that they encounter can be supported.

It should also be noted that mindfulness training and practice, which has attracted a lot of interest, can support the development of emotional intelligence better self-awareness, reflection and has the potential to support the ability to better cope with workplace change. However, while mindfulness can help build resilience, it does not deal with the source of problems.

5.3 New thinking and collaborations

5.3.1 Tackling stigma through employer outreach activity

Awareness of mental health amongst employers can be increased through outreach activities in local communities. The personal testimonies and work experiences of people with mental health conditions have an invaluable role to play in this. As seen in Chapter 3 , CharityOrg and BCP have both been undertaking work with employers, BCP in its local area and CharityOrg in its local area and beyond.

Feedback from BCP's employer outreach programme suggested that it was working well, raising awareness and fostering employer interest in mental health needs as well as improving the prospects for disclosure:

"We've had a few members of staff at various organisations who have actually stayed behind to talk to us and say, you know what, I think I'm struggling with this, or, I'm going through this problem, how do I address it? So it's obviously touching a nerve and there's a need for it." (Line manager, BCP)

Similarly, in CharityOrg there are signs that this kind of outreach activity facilitates ongoing relationships with employers who seem keen to follow-up on the first outreach visit. For example, an airline subsequently asked for help developing a wellbeing day involving a mindful workplace training package. This package was mainly for managers, helping them to have conversations with colleagues in need of support and they subsequently ran a mental health in the workplace course which was about managing stress and building and taking ownership of resilience:

"The good thing is that people that we have engaged with previously understand the importance of [engaging with the project] and will touch base with us roughly throughout the coming months afterwards. So we do have, we do keep close contact with them. So it’s good. We saw that with one of the airlines we worked with. So after we worked with their management team, then we worked with all of the frontline staff. They then said they wanted a bit more support." (Project worker, CharityOrg)

Having an ethnically diverse group of trainers, men and women has allowed the voluntary trainers in CharityOrg to engage with the cultural elements of stigma in their interactions with employers:

"Culturally we've been able to really tap into the cultural elements of it, of the stigma within it and people talking quite openly about how their families treated them and their perception of mental illness before they were really faced with it themself. And sharing that within a group as well, so that’s been really, really, beneficial for them and for people when we’ve gone out and delivered as well. Because the part of the training we deliver has an element of cultural stigma and cultural mental health and different sort of faiths, [employers’] perception of it." (Project manager, CharityOrg)

There are not only reported changes in the employers as a result of this activity. BCP and CharityOrg reported that people with mental health conditions who get involved in these projects, many of whom have been long-term unemployed, also grow in confidence and develop new and transferable skills, sometimes helping them to try to develop new careers:

"They have, I mean many of them have achieved fantastic things within being, within the project. Not solely my doing, but the fact they have finally had a platform where they can feel comfortable, that they can kind of explore and look at different options that they may not have done before. Some people have started businesses; some people have gone into doing their Masters, which within maybe a 2-year period being on a ward seemed really unrealistic for them." (Project manager, CharityOrg)

5.3.2 Staff empowerment

A further lesson emerging from this research is the potential for developing a broader approach to mental health to give employees and line managers greater control over its management. Again this was evident in BCP and CharityOrg.

Chapter 3 referred to CharityOrg's introduction of a supervision policy which supported the development of a workplace culture where staff feel empowered to have as much control and say as possible in their role, and how the service they deliver works. The role of line managers was spelt out in the supervision policy reinforcing messages around the importance of supportive practice and reasonable adjustments.

In BCP one of the challenges encountered was that dependency could arise in the supportive and empathetic working environment being provided, which was not necessarily healthy in the longer-term. To remedy this, instead of assuming responsibility for people's problems BCP actively encouraged and supported people to empower themselves to continue to solve their own problems and move to independence. On the other hand, as people’s confidence increased, with exposure to new work challenges, that sense of dependency could be lessened.

Gallie et al, (2016) argue that employee participation in decision-making around organisational change can have a positive effect in reducing anxieties because it helps to reduce uncertainty and increase trust in management. A sense of procedural fairness is generated by providing opportunities for employees to influence the details of decisions affecting their work lives.

The results of their analysis, drawing on nationally representative data for British employees, suggest that "if policies to raise levels of employee effort and achieve greater workforce flexibility are to be compatible with a work environment that is supportive of employees’ psychological and physical health, they will need to be accompanied by measures to enhance employee participation in decisions that affect their work lives" (Gallie et al, 2016: 16).

