Mental Health and how to ‘Sustain Resilience at Work’
Neil Greenberg Professor of Defence Mental Health at King’s College London Managing Director of March on Stress Limited
Who am I? » Professor of Mental Health based at King’s College London » Managing Director of March on Stress Ltd » Military background in the Royal Navy for >23 years » Advised/supported – – – – – –
UK Government (e.g. FCO, DFID) Media (e.g. BBC, NUK) Emergency Services (e.g. Fire, Ambulance, Police) Railway operators, accident investigators Security Companies (e.g. Maritime, Land) Military (e.g. UK AF, US, CAN)
So what’s the deal with mental health and work
?
The ‘pessimistic view’!
So is work good for you? • Probably yes (physically and psychologically) – Work pressures can be both sustaining and damaging (‘it’s all about the dose’) – Galen (129-200) “Employment is nature’s physician and is essential to human happiness.” – Self-esteem and social contact at work probably key [+ and -] elements
• However for some (est 10%) maybe not – Work can be a significant stressor (e.g: HSE six domains – work stress)
• 2008 DWP survey suggests that ~80% of employees think work is good for them
Mental Health Problems are Common Health and Work Spotlight on Mental Health Almost
1in 6
people of working age have a diagnosable mental health condition
Mental health conditions are a leading cause of sickness absence in the UK
OVER
15m days
In 2015, some
48%
were lost to
stress, depression and anxiety’ in 2014 – an increase of 24% since 2009
19%
long-term sickness absence in England attributed to mental ill health
of
Employment and Support Allowance recipients had a ‘Mental or Behavioural disorder’ as their primary condition
Each year mental ill-health costs the economy an estimated
£70bn
£
through lost productivity, social benefits and health care.
Of people with physical long term conditions,
1in 3
also have mental illness, most often depression or anxiety
Work can be a cause of stress and common mental health problems: in 2014/15 9.9m days were lost to
work-related stress, depression or anxiety
In 2016,
42.7%
employment rate for those who report mental illness as their main health problem (Mental illness, phobia, panics, nervous disorders (including depression, bad nerves or anxiety. Compared to 74% of all population
Sources: Adult Psychiatric Morbidity in England, 2007; Health and wellbeing at work: a survey of employees, 2014; Cimpean & Drake 2011; Naylor et al 2012; OECD, 2014; Labour Force Survey, various years
Days lost for MH over time
Presenteeism and mental ill health % of workers with productivity loss in past 4 weeks due to a mental health problem
Source: OECD calculations based on Eurobarometer Survey of 21 countries 2005
very bad outcomes
Sources of Stress
Sources of ‘Stress’
What are ‘Common’ Mental Health Disorders • • • • •
Anxiety Depression Adjustment Disorders Post Traumatic Stress Disorder Alcohol misuse
Anxiety Disorders • A disorder when – more than ‘normal anxiety’ – interferes with everyday function – Last for weeks rather than days
• Types include: Phobias, Obsessive Compulsive Disorder and Generalised Anxiety Disorder (GAD) • Severe feelings of tension, fear, agitation • Panic attacks often manifest as physical ill health Note: anxiety disorders can be ‘infectious’ or cause colleagues considerable irritation
Depression • A disorder when – Last for more than 2 weeks – Affects day to day function
• Three key symptoms: • Low mood • Tiredness • Lack of enjoyment •
and poor sleep, concentration, appetite & sex-drive; negative views of the future; worthlessness
• Depression is importantly a risk factor for self-harm and suicide especially when associated with hopelessness
Adjustment Disorders (AD) • Relatively common; usually short-lived. • Disturbance of • • • •
Thoughts Emotions Behaviours Impairs day to day function
• Represent the ‘extreme ends of the normal spectrum • Once stressor removed ADs tend to improve • LT problems may result from 'unhelpful’ behaviour whilst distressed • People who have a AD may well act “out of character”
Traumatic Stress Disorders
Is this traumatic stress?
