Workplace psychological health and wellbeing: An overview of key trends

There has been a steadily increasing focus on workplace psychological health and wellbeing over the past decade. Indeed, the recent beyondblue Heads Up campaign has been very successful and generated heightened awareness about workplace mental health issues, particularly in the corporate sector. However, organisations still show uncertainty about how to appropriately respond and a number of key challenges persist across the intervention spectrum, as summarised below.

This article provides an overview of selected key trends and challenges in the workplace wellbeing field, and is organised in three sections that reflect the intervention spectrum from prevention to early intervention and tertiary management.

Prevention

LaMontagne and colleagues (2014) identified the three main approaches dominating the workplace mental health and wellbeing field – public health, medicine and organisational/positive psychology – which have evolved relatively independently of each other to date.

The public health approach has largely emerged out of the traditional stress literature, and is particularly indebted to Karask and Theorell’s (1990) demands-control model. Its major impact has been on workplace health and safety practices, contributing to the contemporary focus on psychosocial hazard management and risk reduction.

Workplace health and safety legislation now applies equally to the psychological dimension of the work environment and has resulted in significant advances, particularly in relation to the bullying phenomenon. For example, there have been more than 40 successful prosecutions in Victoria to date. One only needs to read some of the court transcripts to recognise that there are still some sinister workplaces that need the accountability lens that is afforded by contemporary legislation directed onto them. This legislation provides a counterweight that helps to prevent employers from skewing the balance between wellbeing and performance imperatives too far in favour of the latter.

The medical approach has had a strong and positive impact in the workplace early intervention space (see below). However, overly extending the medical approach into the prevention domain has highlighted critical limitations. The key concern is that medical approaches are basically blind to the crucial role of organisational climate. Interventions and workplace tools derived from this approach often reflect a degree of naivety about organisational behaviour and how organisations actually function.

Organisational and positive psychology approaches build on ongoing organisational climate research and studies that link employee wellbeing with engagement and performance. The focus is around building positive and protective factors in the workplace, and also embedding the management of employee mental health problems in a broader focus on promoting employee wellbeing (also often referred to as ‘positive mental health’ or ‘psychological wellbeing’). Another strand has explored the construct of psychosocial safety climate developed by Maureen Dollard and colleagues (e.g., Law, et. al. 2012) and its impact on a range of workplace wellbeing and behavioural outcomes.

Whilst positive psychology has thus far focused more at the individual employee level (e.g., the numerous available programs designed to increase personal resilience levels), there are organisational level interventions. Hart and colleagues (2014) have recently detailed such an approach and have evaluated numerous related development programs. The emphasis is on building the quality of the core people management environment, and employee and team level day-to-day experience of positive emotions. Supportive leadership factors and the quality of team-based climate regularly explain around 30 per cent of the variance in bottom-line financial performance and/or service delivery (i.e., over and above equipment, resources and training), and at least 50 per cent of the variance in levels of wellbeing (Hart et al., 2012). Strong high quality climates also increase team level resilience. There is even some preliminary evidence that team level morale (i.e., group affective tone) has a positive containing and reductive impact on employee depressive symptoms (Cotton, 2014).

Mental health problems are one risk within the broader range of organisational ‘people risk’ issues that also include withdrawal and counterproductive workplace behaviours. Progressive organisations are increasingly developing overarching wellbeing frameworks that strategically integrate a range of initiatives, to achieve more impact and move beyond the current piecemeal and silo-oriented approach that still characterises the majority of workplaces (e.g., a mindfulness workshop here, a mental health literacy program there, a psychosocial risk reduction program somewhere in between, and leadership development programs that are not aligned with any of these other initiatives).

Workplace early intervention

Until recently, workplace early intervention has been dominated by mental health literacy programs: educating managers and employees about mental health disorder symptom profiles, with a view to reducing stigma; appropriately supporting employees; and encouraging early access to mental health care and treatment. These programs (e.g., as delivered by beyondblue and Mental Health First Aid) have been enormously successful. Supplementing these initiatives, many organisations have also introduced training for managers in conducting (e.g., ‘sensitive’, ‘courageous’ or ‘difficult’) conversations with at-risk employees.

Manager response to warning signs

Endeavouring to move upstream and introduce workplace-based early intervention programs is becoming increasingly common. The pre-claim trajectory of a psychological injury is typically discernable in the workplace via a range of early warning signs over approximately six months. The real issue is not so much early detection as what to do in response. Many managers still avoid engaging with employees they regard as ‘challenging’ until they are required to through the annual performance appraisal. There is often then delivery of critical feedback and abruptly apparent disparity in the respective views of performance, which causes conflict that can generate a psychological injury claim.