Interestingly in BCP, fostering a climate of social inclusion in which staff and clients felt that they had some influence and control over decisions supported the early detection of a change in mental health, having a positive influence on inclinations to disclose:

"We do a lot of social inclusion work and consider that everybody's contribution is important. If there are any decisions that need to be taken in a business of course, there are decisions that need to be taken at directorship level, that's obvious. But for the directors to reach that decision the whole team would be involved with the decision making process. This I think fosters a nice atmosphere of involvement and team inclusion for our staff and clients. You feel that your input does matter and you are being listened to." (Line manager, BCP).

The use of a document outlining employee support needs that could be updated as needed (see Chapter 3) can also be seen as a mechanism for giving both employees and line managers greater control over the management of their mental health in the workplace. It is an approach that could be rolled out across a wider range of organisations. An HR manager and line manager commented on the benefits of this approach in minimising potentially stressful conversations and meeting the needs of complex family needs:

"I think it saves employees when they change line manager and sometimes in PrivateCo they can change line manager quite frequently to be honest, then the employee having to re-explain himself and go into, you know, the detail in their condition because for some people that could be quite painful or they wouldn't feel comfortable doing it as I wouldn't either." (HR manager, PrivateCo)

"I know of somebody that had [a document outlining reasonable adjustments that she needed], but she also had [a flexible work arrangement] for her son, because he was on the autistic spectrum. She had to be there for him quite a lot, basically. So if she needed to leave work to be with her son, there are measures in place to free that time up for her, an agreement of when she could maybe pay that time back, if you like. (Line manager, PrivateCo)

Acas (2014), Promoting positive mental health at work 

Alvesson M, and Deetz S (2000), Doing Critical Management Research. London: Sage 

Alvesson M, and Sveningsson S (2003), Managers Doing Leadership: The Extra-Ordinarization of the Mundane, Human Relations, 56(12):1435-1459 

Beauregard A, Basile K, and Canonico E (2013), Home is where the work is: A new study of homeworking in Acas – and beyond (PDF). Acas research paper 

Bryson A, Forth J, and Stokes L (2014), Does Worker Wellbeing Affect Workplace Performance? Department for Business Innovation and Skills, October

Burchell B, Day D, Hudson M, Ladipo D, Mankelow R, Nolan J, Reed H, Wichert I, and Wilkinson F (1999), Job Insecurity and Work Intensification: Flexibility and the Changing Boundaries of Work. Joseph Rowntree Foundation Work and Opportunity Series, 11. York

Burchell, B, Ladipo D and Wilkinson, F (2002), Job Insecurity and Work Intensification. London: Routledge

Chief Medical Officer (2013), Annual report of the Chief Medical Officer - public mental health

CIPD (2016a), Mental Health - Employee Outlook

CIPD (2016b), Growing the health and wellbeing agenda: From first steps to full potential. Policy report

Collinson D, Knights D and Collinson M (1990), Managing to Discriminate. London: Routledge

DWP and DoH (2016), Work, health and disability green paper: improving lives

Eisenhardt, K M (1989), Building theories from case study research, Academy of Management Review, 14 (4): 532-550.

Engel, G (1977), The need for a new medical model: a challenge for biomedicine, Science, 196(4286): 129-136.

Fevre R, Robinson A, Lewis D and Jones T (2013), The ill-treatment of employees with disabilities in British workplaces, Work employment and society, 27(2): 288-307

Foster D (2007), Legal obligation or personal lottery? Employee experiences of disability and the negotiation of adjustments in the public sector workplace, Work employment and society, 21(1): 67-84

Gallie D, Felstead A, and Green F, (2016), 'The hidden face of job insecurity'. Work, employment and society, 1 to 18

Grove B, Secker J and Seebohm P (2005), New Thinking About Mental Health and Employment. Oxford: Radcliffe Publishing

Hanisch S, Twomey C, Szeto A, Birner U, Nowak D and Sabariego C (2016), The effectiveness of interventions targeting the stigma of mental illness at the workplace: a systematic review, BMC Psychiatry (2016) 16:1. Open Access

Hatfield I (2015), Self-employment in Europe (PDF). London: IPPR

Hoque K and Bacon N (2014), Employer disability practice in Britain: assessing the impact of the Positive About Disabled People 'Two Ticks' symbol. Work, Employment and Society 28(3)

HSE (2012), Health and Safety Executive Management Standards for Work-related stress

Hudson M, Ray K, Vegeris S and Brooks S (2009), People with mental health conditions and Pathways to Work. Department for Work and Pensions Research Report No 593

