8 WORK AS A MENTAL HEALTH PROMOTION SETTING

Almost one third of Canadian workers report high levels of stress on a regular basis (Crompton, 2011). The following chapter will discuss how the workplace can be a stressful place and how workplaces can address this by promoting positive mental health.

8.1 KEY THEMES AND MAIN IDEAS

8.1.1 Introduction

Mental illness is prevalent among the working population, and the workplace itself plays a major role in employees’ mental health. For this reason, it is imperative to understand the mechanisms through which work impacts mental health, and to develop and implement effective, sustainable, accessible, and equitable workplace interventions. The following chapter will discuss the importance of addressing mental health in the workplace, before outlining some of the most common intervention approaches, identifying some of the major limitations in the literature, and proposing some potential future directions researchers could take to address these limitations.

8.1.2 Prevalence and Costs of Mental Health Problems in the Workplace

Mental health problems among the working population produce a substantial burden, not only to the affected individual and their loved ones, but to the workplace, and society at large. Many common psychological disorders, such as mood and anxiety disorders, tend to peak in prevalence in adolescence and young adulthood, coinciding with the ages people begin to enter the workforce. As the age range of the Canadian workforce is increasing, so too is the prevalence of mental health problems in the workplace (LaMontagne et al., 2014). It is unsurprising, then, that significant portions of the working population are affected by mental illness and subclinical mental health problems. For example, of the 1.3 million Canadians living with depression, 1 million were currently employed in 2020 (Chokka et al., 2020). Additionally, the prevalence of anxiety disorders in the workforce has been increasing since 2003 (Dobson et al., 2020). In terms of subclinical mental health concerns, 27% of Canadian workers report high levels of stress on most days (Crompton, 2011).

Poor mental health among the working population places considerable strain on social services. On any given week, 500,000 Canadians are unable to go to work due to a psychological health issue (Government of Canada, 2016). Rising rates of leaves of absence, disability claims, and unemployment due to psychological conditions create significant economic costs. For example, it is estimated that mental health problems account for 78% of short-term and 67% of long-term disability claims. Furthermore, diagnosed and undiagnosed mental health problems cost the Canadian economy $51 billion annually in health service usage, work loss, and reductions in quality of life (Thorpe & Chénier, 2011).

In addition to the costs borne by the social sector, mental illness negatively impacts employers, employees, and the workplace more broadly. Lost productivity, turnover, and absenteeism-related costs exceed healthcare expenses and are estimated to cost employers $20 billion annually (LaMontagne et al., 2014; Erin, 2011). The costs borne by employees are more difficult to quantify and stem from many sources— such as discrimination, stigma, and occupational impairment— creating barriers to seeking and retaining employment (LaMontagne et al., 2014; Chokka et al., 2020). Eighty-three percent of employees living with depression report a reduction in their ability to function at work, with 23% being unable to work altogether and an additional 20% having to reduce their hours from full-time to part-time due to their mental health condition (Chokka et al., 2020).

8.1.3 The Psychosocial Work Environment

Given that the average worker spends 30-40 hours per week at work, it is not surprising that the workplace environment plays an important role in individuals’ mental health. The psychosocial work environment refers to the bidirectional links between socio-political factors, working conditions, health, and illness (Rugulies, 2018). In essence, working conditions — which encompass organizational cultures, job roles and demands, interpersonal relationships in the workplace, and the nature of work-related tasks — interact with individual factors such as personality traits and attitudes to influence employees’ physical and psychological health. Furthermore, these interactions are situated within and shaped by broader socio-political structures (Rugulies, 2018).

Rugulies (2018) provides a conceptual framework to highlight how working conditions affect physiological changes and health behaviours, which then impact psychological and physical health. Psychological and physical health can, in turn, influence behaviours within the workplace. For example, excessive work demands can lead to increased physiological arousal and stress. To cope with stress, employees may begin binge drinking. Binge drinking can then lead to physical health complications such as cancer, or psychiatric conditions such as an alcohol use disorder. These conditions, then, can contribute to absenteeism, lost productivity, or impaired occupational functioning. Broader macro-level phenomena, such as financial crises, can exacerbate these processes by impacting workplace structures; for example, downsizing and layoffs can produce additional stress by contributing to job insecurity and negatively affecting the workplace environment.