Interventions that are having a positive impact on reducing bullying claims are being trialed across a number of organisations. Such interventions include, for example, ‘conciliation’/’coach’ roles that aim to repair work relationships early before they go off the rails, and the introduction of ‘five point conversation plans’ (where five separate informal conversations need to be implemented separately from the formal appraisal). The Queensland Resolve at Work initiative is a whole-of-government workplace-based early intervention program, whereby a multidisciplinary panel of providers deliver a range of fitness assessment, conflict resolution, case management, training and manager coaching services. An evaluation (Queensland Department of Justice and Attorney-General, 2012) concluded that the program has an 8:1 cost-benefit ratio (i.e., for every dollar spent, there are savings of around eight dollars in reduced psychological injury costs, absenteeism and improved performance).

As a people leader, part of a manager’s core role is to ‘keep a finger on the team pulse’. There are some common and generic early indicators around employees behaving differently than usual, and this is what should be responded to. Many organisations are adjusting manager role descriptions to explicitly include responsibility for staff welfare and the expectation to engage in proactive supportive conversations with at-risk employees.

There is also a trend towards more effectively leveraging organisational values and codes of conduct by targeting workplace ‘incivility’ and incorporating a behavioural component into performance management systems. Proactively addressing early warning indicators is also faclilitated when managers foster a ‘climate for wellbeing’ (e.g., messaging in team meetings validating the importance of wellbeing and encouraging early reporting, occasionally reminding staff about available support resources and appropriate role modelling etc).

E-mental health

E-mental health is playing an increasing role. Importantly, there are still significant numbers of working Australians with diagnosable mental health disorders who avoid engaging in any form of traditional face-to-face based treatments. E-mental health is significantly augmenting and expanding the range of available intervention options, and there is solid take-up by organisations promoting various such interventions to their workforces. Further, there are innovative positive psychology-based initiatives emerging, e.g., the team focused online wellbeing program Teamtopia (SuperFriend, 2014).

Tertiary management and treatment

This domain is probably now appropriately differentiated into secondary (post-claim) early intervention and tertiary management.

Secondary early intervention

The traumatic stress and persistent pain research literatures indicate that what happens early (i.e., within the first three months following injury) – in terms of perceived support and setting treatment/recovery expectations – has a profound effect on longer term health and return-to-work outcomes. In recognition of this, for example, Comcare now funds pre-liability treatment costs (the agency pays and is reimbursed following claim acceptance).

It is also clear that approximately one third of psychological injury claims are actually based more on low morale (e.g., job disgruntlement, poor person-job fit or negative work relationships) and not substantive increases in mental health symptoms. We currently overly medicalise these individuals through GPs and psychologists giving them the ‘adjustment disorder’ label and engaging them in clinical treatment, when early access to vocational assessment and guidance, conflict resolution or other human resource interventions is what is required.

Apropos of this, there is an increasing trend towards triaging claims to better identify this cohort and offer early intervention services. For example, the Victorian WorkCover Authority has implemented a Workplace Support Service which triages all new psychological injury claims and identifies those that have a more interpersonal rather than medical barrier to return to work. A skilled rehabilitation provider is then appointed to engage relevant parties in discussion and seek resolution of identified issues. This program has been found to increase rates of successful and earlier return to work.

The psychological aspects of the transition to chronic pain are still commonly under-managed. On average, GPs don't refer to psychologists or pain management programs until around 12 months post injury, whereas indications for such referral are typically clear by three months post injury. Further, mental health status in the first week following significant orthopaedic and other physical injury is the strongest predictor of disability at 12 months post injury, more than twice as strong as any physical injury characteristic and pain severity (O’Donnell et al., 2013). However, whilst there is take-up of mindfulness type interventions, the management of pain is still overly focused on medical and physical treatment modalities – notwithstanding the dominant contribution of mental health-related factors to compensation scheme disability costs, across nearly all injury types.

Tertiary management

The major trend over the past decade has been the increasing focus on health service provider clinical quality assurance and accountability. Individuals with comparable clinical profiles (physical and/or psychological injury) typically have worse health and return-to-work outcomes if they have a compensation claim. There are some ongoing system level challenges (i.e., ‘black flags’) across different jurisdictions in terms of time taken for claim determination, the polarisation that often occurs when claimants read their employer statement, the process of claims administration, and unwitting incentives in some schemes for individuals to maintain their claim. This is a vulnerable population, so the nature of treatment provided to injured employees needs to be of a very particular type and structure.