Jolly D (2012), A Tale of two Models: Disabled People vs Unum, Atos, Government and Disability Charities (PDF)

Layard R (2004), Mental health: Britain's biggest social problem? PMSU seminar paper

Layard R (2006), Happiness: Lessons from a New Science. London: Penguin

Link B and Phelan J (2001), 'Conceptualising Stigma'. Annual Review of Sociology, 27:363-85 

Mental Health Foundation (2016), Added Value: Mental Health as a Workplace Asset (PDF)

National Union of Teachers (2016), Guidance for school leaders on preventing work-related health conditions by tackling stress

Nice, K and Thornton, P (2004), Job Retention and Rehabilitation Pilot: Employers' Management of Long-Term Sickness Absence, DWP Research Report 227, Social Research Division, Department for Work and Pensions, London

Noon M, Blyton P and Morrell K (2013), The Realities of Work: Experiencing Work and Employment in Contemporary Society. (Fourth edition) Basingstoke: Palgrave

Seymour L and Grove B (2005), Workplace interventions for people with common mental health conditions: evidence review and recommendations (PDF). British Occupational Health Research Foundation

Shaw Trust (2010), Mental Health: Still the Last Workplace Taboo

Social Exclusion Unit (2004), Mental Health and Social Exclusion. London: Cabinet Office

Smets M and Jarzabkowski P (2013), Reconstructing institutional complexity in practice: A relational model of institutional work and complexity. Human Relations, 66(10):1279-1309

Thornicroft G (2006), Shunned: Discrimination against people with mental illness. Oxford: Oxford University Press 

TNS BMRB (2014), Attitudes to Mental Illness 2013 Research Report (PDF). Prepared for Time to Change February 2014 

Wakeling, A (2014) Disclosure: the next big barrier for mental health (PDF). Employment Relations Comment. Acas

Warr P (2007), Work, Happiness and Unhappiness. Mahwah, New Jersey: Lawrence Erlbaum Associates

These 3 topic guides were used by interviewers for the Acas management of mental health at work study, and were tailored to job roles:

• HR / general manager/ head of wellbeing
• line manager
• other

HR/ general manager/ head of wellbeing topic guide

Introduction 

• Introduce self
• Explain/reiterate purpose of the research
• State that there are no right or wrong answers, we are interested in the respondents’ perceptions, views and experiences
• Explain that participation is voluntary; they are free not to answer particular questions, to withdraw from the study and free to withdraw their data prior to publication
• Indicate that (as mentioned in information sheet) interview will last about an hour
• Explain purpose of digital-recording (ask permission), transcription, nature of reporting
• Check whether respondent has any questions and is happy to proceed –run through consent form. 
• Check respondent happy to start the recording of the interview

Part A: Background 

Can you please tell me a little bit about [case study organisation name]?  

Probe: 

• key demographics on the organisation - size, industry, location, gender, ethnicity, union presence, availability of a organisation chart

Can you tell me a little bit about yourself? 

Probe: 

• role/responsibilities 
• length of time in organisation 
• briefly, previous jobs/roles 

Part B: Perceptions of mental health and its causes  

1. What factors do you think might influence the mental health of employees?   

Probe as appropriate: 

• triggers within and beyond the workplace 
• examples:  
  • severe or long-term stress 
  • physical causes, such as a head injury 
  • bereavement 
  • relationship breakdown 
• workloads/work-life balance 
• combination of factors 
• has your thinking on this changed over time? How? Why? any influence of experiences/ campaigns beyond/within the workplace 

2. How common is it for employees to disclose mental health conditions? 

Probe as appropriate: 

• incidence of mental health conditions/ whether increased/ decreased/ stayed the same over the years?/ Why do you think this is? 
• how hidden/ signs of mental ill-health 
• at what point do employees tend to disclose their condition and to whom 
• factors influencing disclosure (for example stigma, fear of impact on career progress, line manager/ co-worker capabilities in identifying mental health needs) 
• subpopulations (for example, men/women, younger/older people, ethnicity) 

3. What kind of mental health conditions do employees present with in this organisation? 

Probe as appropriate: 

• perception of prevalence of mental health conditions (in particular areas of work / contexts) 
• depression, anxiety disorders, other  
• severe, moderate, mild (ease of gauging) 
• triggers  
• any monitoring systems  

4. How, if at all, does mental ill-health influence workplace effectiveness? 

Probe as appropriate: 

• absence 
• staff leaving 
• team work (for example, communication, missed deadlines, morale) 
• performance  