What is a Potentially Traumatic Event (PTE)? •
Being exposed to: • • • •
•
Death Threatened death Actual or threatened serious injury Actual or threatened sexual violence
By • • • •
Direct exposure Witnessing in person Indirectly learning of a close relative/friend’s trauma Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties
Type 1 and type 2 traumas Sudden “Type I” trauma 100%
Recovery – identified and addressed
Type II - The final straw Performance
Morale Productivity Self-esteem
Time
Normal Recovery after ‘trauma’ 70
PTSD caseness (%)
60 50 40 30 20 10 0 0
10
20
30
40
50
Time elapsed since trauma (weeks)
60
Alcohol (and Drug) Misuse • Hazardous use (>14 u per week) • Harmful use: psychological and/or physical • Dependency: cravings, inability to control drinking, high tolerance, withdrawal effects
• • • • •
C – Have you felt that you should cut down A – Got angry when reduction suggested G – Had guilt about drinking E - Taken eye openers So…..what’s a unit?
Serious Mental Illness • Include: • Psychosis – Loss of contact with reality • Schizophrenia, Bipolar Disorder (Manic Depression) • Autistic Spectrum Disorders • Eating disorders • Attention Deficit Hyperactivity Disorder • Treatment often involves secondary services at some point
So…. • Common Mental Health conditions are…common • They affect health and productivity • They are pretty well understood • So….just get on and treat them eh?
Physical Health Treatment?
Back to work Treatment Return to good health
Mental Health Treatment? Recognition
Availability
Self stigma
Geography
Barriers to care
Trust
Loss of esteem Loss of confidence
Back to work Treatment Return to good health Career fears
Training
Time off work
Therapeutic Alliance
Fear of relapse
Concerns of colleagues
The reality is that MH treatment processes are complex! Antidepressants
EAP Sick leave
Stigma
Types of stigma •
Self-stigma - occurs when a person with a mental illness starts to believe the negative and inaccurate stereotypes regarding people with mental illness
•
Public stigma – is distinguished from self-stigma as the reaction that the general population has to people with mental illness and typically refers to the uninformed and negative attitudes and stereotypes held by many in the general community towards people with mental illness
•
Discrimination – is the behavioural reaction to prejudice, where prejudice is understood as a general attitude toward a group, usually based on negative stereotypes. The stereotypes lead to negative attitudes which in turn affects the way an individual or group is treated (discrimination) Corrigan, P. W., & Watson, A. C. (2002a). The Paradox of Self-Stigma and Mental Illness. Clinical Psychology: Science and Practice, 9(1), 19.
History of Stigma (and the military) •
WW1 •
•
Cowardice could lead to execution
WW2 • • •
•
LMF and the RAF General Patton Churchill’s view of military psychiatry
Modern day • •
US purple heart Security Clearance and MH
Stigma and barriers to care
% in agreement
Stigma and Barriers to Care 45 40 35 30 25 20 15 10 5 0
USA UK AUS CAN
Don't know where to get help
Difficulty getting time off work
Would harm my career
My unit leadership might treat me differently
Would be seen as weak
Gould et al, 2010, JRSM
Which stigma items rate the highest
Why don’t journalists seek help for MH issues? 45 40 35 30
%
25 20 15 10 5 0 Perceived as weak by managers
Adversly affect promotion
Less chance of being given responsibility
Not trusted by peers
Greenberg et al, JMH, 2009
Embarrassed abt asking for help
Peers would tease
And it’s not just an issue for “stiff upper lip” professions Help seeking for PTSD
80% 60% Non Veterans 40%
Military Veterans
20% 0% No treatment
Medication only
Counselling or therapy only
Woodhead et al, 2010, Soc Sci Med
Learning points…. • Work certainly can be good for mental health but it can also be ‘bad’ • Common mental health disorders are common and… • Productivity can be affected even if someone is not ill
• Problematically most ‘distressed’ people don’t seek help
So if stigma prevents help seeking….when do people seek mental health care?
What leads people to seek help?
Where do people get ‘help’ from?
%
And where do people get help from “at work”? 70 60 50 40 30 20 10 0 Friend
Chain of Command
TRiM practitioner
Chaplain
M ental Health Professional
Source of Help Operational Mental Health Needs Evaluation- Afghanistan 2010
Other medical
Doctor or RM O
Who do people get support from after work? 100 90 80 70 60 50 40 30 20 10 0
military peer group same deployment
spouse or partner
another family military peer member group not on same deployment
civilian friends/peer group
chain of command
medical services
welfare services
Greenberg et al, JMH, 2003
Learning points…. • Most people do not seek help for MH problems • They tend to wait until the last moment before asking for assistance (? too late) • When they do seek help they prefer informal sources over professionals
So…. • Organisational MH improvement is a complex intervention • It requires a balance of: • • • •
What you want v what is acceptable to people who might benefit Costly professionals v motivated peers Reach v impact All levels of MH prevention • 10 • 20 • 30
Primary Prevention • Policy •
Sets culture (“this organisation believes that…..”)
