Abstract
Introduction
As the incidence rates of mental health (MH) have increased so have the financial burdens for employers and the need for increased supports in the workplace for individuals with MH conditions. Increases in workplace mental illness are a “growing concern to the disability community” (Wagner & Harder, 2011, p. 215). Vocational rehabilitation (VR) professionals providing direct support to individuals with MH conditions, need to be competent in identifying workplace culture, practices, and programs that support MH. In addition, VR must also recognize employment settings and practices that contribute to increases in MH conditions for employees (or potential employees). Often underestimated is the impact that the employment environment has on employees with MH conditions and the employers’ responsibility for the onset, or exacerbation, of MH conditions in their own workers through a poor work environment. Understanding the impact of the workplace culture and creating psychologically healthy workplaces is an important factor in decreasing the impact of MH and ensuring continued employment for those with a MH condition.
Disability management programs have been around since the 1980’s (Harder & Geisen, 2011) and have focused heavily on physical impairment in the workplace and mitigating employer exposure to costly expenses through programs designed to keep injured employees at work, or to help them return-to-work quickly. Disability management principles can also be applied to MH conditions to decrease costs and the likelihood of unemployment. Wagner and Harder (2011) report that DM professionals are “being called upon to provide information about intervention and accommodation” for MH in the workplace (p. 215), meaning professionals working in this area need to recognize and become skilled in workplace MH.
Culture of the workplace is an important factor in employers adopting practices of psychologically healthy workplaces and implementing DM strategies. A culture that values its’ employees, and understands the impact positive and negative work environments can have on employee MH, can go a long way in ensuring healthier work environments. In this paper we will explore organizational features of psychologically healthy workplaces, disability management programs, and the interplay between the two, including impact on employee mental health.
Mental health in the workplace
Whereas organizations are becoming more aware of psychological health issues, high rates of mental illness in the United States (U.S.) suggests that workplaces are facing many barriers creating psychologically healthy workplaces. Approximately 20% of the adult U.S. population is diagnosed as having a significant MH issue (National Institute of Mental Health [NIMH], 2013). In a given year, 18.8 million American adults (9.5% of the adult population) will experience a depressive illness, 2.2% will experience symptoms of bipolar disorder, 1.1% will have schizophrenia (NIMH, 2013), and schizoaffective disorder will affect 1% of the U.S. adult population (NIMH, 2013, National Alliance on Mental Illness [NAMI], 2012). The World Health Organization (WHO) has documented the fact that mental illnesses are the leading causes of disability worldwide (WHO, 2011). Depression alone accounts for one third of all who experience mental illness worldwide (WHO, 2011).
There are significant environmental barriers such as workplace stigma and work disincentives, which are disability-related factors that diminish return-to-work outcomes for persons with mental illness (Baron & Salzer, 2002). In addition, there are often insufficient community resources to provide adequate psychiatric vocational services for persons with mental illness. Despite a myriad of challenges and barriers to employment, many individuals experiencing mental illness are successfully employed at competitive jobs (Cook & Razzano, 2000; Drake, Becker, & Bond, 2003; Rogers, Anthony, Toole, & Brown, 1991). Persons with psychiatric disabilities who are not working report that they want to work and usually can be successful in integrated employment settings if appropriate community supports exist (Bond, Drake, & Becker, 2008; Cook & Razzano, 2000). Workplace discrimination is also heightened for persons with psychiatric disabilities because they experience increased stigma, the lowest employability rankings, and the largest wage differential to productivity rankings when compared to persons with physical disabilities (Baldwin & Johnson, 1994).
The cost of mental illness in the workplace
The Agency for Healthcare Research and Quality (2009) cites that the cost of mental health care in the U.S. is higher than the cost of cancer care. However, unlike cancer, much of the cost associated with mental illness is not the cost of direct care, but the loss of income due to unemployment, expenses for social supports, and a range of indirect costs due to a long term, pervasive illness that often begins early in life.