Part C: The development of policies on managing mental  health at work  

5. How would you describe [organisation’s] approach to the management of mental health at work? 

Probe as appropriate: 

• reactive (for example, responding when someone goes off sick/ill-health) and preventative strategies 
• main initiatives / programmes (for example, health and wellbeing, mindfulness initiatives, employee assistance programme, occupational health support) 
• part of a cohesive/integrated wellbeing strategy? in what way? 
• aims – whether emphasis on changing workplace culture (formal/ informal); people management (particularly line management role); leadership 
• whether joined up approach (particularly between healthcare providers and business) 

6. To what extent is there a business case for the management of mental health at work in [organisation]? 

Probe as appropriate: 

• ease of developing a business case / constraints 
• importance of moral arguments 

7. Do you currently have a corporate policy in place on mental health at work? 

Probe as appropriate: 

• can you tell me a little bit about it 
• length of time policy in place / when introduced 
• whether defines mental ill-health and prevalence 
• whether specifically addresses recruitment 
• whether links to other (disability) policies, for example, disability leave, flexible working, dignity at work, two-tickets symbol / commitments 
• whether equality impact assessment undertaken
• whether policy provides some indicators of mental health needs, for example:
  • changes in an employee’s usual behaviour such as poor performance
  • tiredness or increased sickness absence
  • an increased use of alcohol, drugs or smoking 
  • tearfulness, headaches  
  • loss of humour and changes in emotional mood 
• whether provides clear understanding of the role of line managers, for example:
  • practical steps to encourage the disclosure and discussion of mental health conditions and outlines identify appropriate support 
  • signals that managers should be aware that mental ill health can influence the self-confidence of people who may be unable to confide in others or seek help
  • signals that managers should endeavour to support those experiencing mental ill health in a sympathetic, empathetic, non-judgemental and confident manner
• clarifies the specific role and responsibilities for the human resources team, for example:
  • central responsibility of developing a policy and procedures on mental health for managers and employees  
  • pledge to review and update other policies, procedures and practices that are linked and could affect the implementation of a mental health policy; for example, an employee assistance programme or staff training programmes 
• whether policy embodies a commitment to promote awareness: 
  • a clear list of local and national key contacts of support and advice agencies. 
  • a designated contact for further information on the policy 
  • is reviewed on an annual basis by gathering information on how the policy is working for employees and managers. 
• workforce coverage/ any priority areas 
• request copy of corporate policy document outlining organisation’s approach to the management of mental health at work 

8. Why did you introduce this policy? 

Probe as appropriate: 

• concerns about mental health and wellbeing / signs that policy/practice development was needed / main issues seeking to address 
• influence of legislative requirements 
• have you ever revised/made changes to this policy?  If so, why? 
• what, if any, policies were previously in place? Who was involved in policy development 

9. What kind of support and guidance have you drawn on in developing mental health at work policies?  

Probe: 

• consultation with key stakeholders (for example, disability staff group, occupation health, mental health specialists, charities, psychologist, mindfulness teacher)  
• use of guidance, Acas mental health guidance, Health and Safety Executive (HSE), EHRC /other? 
• helpfulness of guidance / what was useful/ what was not useful / why?/ what was missing? how / why was this important? 

Part D: The development of practice in managing mental health at work 

Can you tell me [a little bit more] about how have you gone about putting policies into practice? 

Probe as appropriate: 

• senior management support 
• champions/ role 
• corporate campaign 
• development/ role of an action plan (availability of this document) 
• role of communication, awareness raising 
• role of any channels for employee voice / input into decision-making (for example, employee representatives, telephone hotline) 
• role of guidance 
• external support 
• role of workplace training (coverage, frequency) 
  • raise awareness – recognising possible signs of ill-health 
  • clarity around roles and responsibilities   
  • mental health link staff / first aiders
• any implementation of two-ticks commitments  
• role of monitoring, for example revisions to any action plan 
• any other initiatives considered /put in place 

11. Have you encountered any challenges in putting policies into practice? 

Probe as appropriate: 

• pockets of good practice / implementation gap(s) 
• most difficult challenge  
• senior manager leadership / support 
• attitudinal barriers (stigma and discrimination) 
• lack of awareness / understanding  
• organisational context, resources, priorities 
• line manager response / buy-in 
• responses from co-workers  
• response from employees mental health conditions (depression, anxiety, other) 
• other

 12. How have you tried to engage with these challenges? 

Probe as appropriate: 

• why/why not? 

Part E: Effectiveness of the management of mental health at work  

13. How different does the management of mental health at work look from where you started on your journey to improve it?

