Health Education Research, Vol. 18, No. 2, 207-215,
April 2003
© 2003 Oxford University Press
Promoting mental health through employment and developing healthy workplaces: the potential of natural supports at work
Institute for Applied Health and Social Policy, King’s College London, Waterloo Bridge Wing, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NN, UK1 Present address: Anglia Polytechnic University, 3rd Floor, Ashby House, Bishop Hall Lane, Chelmsford CM1 1SQ, UK. E-mail: j.secker{at}apu.ac.uk
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In England, policy developments in the field of mental health are stimulating interest in employment for mental health service users as a means of mental health promotion. To date, research that might assist in increasing employment rates amongst this group has focused largely on the question of which service users are most likely to benefit from vocational interventions and, more recently, on models of vocational support. Less is known about how employers can assist people in their transition or return to work. In this article we draw on the accounts of 17 employment project clients to identify workplace factors that were associated with job retention. Specific adjustments such as flexibility about working hours, work schedules and job tasks emerged as crucial in enabling clients to deal with the effects of medication, and to regain stamina and confidence. Over and above these, however, ‘natural supports’ of a kind from which any employee would arguably benefit were equally important. In this respect the main themes revolved around training and support to learn the job, supportive interpersonal relationships at work, workplace culture, and approaches to staff management. These themes might equally provide a productive focus for workplace health promotion more generally, using organization development approaches.
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Introduction |
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Recent policy developments in England in the field of mental health are stimulating interest in employment for mental health service users. The mental health promotion standard included in the National Service Framework (NSF) for Mental Health (Department of Health, 1999
) requires health and social services to reduce discrimination and social exclusion amongst people with mental health problems and increasing employment opportunities is highlighted as a means to that end. In addition, the NSF requires service providers to include action for employment, education, training or other occupation within the care plans for people on the enhanced Care Programme Approach, introduced in 1993 as the framework underpinning practice in this field.
There is no shortage of evidence that mental health service users want and are able to work or that employment can benefit their mental health. Surveys have found that aspirations to work are widespread, even amongst those who have lost touch with the labour market over an extended period (Bates, 1996; Rinaldi and Hill, 2000; Secker et al., 2001). Studies in the US indicate that with appropriate support between 55 and 75% of people who have experienced serious mental illness can find and keep competitive employment (Bond et al. 1997). Equally, research has demonstrated strong links between unemployment and mental ill health (Warr, 1987), and between meaningful occupation, clinical improvement and decreased levels of service use (Wing and Brown, 1970).
Nevertheless, implementing the recent policy initiatives is unlikely to be straightforward. Even in the US, where employment has been a focus of policy and rehabilitation practice for over a decade, unemployment rates amongst mental health service users remain high (National Organization on Disability, 1998). To date, research which might assist in turning this situation around has focused largely on attempts to ascertain which service users will respond best to vocational interventions (Arns and Linney, 1993; Anthony, 1994; Regenold et al., 1999) and more recently on approaches to vocational support [(Blankertz and Robinson, 1996; Drake et al., 1996, Bond et al., 1997); see (Crowther et al., 2000) for a systematic review]. Although the Disability Discrimination Act of 1995 now requires employers to address the needs of disabled people in the workplace, few studies have examined the specific needs in the workplace of people with mental health problems. Research that does shed light on this indicates that needs vary widely for each individual (Fabian et al., 1993). However, flexible working, and modifications to the job, working environment or workplace policy, together with human and technological assistance and additional supervision, have emerged as important (Maida, 1995).
As part of a broader study exploring factors associated with the successful retention of open employment, we aimed to make a further contribution to knowledge in this area, by identifying the nature of the support and workplace adjustments required to achieve a successful outcome. [Open employment was defined as encompassing any job paid directly by the employer at the market rate for the work. Thus jobs paid under the therapeutic earnings scheme were included, as were both full-time and part-time jobs (any number of hours per week)]. Specific objectives were:
(1) To identify a sample of employment support service users who had retained open, competitive employment for 12 months or longer.
(2) To identify a sample where employment had broken down after a period of less than 12 months employment.
(3) To explore the experiences of both groups from their own perspective.
(4) To explore the perspectives of the other key individuals involved, including employment project workers and workplace managers.
(5) To identify factors associated with the success or breakdown of supported employment on the basis of the accounts obtained.
In this article we focus on project clients’ accounts of workplace factors that had helped or hindered them in keeping their job.