Data from 2010 estimated the global cost of mental illness at nearly $2.5 trillion (two-thirds in indirect costs), with a projected increase to over $6 trillion by 2030. To put this in context, the entire global health spending in 2009 was $5 trillion. The annual GDP for low-income countries is less than $1T. The entire overseas development aid over the past 20 years is less than $2T (Bloom, et al., 2011).
A World Economic Forum (WEF) report also provides comparisons across non- communicable diseases (NCDs) to provide the context of the drivers of global costs and economic burden. Mental health costs are the largest single source; larger than cardiovascular disease, chronic respiratory disease, cancer, or diabetes (WEF, 2011). In fact, mental illness is projected to account for more than half of the projected total cost of NCDs over the next twenty years. It is also important to consider that persons experiencing mental illness are more susceptible to developing cardiovascular disease, respiratory disease, and diabetes, and the true costs of mental illness must be even higher (Bloom, et al., 2011).
Mental illnesses are the largest single driver to all health care costs (WEF, 2011). Consider one of the costliest illnesses to employers, bipolar disorder. A study published in 2008 by Laxman, Lovibond and Hassan, collected data on a sample of 761 workers with bipolar disorder and 229,145 workers without bipolar disorder. The annual cost of healthcare for an employee with bipolar disorder was $6,836 more than the control group average ($9,983 vs. $3,147). The costs were not primarily associated with the cost of direct care because many physical health conditions are comorbid with bipolar disorder, so the group with bipolar disorder scored higher costs in every measurable health care cost category. The absentee rate for the bipolar group was 18.9 workdays per year, while workers without bipolar disorder missed 7.4 workdays. Because the number of missed workdays was so large, many in the bipolar group spent time on short-term disability, adding increases in insurance premiums and ratings to the cost of lost days of work. Worker compensation 2008 costs also were significantly higher. In terms of productivity, the output of the workers with bipolar disorder was 20 percent less than that of those without the illness. This was affected by the decrease in performance brought on by working while cycling through a depressive or manic episode (Laxman et al., 2008).
Additional costs associated with mental health
Businesses and DM professionals are proficient at addressing employee physical health, yet promoting employee MH is often ignored. The financial burdens of depression, anxiety, and emotional disorders are among the greatest of any disease condition in the workforce (Johnston, Westerfield, Momin, Phillippi, & Naidoo, 2009). Globally, a fifth to a quarter of employees go to work every day with a mental illness (Lorenzo-Romanella, 2011). Health care research has shown the impact of mental illness on work performance, however, many employers and researchers are unaware of the value that quality mental health care poses for employees and organizational costs (Langlieb, & Kahn, 2005).
The effects of mental health issues in the workplace span beyond what was previously only identified on a spreadsheet through costs associated with absenteeism. Presenteeism includes characteristics of lost productivity including lower concentration, energy level and quality of work (Hargrave, Hiatt, Alexander & Shaffer, 2008). Since many people with mental illness feel stigmatized, many do not disclose their condition to their employer. In fact, Lorenzo-Romanella (2011) states that many of the reasons for absenteeism and presenteeism are not under the employees control and even when an invisible disability, such as mental illness, is cause for poor performance and increased absenteeism, employees still will not disclose their condition.
Schultz and Edington (2007) reported on studies finding that for many chronic health conditions, lost productivity costs were higher than costs associated with medical care. Specific to employees with psychiatric diagnoses, Hargrave et al. (2010) found that 80% of lost productivity costs were associated with presenteeism with the remainder attributed to absenteeism whereas for individuals with depression, 50% of lost productivity time was attributed to having major depression (Stewart, Ricci, Chee, Hahn, & Morganstein, 2003).
A study by Stewart et al. (2003) found that costs for loss productivity in employees with depression was estimated at $44 billion per year, which was an excess of $31 billion per year when compared to employees without depression. Compared with other disease groupings, it was found that depression, anxiety and emotional disorders were the fifth costliest, with 47% of costs related to direct costs and 53% linked to indirect (Johnston et al., 2009).