14. What would you say is innovative about the approach to managing mental health at work in [organisation]?

15. Overall, how well do you feel that your approach to the management of mental health at work is working?

Probe as appropriate: 

• successes  
• key enablers 
• sustainability 

16. How do employees with mental health conditions benefit from [organisation’s] approach to managing mental health at work? 

Probe as appropriate: 

• employees with depression and anxiety, other, men/women, older/ younger 
• improvement in emotional, physical health/well-being, sense of isolation, easing of symptoms (signs/ examples of this) 
• how do you gauge the benefits (approach/ ease) 
• key enablers 

17. Does your approach to managing mental health at work benefit organisational performance?  

Probe as appropriate: 

• mental health related sickness absence; recovery time 
• (regrettable) turnover – retention of skills / knowledge / experience 
• reputational benefits linked to staff recruitment/ retention 
• key enablers 
• any process / impact evaluations undertaken 
• patterns of employer expenditure on (a) health and wellbeing and (b) the management of mental health at work; budget constraints  

18. Can I please check, are there any signs that there is an implementation gap between formal policy and practice in the management of mental health at work? 

Probe as appropriate: 

• any awareness of gaps / ease of identifying 
• nature/importance/consequences of gap(s) 
• causes of gap(s) 
• whether being tackled? why / why not / how? 

19. What advice would you give to other organisations / HR managers / line managers trying to develop mental health at work policies and practices? 

Probe as appropriate: 

• why? 
• with hindsight is there anything that you would have done differently? 

20. Do you have any future plans to further develop your approach to the management of mental health at work? 

Probe as appropriate: 

• why? why not? how? 
• what challenges remain 

21. Is there anything else that you would like to add? 

Line manager topic guide

Introduction 

• Introduce self  
• Explain/reiterate purpose of the research 
• State that there are no right or wrong answers, we are interested in the respondents' perceptions, views and experiences
• Explain that participation is voluntary – they are free not to answer questions that they would prefer not to, free to withdraw from the study and free to withdraw their data prior to publication 
• Indicate that (as mentioned in information sheet) interview will last about an hour
• Explain purpose of digital-recording (ask permission), transcription, nature of reporting
• Check whether respondent has any questions and is happy to proceed – run through consent form 
• Check respondent happy to start the recording of the interview

Part A: Background 

1. Can you tell me a little bit about yourself? 

Probe: 

• role of person 
• length of time in organisation 
• line management – number and roles of team/employees  

Part B: Perceptions of mental health and its causes  

2. What factors do you think might influence the mental health of employees?   

Probe as appropriate: 

• triggers within and beyond the workplace 
• examples:  
  • severe or long-term stress 
  • physical causes, for example, head injury 
  • bereavement 
  • workloads / work intensification / pressures to meet deadlines / customer demands / performance targets / work-life balance 
• combination of factors 
• has your thinking changed at all over the years? why? / why not? 

3. In your experience, how common are mental health needs relative to other health issues? 

Probe as appropriate: 

• kind of mental health conditions (for example, depression, anxiety disorders, other)  
• severe, moderate, mild (ease of gauging) 
• triggers 

4. In your experience, how common is it for employees to disclose mental health conditions? 

Probe as appropriate: 

• how hidden/ signs of mental ill-health 
• changes in an employee's usual behaviour such as  poor performance, tiredness or increased sickness absence, an increased use of alcohol, drugs or smoking, tearfulness, headaches, loss of humour and changes in emotional mood 
• factors influencing disclosure (for example, stigma, fear of impact on career progress) 
• subpopulations (men and women, older and younger people) 

How if at all does mental ill-health influence workplace effectiveness? 

Probe as appropriate: 

• absence 
• staff leaving / regrettable labour turnover 
• team work (for example, missed deadlines) 
• other 

Part C: Support received in line managing mental health at work  

5. Do you currently have a corporate policy in place on mental health at work?  

Probe as appropriate: 

• whether policy provides clear understanding of the role of line managers?  
• what is explained well 
• suggestions for improvement 

6. What kinds of support do you receive to help you assist in the management of mental health and wellbeing at work?  

Probe as appropriate: 

• clarity of organisational policies? written guidance? in what way helpful / unhelpful? 
• role of workplace training; preventative/reactive; mindfulness training 
• coverage – for example, recognising possible signs of ill-health; engaging with depression and anxiety / other mental health needs; inter-personal skills / handling difficult conversations; absence-handling; clarity around roles and responsibilities; advice on mental health link staff / first aiders; links to other disability policies, such as disability leave, flexible working, dignity at work, two-tickets symbol / commitments 
• whether any ongoing support being received and nature of this 
• any skills gaps? whether more/ different support needed? why? in what way? 
• any training received? 
• support from their manager / HR / senior managers? 