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Methods |
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Access and participant recruitment
Initial contact was made with 11 projects offering employment support to people with a serious mental illness. From discussions with the project managers it emerged that six of the projects were at too early a stage of their development to facilitate access to people who had retained open employment for a year or focused on sheltered rather than open employment. The remaining five projects were able to facilitate access to people with relevant employment experiences. Of the five projects, two were based in geographically and demographically diverse areas of outer London (Projects A and B), one operated in a semi-rural area of southeast England (Project C), and one in an urban area of the southeast (Project D). The fifth project (Project E) was based in a Midlands city.
Clients of the five projects who had current or recent experience of open employment were invited to a meeting at their project where the research and what would be involved was explained. As a result of the meetings some clients decided not to take part because they had not disclosed their mental health problems at work, while others who were currently employed had not yet been in their job for a year. These clients therefore withdrew from the study. In total, 10 male clients and seven female clients did take part. Eleven clients had been able to retain open employment for 12 months or longer, while the other six clients’ jobs had ended within 12 months for reasons they themselves saw as problematic.
Interview schedule
Since the aim was to explore clients’ perceptions of their employment experiences, a semi-structured interview schedule was developed to enable each participant to tell the ‘story’ of the job concerned from its beginning in the assessment and preparation stage leading up to the job, through its development to its end or to the present time in the case of ongoing jobs. The schedule explored key events during each stage of the job, including clients’ first meetings with their manager and colleagues, their induction, and subsequent significant developments identified by participants themselves. Throughout the interview, participants’ feelings and attitudes, their accounts of factors which had either positive or negative effects, and their views about what else might have been helpful were explored. Questions were also included to obtain background data, including clients’ employment and mental health history. The interviews varied in length from 40 min to just over 3 h.
Analysis
With participants’ permission, the interviews were tape recorded and transcribed verbatim. A staged analysis was then carried out. Initially, each job was treated as a ‘case’, and the 17 cases were divided into jobs that had been retained and jobs that had broken down. Data relating to each case (i.e. the client’s, project worker’s and manager’s accounts of a job) were then grouped under broad categories according to whether they related to employment support, workplaces or service users’ personal circumstances. Data within each category were analysed to generate subcategories within each main category, e.g. workplace factors relating to managers, colleagues and conditions of employment. These were then compared across cases in order to identify those factors that were associated with job retention and job breakdown. As noted earlier, in this article we focus on clients’ accounts of those factors relating to the workplace.
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Difficulties experienced in the workplace
In terms of the difficulties they experienced in the workplace, few clients described problems that could be attributed solely to their illness. Two clients described experiencing high levels of anxiety as a result of their mental health problems and one client explained that he could become restless if he was not sufficiently occupied. A fourth client recognized that she could become rather loud at times as a result of fluctuations in her mood, while a fifth found her concentration affected by the experience of hearing voices. In other cases, clients described their medication as more problematic in terms of work than their illness per se, the most common problem being the effects of medication levels on sleep patterns, concentration and energy levels.
In comparison with these difficulties, however, difficulties stemming from low levels of confidence and from psychological barriers to particular types of work or work environment were more common. All 17 clients described how their confidence had been affected by their absence from the workplace and the experience of mental illness, and in some cases by actual or feared experiences of stigma and negative attitudes. The majority also felt intimidated by some of their new job tasks and would try to avoid these. From these clients’ accounts, certain types of task appeared particularly likely to prove daunting. These included contact with customers, especially in situations where they might be impatient or angry, or where the contact was via the telephone. In addition, computerized systems could be daunting, especially for older clients who were unfamiliar with computers, as could tasks that were perceived to involve high levels of responsibility, such as working alone with social care clients, stock control or handling cash.
Some clients who experienced these difficulties identified specific adjustments negotiated with their employer to their hours of work, work schedules and job tasks as invaluable in enabling them to retain their job, and we will focus in detail on these in a further article. Strikingly, however, the kind of support clients needed from their workplaces in order to grow in confidence was in many ways little different to that arguably needed by any other employee and we therefore wish to focus here on the nature of that support.
In this respect, the main themes to emerge from the clients’ accounts revolved around four issues:
(1) Training and support to learn.
(2) Relationships with colleagues.
(3) Workplace cultures.
(4) Approaches to staff management.
In effect, where these were present they constituted ‘natural supports’, a concept proposed by Nisbet and Hagner (Nisbet and Hagner, 1988) as a strategy to eliminate the discrimination associated with more intrusive approaches to supporting disabled people in work, such as job coaches and specialist trainers. Defined by Rogan et al. (Rogan et al., 1993) as ‘any assistance, relationships or interactions that allow a person to secure or maintain a community job in ways that correspond to the typical work routines and social interactions of other employees’, there was considerable overlap between this concept of natural supports and the themes to emerge from clients’ accounts. The four themes are examined in turn below.