As the above example demonstrates, working conditions serve as a risk factor for mental illness. Poor working conditions are a major source of stress and can trigger or exacerbate mental health problems among workers. Observational research has provided indirect links between working conditions and mental illness; for example, lower occupational status workers experience the poorest working conditions and the highest rates of mental illness (LaMontagne et al., 2014). Job strain— defined as the combination of high job demands and low control over or ability to cope with these demands— is positively correlated with mental illness, as are low social support and effort-reward imbalances (Stansfeld & Candy, 2006). Furthermore, poor interpersonal relationships and bullying within the workplace are positively correlated with anxiety symptoms and other mental health problems (Holmgren et al., 2022). In addition to clinical conditions, job stress exposure is associated with subclinical concerns such as burnout (LaMontagne et al., 2014).

Among workers with existing mental illnesses, complicated organizational practices can be a source of stress and present a barrier to help-seeking. For example, one study examining organizational procedures around requesting sick leave for depression found that these processes may prevent employees from seeking accommodations or force them to find alternatives (i.e., using vacation time; Malachowski et al., 2016). Misconceptions about mental illness are prevalent within the workplace, and many employees report that the stigma associated with mental illness is a major barrier to disclosing their struggles or seeking help (LaMontagne et al., 2014; Malachowski et al., 2016). Many employers report feeling ill-equipped to support employees with mental disorders, and some believe that providing support for employees is beyond the scope of their responsibilities (Malachowski et al., 2016; Nielsen et al., 2010).

Although poor working conditions are a risk factor for mental illness, work can also serve as a protective factor. Job insecurity and low socioeconomic status are major determinants of mental health, and stable employment can mitigate the risks conferred by these factors. Among employees with mental health conditions, occupational impairment can be a source of additional stress, and most individuals with depression report a desire to work (Chokka et al., 2020). For people with mental health conditions, supporting their ability to return to and remain at work is a desirable outcome due to the benefits that employment provides. For example, work can provide individuals with structure and purpose, as well as an environment to build positive social connections. Additionally, having a stable income can alleviate financial stress that may otherwise exacerbate mental health problems (LaMontagne et al., 2014; Kelloway, 2023). Furthermore, positive workplace environments can enhance workers’ resilience and ability to cope with stressors they encounter in the workplace (Rana, 2015).

The benefits of work not only function as a buffer against mental ill health but can promote mental well-being as well. Good work provides individuals with a sense of meaning and self-efficacy, in addition to supporting socialization and identity development (LaMontange et al., 2014). Supportive leadership and positive organizational norms can improve individuals’ attitudes about work, job satisfaction, and productivity, in addition to improving interpersonal relationships, promoting positive emotions, and enhancing adaptiveness, intrinsic motivation, and creativity. Ultimately, these benefits can enhance workers’ psychological well-being (Rana, 2015). Furthermore, the physical attributes of the workplace itself play an important role in employees’ psychological well-being. It has been found that open, well-lit spaces can foster positive workplace environments that are perceived by employees to promote feelings of empowerment, facilitate collaboration, encourage healthier thought processes and behaviours, and enhance productivity (Grant et al., 2019).

8.1.4 The Workplace as a Mental Health Promotion Setting

In recent years, there has been a growing acknowledgement of the role work plays in mental health, compounded by growing concerns over the economic impacts of mental illness in the workplace. In light of this awareness, there has been an increased interest in implementing mental health promotion (MHP) initiatives within the workplace. Many countries have developed standards and guidelines to assist employers with the development of psychologically-safe workplaces. Canada established the Mental Health Commission of Canada in 2007, which issued the Standard for Psychological Health and Safety in the Workplace in 2013. This standard provides voluntary guidelines for organizations to develop workplace mental health programs. Companies are asked to survey the workplace to identify existing issues, formulate plans and strategies to address these issues, and to implement these plans and monitor progress. The standard also identifies key factors that organizations should address, such as providing psychological support, managing workplace demands, and supporting employees’ work-life balance (Kelloway, 2017).