Part D: Experiences of managing employees with mental health conditions  

7. What experience do you have of supporting employees with mental health needs?  

Probe as appropriate: 

• employee characteristics (depression and anxiety / other, gender, age, role) 

8. How confident/able do you feel in providing support to colleagues with mental health needs? 

Probe as appropriate: 

• depression and anxiety; other 
• more confident/able with some mental health needs than others? ask to provide examples 
• ask them to reflect on why they feel this way? 
• which employees with health conditions, if any, do you feel the hardest to support? why? 
• how, if at all, has training/guidance helped?  

9. In your experience, do employees with [depression/anxiety or other mental health needs] require particular kinds of support?  

Probe as appropriate: 

• line manager action to encourage the disclosure and discussion of mental health conditions and identify appropriate support
• line manager awareness and understanding of how mental ill health can influence the self-confidence of people who may be unable to confide in others or seek help
• nature of support needed / reasons needed 
• importance of line manager engaging with employees in a sympathetic, empathetic, non-judgemental and confident manner
• scope to signpost employees to support: for example, employee assistance programme, occupational health, counselling, knowledge of support beyond the workplace 
• variations in support needs 
• how, if at all, has training / other support for you in your role helped?   

10. Have you encountered any challenges in providing line management support? 

Probe as appropriate: 

• most difficult challenge 
• attitudinal barriers (stigma) 
• lack of awareness / understanding  
• organisational context, resources, priorities 
• senior manager support 
• co-worker / employee responses 
• other 

11. How have you tried to engage with these challenges? 

Probe as appropriate: 

• why/why not? 
• effectiveness of actions 
• any additional line management support needs 

Part E: Effectiveness of the management of mental health at work  

12. Overall, how well do you feel that your organisations policies are working for people with mental health needs? 

Probe as appropriate: 

• employees with depression and anxiety, other 
• subpopulations (for example, BME groups, younger people, older people, women, men, those with disabilities) 

13. How do employees with mental health conditions benefit from line management support? 

Probe as appropriate: 

• employees with depression and anxiety, other 
• improved emotional, physical health/wellbeing  
• reduced sense of isolation 
• easing of symptoms 
• how do you gauge the benefits (approach/ease) 

14. How if at all does organisational performance benefit from line management support for employees with mental health needs?  

Probe as appropriate: 

• mental health related sickness absence; recovery time 
• avoidance of regrettable turnover; retention of skills/knowledge/experience 
• employee/team morale 
• reputational benefits linked to staff recruitment/retention 

15. Are there any signs that there is a gap between formal policy and practice in the management of mental health at work? 

Probe as appropriate: 

• nature/importance/consequences of gap(s) 
• causes of gap(s) 
• whether being tackled? why / why not / how? 

16. What advice would you give to other organisations trying to develop policies and practices to more effectively manage mental health at work? 

Probe as appropriate: 

• why? 
• with hindsight is there anything that you would have done differently? 

17. Is there anything else that you would like to add about the management of mental health and wellbeing in [organisation]? 

Thank you  

Next steps: reiterate anonymity in case summaries and research report  

Employees topic guide 

Introduction 

• Introduce self.
• Explain/reiterate purpose of the research.
• State that there are no right or wrong answers, we are interested in the respondents’ perceptions, views and experiences. 
• Explain that participation is voluntary; they are free not to answer any questions that they would prefer not to and they are free to withdraw from the study and free to withdraw their data prior to publication.
• Indicate that (as mentioned in information sheet) interview will last about an hour. 
• Explain purpose of digital-recording (ask permission), transcription, nature of reporting. 
• Check whether respondent has any questions and is happy to proceed –run through consent form.
• Check respondent happy to start the recording of the interview. 