Training and support to learn
For most clients, training and support, or its absence, was a significant factor in their retention or loss of their job. Some clients ran into problems when their training and support needs were not met in the early stages of their job, while others were helped to overcome their initial apprehension with appropriate training and support. The kind of training and support required during the learning phase of the job was related to the nature of the job, and the individual’s particular learning and support needs. However, some clear themes emerged about strategies that were most and least likely to be effective. An approach that was likely to prove counter productive was to throw clients in at the deep end, leaving them to cope alone in a job too quickly. In the early stages of her job, for example, one client was assigned the task of covering a busy reception desk on her own. Telephone callers and visitors to the desk could become impatient or angry, and this aspect of the job caused the client great distress:
I thought I would be there to observe for a longer period than I was. I was actually left on my own at times...you’d be shown once and you’d got to get it right. If you don’t, well I was feeling more as if I was stupid. I thought I must be stupid they’re all very clever here. So I was getting more and more and more depressed about it actually...[I needed] more training. More real training at the beginning. Not being thrown into a situation. Time to observe. Let the, let the employee tell you when they’re ready to have a go at something.
The kind of approach to training and support that did prove effective for many clients involved three key elements:
(1) Allowing clients to learn at their own pace.
(2) Breaking tasks down into manageable components.
(3) Ensuring that support was available in case of problems.
This client described how a supervisor had enabled him to learn more effectively, in part by establishing an appropriate pace and also by breaking a task down into manageable components:
She goes round all the office teaching properly and she had a nice way of doing it. I picked it up quicker that way, I grasped it... And it was OK in the end, so I quite enjoyed doing that... Em, they work from big manuals...and she actually photocopied my section from it, just to, it basically broke down my job, which made it a lot easier and if I wasn’t sure I’d come for it... So yes I felt a whole lot better.
In addition to more formal training, clients found having colleagues or a manager on hand for support in dealing with any problems invaluable and felt able to ask for help when they needed it, as another client explained:
The only problems I have is operating computers up in the operations room...and sometimes I have to go off and ask a friendly member of staff if they could check for me... The staff I work with they’re all very friendly, always willing to help or do what they can to make the job a bit easier for you.
Conversely, when colleagues were unsupportive or impatient, clients’ capacity to learn was diminished and they felt unable to ask for help:
But you see, you’d be on the telephone trying to help someone and the phone, this happened more than once, the phone was snatched from me—oh excuse my colleague they’re new. So immediately you’re demoralized...they’d say, can you send someone up who knows what they’re doing, and then it just dissolves into sheer panic.
Relationships with colleagues
In addition to helping clients grow in confidence and develop into their jobs, supportive colleagues could play a key role in enabling them to sustain their jobs through times of tension or difficulty. Almost all the clients who had been able to retain their job cited their colleagues as a significant factor in enabling them to do so. In one case where the job had not continued, the client nevertheless felt that his colleagues had helped him to succeed in the job for several months. In the other cases where a job broke down, however, the clients concerned described their colleagues as unsupportive or explained that they had not been able to establish strong relationships with them, in one case because the client was working at home on his own.
The part played by more positive relationships with colleagues revolved around two issues:
- Feeling comfortable in the workplace.
- Support in addressing work-related and personal problems.
Unsurprisingly, most clients were concerned about how they would fit into the workplace after a lengthy period away from work. Here, friendly colleagues could play a large part in enabling them to feel comfortable, as this client explained:
I mean I used to talk to [a colleague] about football and that, because she likes football, and she supports the same team as me. So I was quite comfortable talking to her, and then, she was mature enough to know the problems and woes of life...so she was friendly and the same with [another colleague] really.
In contrast, colleagues who were perceived to be unsupportive had contributed to the breakdown of this client’s job:
Sometimes I didn’t want to go there because they were sarcastic...I don’t know, everything, the whole, I cannot say now but you know, bitchy, more bitchy and I didn’t like it very much.
As a further extract illustrates, when clients were able to establish supportive relationships with colleagues they could draw on that support when there were problems at work:
We talked about work, but we talked about finding our own ways. I mean I used to help [a colleague] because she would get stuck, but it would be for us mentally, you know I’ll say sort of like, calm down, and not take things personally, not get paranoid. And if we did get paranoid then we’d talk to each other. I found one member of staff particularly hard to work with, and it was [the colleague] I used to talk to. And I was getting paranoid about that, thinking that it was only me, but in the long run it was everybody, everybody found that.