Addressing mental health in the workplace
Related to psychologically healthy workplaces, successful interventions and programs (including DM programs) that address MH in the workplace show parallel similarities, as shown in Table 1. For example, Lorenzo-Romanella (2011) addresses barriers for employees to disclose MH conditions to employers; however, employers can address mental health in the workplace by incorporating flexible work arrangements and short breaks from work as options for employees. Flexibility in the workplace is linked to healthy workplaces since it encourages work-life balance and increased health and safety.
Employee assistance programs (EAP), which support healthy workplace through work-life balance, employee growth, and development and health and safety, have also shown significant opportunities for employers to address MH issues in the workplace. A return on investment showed that for every dollar spent on EAP programs, a return of between $5.17 and $6.47 was found for employees with various psychiatric conditions who participated in individual counseling through their EAP program (Hargrave et al., 2008).
Organizational culture and impact on employee mental health
Organizational culture is identified by the morals and social concepts shared by members of an organization and are displayed through an organizations’, “corporate objectives, strategies, management philosophies, and in the justifications given for these” (Dextras-Gauthier, Marchand, & Haines, 2012, p. 83; Schein, 2004). Organizational culture has been shown to impact employee MH (Bronkhorst, Tummers, Steijn, & Vijverberg, 2014; Kelloway & Day, 2005), especially anxiety and depression (Arnetz, Lucas, & Arnetz, 2011; Martin, Karanika-Murray, Biron, & Sanderson, 2014). For example, organizations that promote autonomy and independence in employee decision-making have been associated with better MH outcomes (Dextras-Gauthier et al., 2012). In contrast, higher MH distress has been associated with work environments having fewer supports and less encouragement of employees (Eriksen. Tambs, & Knardahl, 2006), and lack of autonomy over work (Michie & Williams, 2003). Additionally, MH conditions can be attributed to work injuries, unsafe conduct, and unsafe working environments (Nahrgang, Morgeson, & Hoffman, 2011), which can also cause and/or aggravate MH conditions (Martin et al., 2014).
Hurrell (2005; as cited in Dextras-Gauthier et al., 2012) conveys that organizational investment in alleviating work-related MH issues has not resulted in the outcomes anticipated. Dextras-Gauthier and others (2012) state that increased attention needs to be paid to organizational culture and its impact on MH, and many interventions do not pay attention to incorporating both individual and organizational facets. Although organizational attitudes towards mental illness are changing, workplaces continue to face issues related to employee MH, revealing that industry must continue to reform DM programs and to improve workplace organizational cultures.
APA 5 Elements of psychologically healthy workplaces
The concept of health and an employers’ role in supporting healthy work environments has evolved over past decades. Sauter, Lim, and Murphy (1996) define a healthy workplace as, “any organization that maximizes the integration of worker goals for well-being and company objectives for profitability and productivity” (p. 250). The duality of this definition is important in that it recognizes the needs of the employee as well as the needs of the organization (Grawitch, Gotschalk, & Munz, 2006). The dual focus reflected in contemporary definitions of a healthy workplace denotes a paradigm shift in the conceptualization of health within organizations (Grawitch et al., 2006).
This paradigm shift is also evident in conceptualizations of health promotion by including both physical and MH. Health promotion, as considered in the organizational and industrial context, was originally conceptualized as a strategy for preventing and mitigating physical injuries incurred in the workplace. As employers developed awareness of the broader implications of disability prevention and management programs, increasingly comprehensive methods for retaining quality employees with physical disabilities emerged. As such, health promotion and DM efforts have gained widespread acceptance as employers and insurers recognize the importance and cost savings involved with promoting employee health as well as retaining quality employees with disabilities.
While businesses and DM rehabilitation professionals, including vocational rehabilitation, have become proficient in addressing physical health issues, awareness of the need to promote and support employee psychological or MH is becoming recognized as an important emergent area. Organizations now realize psychological health is an important issue with 85% of individuals claiming long-term disability (LTD), identifying MH conditions as their primary disability (Carls et al., 2012). Additionally, when reviewing LTD per claim expense, MH disorder claims tend to be more costly given the longer recovery timeframes and increased difficulty returning work (Salkever, Goldman, Purushothaman, & Shinogle, 2000). Hodgson (1996) defines MH promotion as “the enhancement of the capacity of individuals, families, groups or communities to strengthen or support positive emotional, cognitive and related experiences” (p. 1). Interestingly, the workplace has remained an underutilized setting for mental illness prevention and MH promotion in the United States (Barkway, 2006).