Part A: Background 

1. Can you please tell me a little bit about yourself and your current situation?  

Probe as appropriate: 

• whether lives/works locally 
• age 
• household composition 
• whether works full time/part time 
• length of time in organisation 
• brief work history: current/previous roles in this organisation and with other employers 
• whether current role involves team working 

2. I understand that in recent years you have been unwell, can you tell me a little bit about that? 

Probe as appropriate: 

• nature of mental health condition 
• whether ongoing/recurring/when first occurred (whether gaps in work history linked to mental health needs) 
• whether identified a particular trigger(s) for health condition 
• beyond the workplace (for example, bereavement, financial worries, relationship breakdown) 
• within the workplace (for example, workloads / performance targets, unachievable deadlines, emotionally demanding role, bullying) 

3. How were you feeling when you first became aware that there was an issue? 

Probe as appropriate:

Symptoms, such as:

• unexplained absences; sick leave 
• poor performance
• poor timekeeping 
• poor decision-making 
• lack of energy 
• uncommunicative/ moody behaviour 
• any sense of isolation 
• how [health condition] did/has/does affect day-to-day activities?  Within the workplace / beyond the workplace 

4. How are you feeling at the moment? 

Probe as appropriate: 

• within the workplace 
• outside of work 

5. Can you please tell me a little more about what your work environment was like? 

Probe as appropriate: 

• degree of control over way worked 
• support – for example, encouragement/support from line managers, adequate resources for role 
• working relationships – positive/negative 
• clarity around role / whether conflicting roles 
• management and communication of organisational change 

Part B: Disclosure of mental health condition and support received within and beyond the workplace 

6. At what point did you disclose your [health condition] to your employer?  

Probe as appropriate: 

• who spoke to; line manager / co-worker/ HR / other; why; formal / informal meeting(s); how responded (for example, whether listened, whether judgemental, whether generated action points, whether agreed review date), agreement around what team would be told about condition; what thought of this response; how helpful 
• any anxiety about disclosure (for example, stigma, discrimination, impact on career); why/ why not; whether any fears realised 
• any experience of leavism 
• any contact with line manager(s) while on sick leave 

7. Have you received any support in managing your [health condition] outside of the workplace?   

Probe as appropriate: 

• family and friends 
• health professionals (for example, medication, access to talking therapies)  
• other 
• how accessed this support / ease of access 
• whether / how helped 

8. Have you received any support for your [health condition] from your employer?  

Probe as appropriate: 

• employee assistance programme 
• occupational health 
• talking therapies, for example counselling (one to one or group) 
• mindfulness therapies / training (one to one or group) 
• sick leave; disability leave 
• time off for medical appointments/therapies 
• changes to working patterns / workload (over what period) 
• specific support from HR/line manager/senior managers 
• how accessed this support / ease of access/ clarity around support available / whether felt consent was sought / how? 
• whether support tailored to individual’s needs / reasonable adjustments made to improve work context 
• whether/how support helped (signs of this) 
• when returned to work 

Part C: Effectiveness of policies to support the management of mental health at work 

9. Overall, how well do you feel that your employer’s [approach/ policies] on the management of mental health have worked? 

Probe as appropriate: 

What worked well for you 

Whether anything more could have been done/ done better, such as: 

• role of HR/ importance 
• role of line manager(s)/ importance
• role of co-workers/ importance
• other 

10. Do you have anything more to say about how you may have benefited from support received at work?  

Probe as appropriate: 

• improved emotional, physical health/wellbeing  
• reduced sense of isolation 
• easing of symptoms 
• job retention / returning to work 
• difference made to day-to-day activities 
• key enablers, such as timely advice, early intervention, appropriate referrals, tailored support 

11. Do you have any particular aspirations for the future? 

Probe as appropriate: 

• any aspirations to change role/promotion 
• whether optimistic about prospects for this; why / why not?  
• any concerns about potential discrimination in the future; why? why not? 

12. How does line management support for mental health at work benefit organisational performance?  

Probe as appropriate: 

• mental health related sickness absence; recovery time 
• avoidance of regrettable turnover; retention of skills/ knowledge/ experience 
• morale 
• reputational benefits linked to staff recruitment / retention 

13. Are there any signs that there is a gap between formal policy and practice in the management of mental health at work? 

Probe as appropriate: 

• nature / importance/ consequences of implementation gap(s) 
• informal actions / behaviours 
• causes of gap(s) 
• whether being tackled? why / why not / how? 

14. From your experience, what advice would you give to other employers trying to develop mental health at work policies and practices? 

Probe as appropriate: 

• why? 
• with hindsight, is there anything that you would have done differently? 

15. Is there anything else that you would like to add about the management of mental health and wellbeing in [organisation] and your experiences? 