Workplace culture
The extent to which the needs discussed so far could be or were addressed in the workplace revolved largely around the prevalent workplace culture. Clearly, the friendliness of individual staff stemmed from and fed into the wider workplace culture, and it was important that the supportive relationships described above were part and parcel of everyday life at work. When clients felt they were being singled out for special treatment, they were uncomfortable at work and unable to develop in confidence. For example, feeling ‘fussed over’ by colleagues had contributed to this client leaving her job:
They were quite nice, yeah. But I sometimes think they must have thought I had a screw loose, because the way they were... How can I say it, they sort of tiptoed around you. Sort of, I hope it isn’t too much excitement... And when I came in, do you want to sit down? I said, no, I just came. Do you want a cup of tea or coffee? I said, no, later when you have one. And everyone was very concerned, they thought I might kick the curb at any moment.
Three aspects of workplace culture emerged as important factors in clients’ adjustment to work:
- A relaxed informal atmosphere.
- A culture within which difference was accepted.
- A concern for employees’ welfare.
From the perspective of most clients who took part in the study, workplace cultures that were relatively informal were reassuring, and assisted them to feel at home and establish relationships with colleagues. In this respect, first impressions were important. This client, for example, described how his manager’s and colleagues’ informality had put him at ease on his first visit to the bank where he worked:
It was nice. It didn’t feel so intimidating. Plus the fact that he’d got a Donald Duck tie, or something like that...he was prone to wearing one or two of those ties... But yes, he put me at ease as much as he could... And then when I went into the office situation, it was the same, all first names... So that way brought people on the same level, who you were talking to, as much as you could with the manager, or assistant manager, or supervisor. I think that was one of the most notable, noticeable things that I felt.
As was seen in the previous section, being singled out as different was an uncomfortable experience for clients and for this client it was a key factor in his decision to leave his job:
Well they would make jokes and things and take the mickey...out of things I was doing. They were finding flaws in my work and things. ..because I was doing this written job and they were working as manual labour... The racist thing was going on as well you know... Well they would just you know, whenever they had the chance they would just take the mickey out of me you know.
Conversely, a culture within which difference was accepted and where employees were valued for their strengths emerged as a key factor in enabling clients to sustain their jobs. In some cases, clients were particularly sensitive about what they saw as limitations, e.g. literacy problems or a physical disability. As this extract illustrates, the reactions of supportive colleagues could provide the reassurance needed for them to develop confidence:
I’ve had to explain it [a literacy problem] to one or two, and they’ve said, oh don’t worry, most of the bloody management can’t bloody write things down properly, and what they put is a scribble or something like that, you know, don’t worry about it and so on. Let me do it, let me do it, I mean they’re very friendly, yeah, they are very helpful, and very friendly.
Like any employee, there were times when clients needed to take time off work, in some cases as a result of mental ill health, or because of physical illness or caring responsibilities. The way in which this was managed highlighted the extent to which a concern for employees’ welfare was part of a workplace culture. In one case, for example, a client felt she had been put under pressure to return to work before she was able to do so:
I came from the doctor and I said, I have a sick note, I’ll send it to you. And after 1 week they asked me if I’m well, if I can come back, and I said, not yet, I’m not well enough. So they were sort of pushy, somehow pushy. They wanted me to come back again after 1 week but they didn’t understand really that I needed the break.
In contrast, at other workplaces efforts were made to accommodate employees’ needs. For example, one client who needed to take time off to care for his partner explained that he was always offered the opportunity to make up his hours so he was not financially disadvantaged. In other cases, as noted earlier, specific adjustments were made to clients’ hours of work or job tasks to accommodate specific needs.
Approaches to staff management
The approach taken to managing staff by individual managers emerged from clients’ accounts as a central theme that underpinned all those discussed so far. The quality of training provided, the nature of interpersonal relationships in the workplace and workplace culture itself depended in large part on the manager concerned. A helpful approach to staff management combined three elements:
- A genuine interest in employees’ welfare.
- Clear boundaries in relation to getting the job done.
- Constructive criticism.
Most clients who had been able to retain their job singled out their manager, as well as their colleagues, as key to their success and several of these clients spoke warmly of their perception that the manager genuinely cared about their welfare as well as the quality of their work. This level of concern was particularly valued by clients who experienced mental health problems while in their jobs:
She was very sort of kind and caring. Because she constantly every morning, most mornings I would come in and even sometimes throughout the day she would be saying to me, are you OK, are you fine, or how are you feeling. And stuff like that, and that helped because I knew that she cared and she was there if anything...