Five elements of a psychologically healthy workplace
The APA has identified five categories of workplace practices that positively promote the psychological health of employees in the workplace. Specifically, employee involvement, work-life balance, employee growth and development, health and safety, and employee recognition are acknowledged as having merit in promoting the psychological health of employees (APA, 2014). The reported organizational benefits of adopting the five elements of a psychologically healthy workplace include (a) improved quality, performance and productivity, (b) reduced absenteeism, presenteeism and turnover, (c) fewer accidents and injuries, (d) improved ability to attract and retain top-quality employees, (e) improved customer service and satisfaction, and (f) lower healthcare costs (APA, 2014).
Employee involvement
Employee involvement efforts empower workers, increase autonomy, and involve employees in decision making on behalf of the organization. Grawitch, Ledford, Ballard, and Barber (2009) suggest that employee involvement efforts can be identified and measured for efficacy along a continuum. Low involvement strategies are primary management-driven initiatives that include open door policies, suggestion forums, and employee surveys. Moderate involvement strategies require more participation by management and involve joint committee work, employee-driven committees and tasks forces, and continuous improvement teams. High involvement strategies are construed of high involvement systems, self-managed work teams, and employee ownership. High involvement strategies have been found to be predictive of employee quality of work life and performance, morale and organizational effectiveness, and overall organizational performance (Cohen, Ledford, & Spreitzer, 1996; Gibson, Porath, Benson, & Lawler, 2007; Vandenberg, Richardson, & Eastman, 1999). The issue is global in context, and consistent with the World Health Organization’s (WHO) guidance on MH promotion (WHO, 2002, 2007, 2010). The European Network for Workplace Health Promotion (2009) recommends that mental or psychologically healthy interventions should promote empowerment and control over one’s work, and include employees in decision making. Interestingly, localized rather than organization-wide employee empowerment strategies may be more appropriate, feasible, and effective (Foster-Fishman & Keys, 1997).
Work-life balance
Work and other life responsibilities can conflict, resulting in a reduced quality of work and home life for employees. Subsequently, this can impact organizational outcomes such as productivity, absenteeism, and turnover (APA, 2014). The APA recommends policies and programs that enhance work-life balance including flexible work arrangements, childcare and eldercare assistance, and family and partner benefits. Efforts to help employees improve work-life balance can improve morale, increase job satisfaction and strengthen employees’ commitment to the organization in addition to increasing employee productivity and reducing absenteeism and turnover. While organizations may be willing to implement the latest “work-life balance” programs, it is important to note that achieving a healthy workplace requires consideration of the interplay among the employee, the organization, and the specific practice itself when adopting healthy workplace strategies (Grawitch, et al., 2009).
Employee growth and development
Increased motivation and job satisfaction are outcomes of workplace learning and development activities. Opportunities that offer employees ways to increase their knowledge, skills, and abilities can also have the side benefit of stress management (APA, 2014). Overall workplaces that have a well-formulated learning philosophy continually improve existing talent and are attractive to new talent as well. The APA identifies the following opportunities for employee growth: Continuing education courses Tuition reimbursement Career development or counseling services Skills training provided in-house or through outside training centers Opportunities for promotion and internal career advancement Coaching, mentoring, and leadership development programs
Health and safety
When deconstructing the link between workforce safety and profitability, evidence seems to support that building cultures of health and safety provides a competitive advantage in the marketplace. There is an association between companies that focus on health and safety and companies that manage other aspects of their business equally well. Organizations that form a culture of health by focusing on the wellbeing and safety of their staff yield greater worth for their stakeholders (Fabius et al., 2013). Additionally, in their State of the American Workplace report, Gallup (2013) found that the best-managed teams versus the worst managed teams have approximately 50% fewer accidents and 41% fewer quality defects.