•
Clarifies responsibilities (organisation and individual)
•
Details support options (EAP, BUPA, OH, staff counsellor etc)
• Leadership training (esp junior leadership)
Leadership and PTSD – Afghanistan 2010 7 6 My immediate leaders do not: Embarrass people in front of others Accept extra duties/tasks to impress bosses
And do: Treat all members of the team fairly Show concern about the safety of team
5 4
Overall
3
Good Leadership
2
Poor Leadership
1 0 Prevalence of probable PTSD*
Jones et al, Psychiatry, 2011
GHQ and Leadership My immediate leaders do not: Embarrass juniors in front of other unit member Accept extra duties/tasks to impress their superiors
And do: Treat all members of the unit fairly Show concern about the safety of unit members
(non-deployed personnel)
Primary Prevention • Policy •
Sets culture (“this organisation believes that…..”)
•
Clarifies responsibilities (organisation and individual)
•
Details support options (EAP, BUPA, OH, staff counsellor etc)
• Leadership training (esp junior leadership)
• Training should specifically aim to forge supportive teams
GHQ and camaraderie In my team I feel a sense of comradeship (or closeness) with others I can go to most people when I have a personal problem My bosses are interested in what I do/think I feel well informed about what is going on
The seduction of pre-screening • Screening beforehand for “vulnerability to PTSR” is seductive • The grandmother test is good…however other tests are very poor • Historically - US Army and WW2
King’s College London – Screening research
Data collected in 2002
Troops sent to Iraq in 2003
Follow up in 2004
Pre deployment Selection/Screening: PTSD Cases Main Study (04)
Screening Study (02)
+
-
Total
6
27
33
-
41
1540
1581
Total
47
1567
1614
+
PPV 18% (5-31%); NPV 97% (96-98%)
Post Incident Screening • Within organisations this can be problematic
• Concerns about stigma/labelling and confidentiality may hinder benefit • Routinely used by US, CAN, ADF, NLD and many others
Post Operational Screening Trial (POST) •
Part of the 2010 Murrison Report on MH
•
US funded ~ $3M RCT
•
Involved ~9000 troops returning from Afghanistan (Herrick 14-16)
•
Computer based screening vs. control group
•
Tailored feedback offered to screened troops
•
6-12 weeks (initial); 10-24 months (follow up; mean 15 months)
POST Screening outcomes - MH
POST Screening outcomes - behaviour
Secondary Prevention • Early detection of emergent difficulties • Proactively asking the right questions • Overcoming FINE • Monitoring and intervention by by peers who know what to ask: – TRiM (trauma risk management) – StRaW (sustaining resilience at work)
• www.kcl.ac.uk/kcmhr under publications
TRiM and Cumbria ‘Bird’ shootings
Results – Exposure, Interventions & Sickness Absence Exposure Shorter (n) sickness length n (%)
Longer OR sickness length n (%)
AOR*
AOR**
AOR***
Lower (160)
126 (79)
34 (21%)
1
1
1
1
Higher (127)
77 (61)
50 (39%)
2.41 (95% CI: 1.434.05)
2.33 (1.363.99)
1.87 (1.043.37)
1.75 (0.943.25)
*Adjusted for rank, age, length of service, whether in a relationship, and sex. **Adjusted for attending a TRiM briefing or receiving a TRiM intervention. *** Adjusted for rank, age, length of service, whether in a relationship or not, sex, and attending a TRiM briefing or receiving a TRiM intervention.
StRaW • A peer support package designed to improve organisational resilience • Based on good science and best practice • A ‘novel’ approach for non-traumatic stress • Empowers self-reliance whilst encouraging appropriate help-seeking
Conducting StRaW Interviews • The Basics – Informal approach; don’t judge not even a little bit – Be cautious of rumour and hearsay beforehand
• Active listening – Minimal encouragers – Open ended questions – Reflecting – Emotion labelling – Posture/eye contact – ‘Ignore’ your own irritation – Effective pauses – Summarise/paraphrase
Communication requires people to be on the same wavelength
StRaW Risk Assessment Checklist No
RISK FACTOR
1
The individual considers that they have little or no control over the way they conduct their work
2 3
The individual considers they have recently faced or faces substantial and significant changes or transitions at work The individual considers that their efforts at work are poorly rewarded
4
The individual considers that their managers are supportive of their welfare and/or well-being
5
The individual considers that their colleagues are supportive of their welfare and/or well-being
6
7
The individual considers that work-load persistently interferes with their work-life balance/cannot ‘switch-off’ The individual is experiencing substantial life stressors outside of work The individual is experiencing substantial life stressors outside of work
8
The individual is experiencing symptoms of distress
9
The individual is lacking in suitable social support or unable to access it
10
The individual has been drinking alcohol excessively or has been using negative coping strategies to get by
What to make of the information gathered during the StRaW interview?