The growing recognition of the importance of mental health is reflected by an increased receptivity to and adoption of workplace-based mental health interventions. Organizations are increasingly seeking out interventions and programs focused on mental health-related issues. Among the most commonly adopted interventions are those focused on addressing organizational norms and improving mental health awareness. For example, one of the most popular interventions is the Mental Health First Aid initiative, which strives to improve mental health literacy by developing leaders’ and employees’ recognition of mental disorders and teaching them skills to provide support until professional help can be obtained. The goals of this initiative are to improve knowledge about the causes of mental disorders, enhance understanding of evidence-based treatments, and reduce the stigma associated with mental illness (LaMontagne et al., 2014).

Despite the growing awareness of and receptivity to workplace MHP initiatives, evidence-based practices and organizational resources are under-utilized (Kelloway, 2017). Concerns have been raised that employers are relying too heavily on individual-level secondary and tertiary strategies, to the exclusion of organizational-level primary approaches. Indeed, although mental health literacy (MHL) programs are increasingly being taken up by employers, organizational-level interventions that aim to address workplace risk factors, promote positive mental health, or support and accommodate employees with mental health conditions are being neglected (LaMontagne et al., 2014; Kelloway, 2017). There are a number of potential explanations for the slow uptake of these types of programs.

First and foremost, stigma can contribute to the slow uptake of preventative measures due to misconceptions that mental health problems are a result of personal weakness, or that mental illness is a personal issue which falls beyond the purview of leaders’ responsibilities (LaMontagne et al., 2014; Malachowski et al., 2016; Nielsen et al., 2010). Furthermore, organization-level interventions are resource-intensive, time-consuming, and require collaboration to guide their implementation and evaluation over the long term. Such interventions require buy-in and ongoing commitment on the part of employers, who may feel that these programs are intrusive or disruptive to their everyday duties (Nielsen et al., 2010). Finally, interventions must be adaptive to the unique work context; strategies will differ depending on the characteristics and demographics of the workers, the structure and size of the workplace, the roles within the workplace, and the resources available (LaMontagne et al., 2014). This makes the process of implementing these strategies more involved and labour intensive.

8.1.5 Current Evidence-Based Interventions

Workplace MHP initiatives can be conceptualized in terms of their theoretical origins. For example, most common approaches stem from the fields of psychology, public health, or medicine. Furthermore, they can be conceptualized in terms of the point at which they are implemented. Primary prevention strategies are designed to prevent the onset of mental illness before it occurs, secondary strategies aim to prevent the exacerbation or progression of a problem once it has occurred, and tertiary interventions aim to address and alleviate the symptoms of an existing problem. Finally, these programs can be conceptualized in terms of their desired outcomes— whether they are intended to prevent mental health problems, promote well-being, treat existing mental health problems, or accommodate and support the rehabilitation of those with mental health problems (LaMontagne et al., 2014; Kelloway, 2017).

Prevention-Based Approaches

These strategies can be thought of as primary interventions and find their roots in the fields of psychology and public health. The aim of these types of programs is to reduce the prevalence and impact of work-related risk factors by modifying working conditions and limiting exposure to job stressors. In light of the established links between working conditions and mental illness, stressors such as interpersonal conflict, high job strain, and effort-reward and work-life imbalances represent promising targets to be addressed by prevention strategies (LaMontagne et al., 2014). Although the literature on preventative strategies is currently limited, preliminary evidence suggests leadership development training can be a viable and effective primary intervention (Kelloway & Barling, 2010). Abusive leadership is associated with increased employee distress, while positive forms of leadership can reduce job-related stress. Workshop based interventions aimed at enhancing positive leadership have been found to improve leadership quality (Kelloway & Barling, 2010), which can improve workplace cultures and reduce the stress associated with negative leadership.

Promotion-Based Approaches

These strategies can be thought of as primary and secondary interventions and stem from the field of psychology. In contrast to the risk-reduction focus of preventative approaches, promotion-based approaches aim to enhance workers’ resilience and ability to cope with work-related stressors. Rather than trying to “fix” mental ill health, these approaches are strengths based and strive to promote well-being. In this way, they can prevent the onset or exacerbation of problems by promoting positive feelings and improving workers’ capacity to handle stressors they encounter in the workplace (LaMontagne et al., 2014; Rana, 2015). These approaches are the least commonly applied in practice, and as such, the literature on their efficacy is sparse. However, preliminary evidence supports the use of promotion-based programs. Leadership development interventions that promote positive leadership behaviours have been found to increase feelings of optimism, happiness, and enthusiasm among employees (Kelloway & Barling, 2010; Rana, 2015). Furthermore, well-designed physical work environments can promote feelings of empowerment and encourage healthier behaviours (Grant et al., 2019). Other research has demonstrated that positive psychology-based employee programs can produce positive changes in well-being, and these improvements were maintained at a 6-month follow-up (LaMontagne et al., 2014).