In addition to shareholder value, organizations that invest in the health and safety of their workforce see yields in increased productivity, reduction in healthcare costs, absenteeism, and injury rates (APA, 2014). The APA provides the following examples of ways to address health and safety for employees (a) training that addresses workplace security issues; (b) initiatives that help workers develop a healthy lifestyle (for example: stress management, smoking cessation and weight loss programs); (c) health insurance benefits that include coverage for mental health; (d) access to fitness facilities and screenings; and (e) support via Employee Assistance Programs (EAP’s) that address worker life issues such as grief counseling, substance abuse programs, and referrals for mental healthservices.
Employee recognition
Recognition efforts provide employees with rewards for their contributions to the workplace. These efforts can take various forms and need not be outrageously expensive; however they must be targeted to the employee and/or team and tied to a specific organizational outcome, strategic initiative or quantifiable effort. When employees are recognized publicly, morale and self-esteem are enhanced as well as productivity and engagement. The APA (2014) offers these examples of employee recognition: fair compensation, competitive benefits, awards (from a simple thank you or publicly displayed plaque), performance-based bonus or pay increase, and ceremony that recognize employee contributions.
Communication
Communication is critical in the success of policies and programs designed to achieve the psychological health of organizations. The APA (2014) posits a variety of ways to communicate employee needs and management support. For example bottom-up communication (employee to management) can facilitate knowledge about worker opinions and values so that programs can be targeted. Top-down communication (management to worker) can increase awareness and utilization of programs. Using multiple channels of communication such as print, electronic, and face-to-face meetings will aid in getting the message out regarding the benefits and importance of a psychologically healthy workplace.
Disability management and impact on employee mental health
Disability management is defined as “a workplace prevention and remediation strategy that seeks to prevent disability from occurring or, lacking that, to intervene early following the onset of disability, using coordinated, cost-conscious, quality rehabilitation service that reflects an organizational commitment to continued employment of those experiencing functional work limitations. Disability management means using services, people, and materials to (a) minimize the impact and cost of disability to employers and employees; and (b) encourage return to work for employees with disabilities” (Akabas, Gates, & Galvin, 1992, p. 2). A valuable DM program utilizes a company’s financial and human resources in the most efficient manner and helps employees with disabilities and illnesses perform at their greatest potential and satisfaction. Disability management, therefore, complements corporate values in both human resources and fiscal performance. Simply put, a DM program encourages a healthy workforce while ensuring the company’s long-term profitability (Akabas et al., 1992).
Tweed (1994) stated that the culture of a company and whether management demonstrates it cares about employees are key factors influencing the potential for injury and lost time. Bronkhorst and colleagues (2014) confirm that employers’ positive views of DM in the workplace reduce job stress and result in improved MH. Thus, the culture of the organization impacts the success of DM programs. In fact, Amick et al. (2000) state that people-oriented culture facilitates strong safety environments and DM programs and these policies and practices remain “consistent with a management perspective that views investments in people through safety, health, and accommodation, as an equally important strategy to achieving the productivity and financial goals of the organization” (p. 35).
Successful DM programs exist in organizations that value employees and enhance a supportive workplace culture. Attributes of effective DM programs mirror those found in the American Psychological Associations (APA) elements of psychologically healthy workplaces (Table 1). As MH issues in the workplace continue to remain a global phenomenon impacting both individuals and organizations, employers will need to find ways to expand organizational initiatives (DM programs) while building psychologically healthy workplace cultures.
Elements of successful disability management programs
Successful disability management program components
Harder, Hawley and Stewart’s (2011) review of the literature identified evidenced based components of successful DM programs. Not only did the factors below prove to be successful in DM programs but were also “consistent with the principles and practices of successful employment and intervention strategies for mental health disability in general” (p. 430). These components included: A supportive workplace culture, including management and labor commitment with supportive policies. Early intervention and ongoing monitoring of disability. A collaborative and coordinated team approach. Psychoeducational opportunities for managers and workers. Systematic case management procedures. An organized return-to-work program with supportive policies, modified work options, and workplace accommodations. Use of incentives in benefit design, cost accounting, and performance evaluation to encourage participation. An integrated management system to monitor and evaluate outcomes (p. 429).
