Mental Health and how to Sustain Resilience at Work

Mental Health and how to ‘Sustain Resilience at Work’ Neil Greenberg Professor of Defence Mental Health at King’s College London Managing Director of...
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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