Most compensation jurisdictions now conduct secondary treatment reviews via ‘clinical panels’. The initial clinical quality assurance framework, detailing best practice in the physical treatment of injured workers, was developed in Victoria in 2005. In 2006, a mental health version of the Clinical Framework was released. Both were subsequently amalgamated in 2012 into the National Clinical Framework (available on most compensation authority websites), and now endorsed across all jurisdictions and by major health professional associations (including the APS).

Using this Framework as a reference point, in excess of 1,200 secondary psychology treatment reviews are conducted each year in Australia. These reviews provide unparalleled insights into the quality of interventions delivered to people injured at work or in car accidents. Expert consensus (from clinical panel specialist psychologists across several jurisdictions), is that 50 to 60 per cent of current psychological services delivered to injured employees are inadequate and poorly aligned with the National Clinical Framework.

Too many psychologists do not base their interventions on a clinical formulation and structured treatment plan, and do not set appropriate treatment and recovery expectations at the front end. More broadly speaking, the key dynamic now driving private practice psychology nationally is Medicare rebates. Medicare imposes a 10 session annual limit. Hence, there is an externally imposed end to the services and less demand to establish treatment expectations initially. This influences the delivery of services with compensable clients where the modal form of psychological service delivery seems to involve: excessive deferral to the personal preferences of the injured person; a week-to-week focus on top-of-mind issues; provision of lots of empathy and opportunities for emotional ventilation; and encouragement to engage with various strategies and techniques without any systematic focus on between-session incremental practice. In a compensation context, combined with passive medical treatment, this style of intervention actually fosters inappropriate emotional dependency, poor self-management capability and an expectation of open-ended access to psychology services, and ultimately contributes to excessive levels of ‘medically unnecessary disability’.

The other key development is the recognition of the therapeutic role of work in the delivery of treatment services. Evidence now overwhelmingly indicates that work is generally good for psychological health. However, return to work is still commonly viewed by treating health professionals as something that happens subsequent to the conclusion of their treatment, not as something that should occur concurrently and be integrated into their treatment. Liberal GP certification practices and a lack of adequate access to ‘work-focused treatment’ directly contribute towards work disengagement and increase the risk of drift towards long-term welfare benefits.

Recent initiatives introduced to address these challenges include the Australian Health Benefits of Work agenda (AFOEM, 2012) and Fit Certificates (which require GPs to certify more on the basis of what a person can do rather than not do, and to certify on the basis of their actual presenting capacity). The latter are currently being trialed in WA, ACT and Victoria. Training in work-focused treatment is now also available. These initiatives are focused on integrating return to work as a component in all treatments and increasing the focus of treaters on actual functioning, rather than symptoms per se.

The lacklustre quality of mental health treatment delivered to many injured employees can be contrasted with the work of Orygen, our premier national youth mental health treatment and research centre. Orygen works with a population that generally exhibits more serious psychopathology than the majority of individuals in workers compensation jurisdictions. Orygen provides targeted treatment based on a structured treatment plan and focused on functioning, and regards engagement with employment as a core aspect of the treatment – “participation in work … is a key element of the recovery process” (Orygen, 2014).

There are of course some injured employees with catastrophic injuries or significant pre-existing psychological vulnerabilities that have more complex treatment needs, and some who will unfortunately progress on towards permanent total work incapacity. However, these individuals should still be able to, at least initially, access work-focused treatment that is aligned with the National Clinical Framework, and be triaged out if necessary, as traditional (i.e., not work focused) clinical treatment approaches are associated with an increased risk for long-term disability.

The other issue that warrants mention is the role of personality, which is poorly understood and considered in treatment planning. ‘Trait emotionality’ and ‘trait compulsivity’ (now recognised in the DSM-5 system) are common and impede the effectiveness of standard interventions (physical and psychological). Particularly in relation to trait emotionality, iatrogenic effects tend to occur when psychologists collude with clients’ externalising causal attributions and further entrench identification with the victim role. More specialised depth-oriented and exposure-based interventions are often indicated to contain the impact of personality and develop compensatory self-management strategies.

Conclusion

The field of workplace psychological health and wellbeing is becoming more sophisticated across the intervention spectrum. The impact of psychological science and professional practice is still on the ascent and is directly contributing to enhancing occupational wellbeing, reducing psychosocial risk and improving health and return-to-work outcomes. n

The author can be contacted at [email protected]