Thank you  

Next steps: Reiterate anonymity in case summaries and research report

Other staff, for example psychologists, mindfulness trainers, occupational health, disability champions topic guide 

Introduction 

• Introduce self.  
• Explain/reiterate purpose of the research. 
• State that there are no right or wrong answers, we are interested in the respondents’ perceptions, views and experiences. 
• Explain that participation is voluntary; they are free to not answer particular questions, free to withdraw from the study and free to withdraw their data prior to publication. 
• Indicate that (as mentioned in information sheet) interview will last about an hour. 
• Explain purpose of digital-recording (ask permission), transcription, nature of reporting. 
• Check whether respondent has any questions and is happy to proceed –run through consent form. 
• Check respondent happy to start the recording of the interview. 

Part A: Background information 

1. Confirm current post and length of time in this post and working with case study organisation 

Probe as appropriate: 

• types of services and support involved in delivering 
• whether always worked in this geographical area 
• range of employers worked with (examples) 
• mental health client characteristics (depression and anxiety/ other mental health needs, gender, ethnicity, age, work roles, gaps in work histories) 
• briefly, previous roles 

Part B: General perceptions of enablers, barriers and mental health support needs 

2. What factors do you think might influence the mental health of employees? 

Probe as appropriate: 

• triggers within and beyond the workplace, for example:  
  • severe or long-term stress 
  • physical causes, for example head injury 
  • bereavement 
  • relationship breakdown 
  • workloads / work intensification / pressures to meet deadlines / customer demands / performance targets / work-life balance 
  • other 
• Combination of factors 
• Has your thinking on this changed at all over time? How? Why?  

3. In your experience what are the main barriers to people with mental health conditions receiving the support that they need? 

Probe as appropriate: 

• at work / more generally 
• confidence, motivation, self-esteem  
• appropriate support services 
• awareness of support services  
• joined-up working of support within/beyond the workplace 
• other 

4. In your experience, how much of an impact do employer attitudes about employing people with a history of mental health issues have on labour market and workplace experiences? 

Probe as appropriate: 

• employee perceptions of employer attitudes (stigma, discrimination) 
• employer/ line manager skills in the management of mental health at work (use example of depression and anxiety) 
• ask for examples (positive/negative) from employer’s and people with mental health conditions engaged with  

5. In your experience, do people with mental health needs require specific kinds of support to stay in work?  

Probe as appropriate: 

• nature of support needed / reasons needed (again, focus on example of depression and anxiety) 
• variations by depression / anxiety and other kinds of mental health conditions 
• why is this important? 

6. To what extent is a business case for the management of mental health at work in [organisation]? 

Probe as appropriate: 

• ease of developing a business case / constraints 
• importance of moral arguments 

Part C: The management of mental health at work in [case study organisation] 

7. How would you describe [organisation’s] approach to the management of mental health at work? 

Probe as appropriate: 

• reactive/preventative  
• main initiatives/ programmes (for example, wellbeing, mindfulness initiatives, employee assistance, occupational health support, stress management) 
• a cohesive wellbeing strategy / integrated approach? in what way? 
• aims – whether emphasis on changing workplace culture (formal/informal), people management (particularly line management role), leadership 

8. To what extent are the kinds of support that you think are important being provided in [case study organisation]? 

Probe as appropriate: 

• training/guidance 
• gaps/suggestions for improvements 

9. Can you tell me a little bit more about your contribution to the management of mental health at work in [case study organisation] 

Probe as appropriate: 

• one-to-one / group work 
• journeys of people with mental health conditions worked with / supported  

Part D: Effectiveness of policies / practices to support the management of mental health at work 

10. Overall, how well do you feel that [case study organisation’s] policies on the management of mental health have worked? 

Probe as appropriate: 

• strengths 
• good practice / innovative practice  

11. Do you have anything more to say about how people with mental health needs, who you have worked with in [case study organisation] have benefited from support received at work?  

Probe as appropriate: 

• respondent support 
• depression/anxiety, other 
• improved emotional, physical health/wellbeing  
• reduced sense of isolation 
• easing of symptoms 
• job retention / returning to work 
• difference made to day-to-day activities 
• key enablers, such as timely advice, advocacy, early intervention, appropriate referrals, tailored support

12. How if at all does organisational performance benefit from line management support for employees with mental health needs?  

Probe as appropriate: 

• mental health related sickness absence; recovery time 
• avoidance of regrettable turnover; retention of skills/ knowledge/ experience 
• morale 
• reputational benefits linked to staff recruitment / retention 

13. What advice would you give to other employers/other staff in your role trying to develop mental health at work policies and practices? 

Probe as appropriate: 

• leadership 
• people management 
• workplace cultures 

14. Is there anything else that you would like to add about the management of mental health and wellbeing in [organisation] and/or in general? 

Thank you  

Next steps: Reiterate anonymity in case summaries and research report