However, it was important for clients’ confidence that this caring approach was not at the expense of getting the job done. The same client quoted above, for example, described how her manager had been clear about the need to carry through a task she had been reluctant to undertake, while at the same time helping her to breakdown the task into clear stages and resolve the problems involved at each stage. Although she had resented this at first, the client acknowledged that completing the task had boosted her confidence. Another client also described how, alongside a friendly informality, his manager ensured that work was completed to the required standard:
He was very good, very good to work for. I think, I don’t know, he got the respect of everybody. Because if anybody didn’t do what they were told properly he would tell them so, but on the other hand he wouldn’t do it unless they needed to be told. On the other hand he could have a laugh and joke with everyone.
In addition to the establishment of clear boundaries in relation to getting the job done, constructive criticism, involving both giving positive feedback and addressing problematic performance, was important in enabling clients to develop in their jobs. In one case, for example, a client had initially responded angrily to being reprimanded for poor attendance. Once this was put into the context of her overall performance, however, she was able to respond more positively and with hindsight valued her manager’s approach:
[I was] angry, really angry. I felt picked on and singled out, but in another way later down the line it was the kick I needed. It sort of like pulled my socks up. It made me pull myself together and I don’t think I lost time after that. You know she was saying that she was impressed with everything that had been said... but she couldn’t tolerate how I was. When I was there I’d done my work, it was just that I’d rang in on a few sleep-ins and she wasn’t pleased with that, which is understandable. And she wasn’t harsh or anything, she was just straight to the point.
Conversely, when criticism was not offered in the context of positive feedback, it was experienced as demoralizing and de-motivating. This client described how a supervisor’s implicit and explicit criticism had undermined her confidence:
She’d always change what I’ve done. So I was totally demoralized on that, but I mean we’d get along quite superficially and then, I’d be driving and she’d go, you’re too close, you’re too close, and I’d think, well, OK, OK. So I said, alright, I’m sorry, I’m sorry. But I became extremely, extremely nervous when I was driving, and then one time she really yelled at me, and it’s funny instead of reacting, it’s very strange, I felt really, I didn’t stand up to her at all. I just felt terrible. I felt like crying.
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The factors that enabled some clients to retain their jobs while other jobs broke down did not revolve solely around workplace issues. Rather, a complex mesh of factors appeared to be involved. In particular, the approach taken at the employment projects to job finding and follow-up support for clients in work was central (Secker et al., 2002
). However, the evidence from our study indicates that natural supports revolving around learning opportunities, and supportive colleagues, workplace cultures and managers were also key to enabling clients to retain their job. These findings concur with those from a recent, larger-scale quantitative study indicating that natural workplace supports improve employment outcomes for mental health service users (Banks et al., 2001).
From a health promotion perspective, a striking aspect of our findings was the more general applicability of the support clients described. Indeed, supportive management styles and relationships with colleagues have consistently emerged from an extensive body of research as crucial for employees’ well being (Cox, 1993). This suggests that such natural supports might be a productive focus for workplace health promotion in that they are likely to be of benefit not only to mental health service users returning to work, but also to employees in general.
Historically, mental health has not been a strong focus for employers (Waghorn et al., 1993; Health Education Authority, 1997; Docherty et al., 1999), beyond demonstration projects such as that undertaken within the National Health Service for the Department of Health (Hardy et al., 1997). However, increasing emphasis is now being placed on promoting mental health at work, through initiatives such as the ‘Working Minds’ component of the Department of Health’s ‘Mind Out’ campaign (Department of Health, 2001), the former Health Education Authority’s organizational stress programme (Health Education Authority, 1996) and the HSE’s work in this area [e.g. (Health and Safety Executive, 2001)]. As these initiatives make clear, addressing mental health at work requires approaches at the organizational level as well as at the level of the individual employee. On the basis of this study, four organizational initiatives in particular might help to ensure that workplaces are mentally healthy, both for mental health service users starting or returning to work, and for other employees:
- Ensuring that a formal period of induction, of sufficient length, is routine practice for all new employees. For many jobs, induction will need to include formal training geared to the employee’s pace of learning, opportunities to observe colleagues’ work and the explicit identification of sources of support for tackling problems that arise.
- Embedding attention to employees’ ongoing development in routine workplace practice through formal supervision and appraisal procedures.
- Team building aimed at creating a welcoming workplace where difference is accepted and employees’ strengths are valued.
- Training and other learning opportunities, e.g. action learning sets, for managers, covering mental health and safety at work, team building, and individual staff management. Opportunities to explore the boundaries between a friendly, supportive approach and ensuring that work is completed would be particularly valuable, as would training in techniques for providing constructive criticism for employees.
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Acknowledgments |
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We are immensely grateful to the employment projects that assisted with the study, and to the clients and workplace managers who took part in interviews. The research was supported by the Economic and Social Research Council award no. RO22250144.
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Received on December 29, 2001; accepted on April 18, 2002
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