Treatment-Based Approaches

These strategies can be thought of as tertiary interventions and stem from the fields of psychology and medicine. These interventions aim to address existing mental health problems among workers. The Mental Health First Aid intervention that was previously mentioned falls within this category, as do other MHL interventions. Essentially, the aims of MHL interventions are to improve people’s ability to recognize the symptoms of mental disorders and intervene as necessary. Stigma-reducing programs have been found to be effective in improving people’s attitudes and knowledge about mental illness (LaMontagne et al., 2014), and although there are no direct links between these interventions and mental health outcomes, these types of approaches could potentially have indirect benefits. For example, many employees with mental disorders cite stigmas as a major barrier to getting help, so reducing stigmas can encourage more individuals to disclose their struggles and seek support. Other examples of treatment-based interventions include suicide prevention programs in high-risk occupations, which have been found to reduce suicide rates in the United States air force (Knox et al., 2010). Stress management programs and cognitive behavioural approaches that have a direct focus on mental health have also been shown to reduce depression and anxiety symptoms among employees (Martin et al., 2009).

Accommodation- and Rehabilitation-Based Approaches

These approaches can be thought of as tertiary approaches. In contrast to treatment-based approaches, these strategies focus on facilitating employees’ return to work after mental illness related absences, as well as implementing accommodations to support their ability to remain at work. Despite the fact that most of the accommodation’s employees request are relatively inexpensive and easy to implement, only a third of employees end up receiving the accommodations they require (Wang et al., 2011). According to one survey of employees with depression and/or anxiety, some of the most commonly-requested accommodations included weekly meetings with employers to deal with issues before they escalate, exchanging minor tasks with other employees, quieter work spaces, extra time to learn, the ability to work remotely, slower work places, and modified instruction (Wang et al., 2011). Other research suggests organizational interventions aimed at reducing stigmas can facilitate employees’ return to work after physical injuries, and it has been proposed that such an approach could extend to mental health-related absences as well (Francis et al., 2014; Kelloway, 2017). Furthermore, problem solving interventions that aim to identify and address challenges to staying at work have been shown to be successful in reducing the likelihood of recurrent leaves of absence (LaMontagne et al., 2014).

Integrated approaches

Integrated approaches combine aspects of all the aforementioned interventions (LaMontagne et al., 2014). By combining the strengths of prevention, promotion, treatment, and accommodation, integrated approaches have the potential to optimize outcomes across the mental health spectrum. Many of the interventions that have been listed above are complementary to one another and can be applied at various levels. Following the model put

forward by LaMontagne et al. (2014), it is proposed that some of the most commonly used interventions can be conceptualized within an integrated framework, targeting mental health at various stages. For example, stigma-reducing approaches can be thought of as primary interventions in the sense that they foster more understanding and supportive workplace cultures, and secondary or tertiary in the sense that they can allow employees to feel more comfortable opening up about their struggles. Furthermore, these approaches can allow employees to feel more comfortable returning to work after a mental illness-related absence. Relatedly, risk reduction approaches can be primary in the sense that they can reduce exposure to stressors that may trigger mental illness, or secondary/tertiary in the sense that they can improve working conditions and alleviate the stress that can exacerbate problems or prevent individuals from returning to work.

Positive Mental health in the workplace helps employees have life meaning and can be established through using evidence-based interventions and integrated approaches such as the Canada’s National Standard for Psychological Health and Safety at work.

8.2 GAPS AND LIMITATIONS

Existing research on workplace mental health is limited by lack of evidence on effective program measures, organizational-level interventions, and stigma against some worker populations.