While the list above is not exhaustive, it does identify DM program elements that include multiple stakeholders (e.g. organization, agencies, employees, etc.). Stakeholder involvement at all levels of DM programs is imperative, as is stakeholder accountability (Dyck, 2000). Successful DM programs provide multiple benefits for both employee and employer, which are consistent with psychologically healthy workplaces.
Disability management program benefits
The APA’s five categories of workplace practices that promote psychological health in employees have a similar conceptual basis as successful DM programs, and many corresponding benefits, as shown in Table 1. Employers and DM service providers have moved beyond initial interventions of reactive protocols (i.e. return-to-work after a work injury) to more proactive strategies which included safety/prevention, health/wellness programs, ergonomics, ecological assessments, and specialized case management strategies (Hursh, 1997; Rosenthal, Hursh, Lui, Zimmerman, & Pruett, 2005).
The proactive nature of DM programs is critical as the most successful timeframe for bringing employees back to work from an absence is 30 days (Dyck, 2000). Poor relations between management and employees can discourage employees from following safety practices at work, and even from returning to work after an injury (Tweed, 1994). Companies with low claim rates (for workplace injuries) include safety and prevention interventions, procedures to prevent and manage disability, and an open managerial style and human resource orientation (Amick et al., 2000).
Summary and conclusion
Understanding workplace cultures and supports for individuals with MH conditions involves understanding employer disability policies, programs and interventions. Over the 35-year time span of DM, successful programs have expanded beyond a focus solely on physical impairments to include MH and have expanded beyond reactionary measures to include preventative and proactive interventions, such as absence management. The evolution of DM into absence management is a necessary response to the increases in costs related to absenteeism, to the inefficiencies of a fragmented benefit system, and to an aging and more diverse workforce (Hursh & Shrey, 1994) as well as the increased prevalence of MH. Absence management aims to reduce the incidents of unscheduled employee absences, due to illness, injury, personal or family problems, or other causes. Presenteeism goes a step further, seeking to improve the productivity of those who are still on the job (Lui, 2002). Vocational rehabilitation professionals working in the areas of DM must understand not only the evolution of DM but also how DM can support MH through programs designed to decrease absenteeism and presenteeism, such as psychologically healthy workplaces.
Efforts to keep workers on the job and performing at their best will require an integrated approach, one that can span traditional disability and workers’ compensation programs, group-health, and short- and long-term disability benefits. Expertise in each of these programs and benefits areas, along with an understanding of union and labor practices, federal laws (such as Americans with Disabilities Act or Family Medical Leave Act) and state regulations for workers’ compensation, is a requisite for VR professionals today. The benefits of integrated DM include simplifying of an all-too-often confusing administrative function, utilizing a single point of contact to access services, eliminating the “claims-denial” mentality, and sustaining an overall commitment to health and productivity (Calkins, Lui, & Wood, 2000).
Employers that understand how their culture supports and protects people with disabilities, especially those with MH conditions, will have a competitive advantage over employers that don’t. The same can be said for VR professionals. Understanding the impact of workplace cultures, and the benefits of DM programs on MH conditions will open up opportunities to work with employers in designing such programs to protect the MH of its’ current workforce.
Workplace cultures that value employees create psychologically healthy workplaces and DM programs that include employees with MH conditions. Vocational rehabilitation professionals need to recognize the importance of workplace culture and the positive or negative impact on individuals with MH conditions. Research needs to be conducted to evaluate the financial impact of adopting these principles, behaviors, and programs. Research examining both the direct and indirect costs of MH in these environments can prove a catalyst for other employers to adopt, as well as provide evidenced based best practices. Additional research needs to include role and function studies of those working in the field of DM, such as vocational rehabilitation professionals, and with employers identified as being APA psychologically healthy workplaces. Identifying the financial impact workplace environments have on MH costs can go a long way in making work environments more psychologically healthy and supportive forall.
Conflict of interest
The authors have no conflict of interest to report.