Employee Under Stress Decision Pathway No Distress or Loss of Function: • No major problems • Possibly concerned about ‘normal’ symptoms
Green Zone (Ready): • Good to go • Advise, reassure • Check-in when possible • Advise to make contact again if required
YES
(0-4)*
Distress or Loss of Function:
NO
Yellow Zone (Reacting): • Advise on self-care (including sleep/exercise//leave) • Actively manage work, home & social stressors • Consider mentoring/EAP etc • Plan a review
YES
NO YES
Advise/support them to see GP Consider EAP/BUPA/Occ Health Ensure ‘treatment compliance’ Mentor back to work if possible Liaise with HR/boss
Moderate to high StRaW score?
• • • • • •
Some difficulty relaxing and sleeping Decreased social/recreational activity Unusual and excessive fear, worry, or anger Some negative thoughts about self or future Difficulty performing normal role Mild change from normal personality
Significant Distress or Loss of Function: • • • • • • •
Great difficulty in falling asleep or staying asleep Withdrawal from social or recreational activities Uncharacteristic outbursts of rage/despair/panic Great difficulty controlling emotions Significant negative thoughts about self or future Loss of usual concern for moral values Unhelpful coping behaviour (e.g. alcohol)
(9-13)*
NO
Red Zone (Ill): • • • • •
Low to moderate StRaW score (5-8)*
Orange Zone (Injured): • Improve self care (as above) • Talk to manager/HR - consider temporary workplace adjustments • Consider EAP/GP/BUPA • Mentor and support • Plan a review
Very low StRaW Score
YES
High StRaW score? (14+)*
Highly Distressed or Loss of Function: • • • •
Difficulties lasting for more than several weeks Failure to cope Unable to continue as is Problems that get worse over time *all scores are for guidance only
Increasing the reach of organisational MH support
Peers as psychological mentors? • Basic Cognitive Behavioural Therapy • Motivational Enhancement Therapy • Problem Solving Therapy • Basic relaxation techniques (e.g. grounding)
e.g. MOTIVATIONAL INTERVIEWING A simple method for increasing ambivalence in favour of change
Motivational cycle of change
KEY PRINCIPLES of MI • • • • •
Avoid arguing Roll with resistance Self efficacy promoted Empathic, non coercive approach Discrepancy increased
• You do NOT just tell people what to do
MI STEPS 1. 2. 3. 4. 5. 6. 7.
Describe the target behaviour Identify pros and cons Identify concerns (theirs not yours!) Target ambivalence and heighten conflict Nudge towards a decision to change Action (plan how) Maintenance (or relapse….)
DECISIONAL BALANCE EXERCISE
Carrying on as I am
Changing things
Benefits
Down side
Your aim…. • Is to shift or nudge someone towards a positive outcome • You have to accept that your persuasion may not work at first • But that you may have started a person’s journey towards positive action
And Tertiary intervention (treatment) • Medication may well have a role • Standard psychotherapies and many variants: e.g. •
1 day CBT ‘resilience’ workshops
•
Remote delivered therapy (inc Telephone, Skype, IM)
•
Compressed therapy (e.g. 1 week CBT for PTSD)
•
Guided self-help (has to be guided!)
•
Groups (e.g. BA)
• But you cannot ignore the psychosocial context •
Poor training, uncertainty, harassment, leadership, home pressures etc
Beware - sellers of Bad Science often will say they have ‘the answer’
Summary •
Lots of good reasons to proactively support staff at work
•
Classic treatment only [?small] part of complex spaghetti bowl
•
Paying attention to intra-organisational primary and secondary prevention good for resilience and effective RTW •
Clear policy
•
MH informed leadership and workforce
•
Trained peers (TRiM and StRaW) increase reach
•
Stigma reduction approaches (educate/contact/protest)
•
Occupationally focused assessment / treatment services
Any Questions?
[email protected] www.marchonstress.com