8.2.1 Lack of Evidence

Although there has been significant progress in the promotion of positive mental health in the workplace, there is a lack of conclusive evidence to demonstrate the effectiveness of the measures. This is evidenced by the absence of clear measurement instruments, the lack of robustness of existing research findings, and the lack of research evidence from low- and middle-income countries.

Traditional measurement instruments are not suitable for testing the effectiveness of implementation on mental health in the workplace (Czabala et al., 2011). In a mental health intervention for blue-collar workers, although a significant and steady increase in workers’

autonomy and sense of control was accompanied by a significant decrease in absenteeism, no significant post-intervention changes were found when screening for psychopathological symptoms using the 90-item Symptom Checklist Revised (SCL-90-R) scale (Czabala et al., 2011), a widely used scale of mental status symptoms (Schmitz et al., 2000). Interventions on work-related outcomes typically measure productivity and attendance, as well as job satisfaction, health, and vitality to assess their effectiveness. However, interventions and specific outcome assessment methods are very different across studies, and it is difficult to compare studies because there is no reference standard (Moroni et al., 2023). Thus, traditional instruments for assessing mental health may be limited in their ability to measure improvements in workplace mental health, which has led to studies that have not been able to demonstrate the effectiveness of their interventions. Alternatively, there are no clear measurement tools to demonstrate whether the interventions are ineffective.

On the other hand, according to the scoping review by Czabala et al. (2011), no conclusive evidence on the effectiveness of intervention programs has been found, which requires replication studies or other standard outcomes for evaluation. At the same time, relevant studies now face problems of insufficient data, low sample sizes, wide variation in the number of participants across studies, and different durations of different interventions (Czabala et al., 2011).

Most of the current research on improving mental health issues in the workplace is concentrated in Europe and the United States. Countries in other regions, especially developing countries and low- and middle-income countries, lack research evidence that fits their context.

Edgelow et al. (2022) found that most of the included articles were focused on organizational.

settings in Western countries, with the majority originating from the United States, suggesting that current workplace mental health interventions are concentrated in developed countries, particularly in Europe and the Americas, which leads to a lack of data from low- and middle income countries, where conducting relevant research is more challenging because there is insufficient evidence to support the studies.

8.2.2 Lack of Organizational-Level Interventions

Another limitation plaguing MHP in the workplace is the low number of interventions implemented at the organizational level. According to Czabala et al. (2011), interventions can be implemented at three different levels: individual, organizational, or both, and after a scoping review by Czabala et al. the majority of interventions (52 studies) were implemented at the individual level, 19 at both levels, but only 8 involved implementations at the organizational level.

In many cases, there are insufficient interventions at the organizational level because the employer prefers individual level interventions. Reducing job stressors and improving work quality often requires organizational change, but in the past, mental health programs have largely been education and training programs for individuals, and employers have been more receptive to workplace mental health literacy and related programs than to job stress prevention programs (LaMontagne et al., 2014). Another possible reason for the low number of interventions at the organizational level is the complexity of assessing interventions at the organizational level. Considerations of complexity also include the diversity of groups of workers with different needs, challenges, and factors affecting their mental health at any given time, making it difficult to identify and implement interventions that are effective for a group of employees (Gray et al, 2019). Another factor that may contribute to the low number of interventions at the organizational level is that most workplace stakeholders remain confused about the best practices for workplace mental health interventions (Wagner et al., 2016).

8.2.3 Stigma and Discrimination Against Specific Populations

The lack of exploration of cultural factors or specific groups of workers is also a challenge to promoting positive mental health in the workplace. While there is more research on mental health in general, there is a smaller amount of research being conducted on mental health and illness in specific groups of workers. Examples include workers with unstable work schedules, women, minorities, caregivers (e.g., single parents; adults providing elder care for aging parents), younger or older employees, LGBTQ+ employees, or ways in which multiple identities may intersect to predict mental health.

It is currently common for studies to produce findings that may be generalizable by typically grouping all staff in this research method, but the results of these studies are not particularly meaningful or actionable for specific populations, especially given the high degree of individualization of mental health and mental illness (Kelloway et al., 2023). The reason for focusing on specific populations is that these populations often have multiple identities and are more susceptible to psychological problems resulting from discrimination. For example, a major contributor to mental health problems in the workplace is the vulnerability of workers to discrimination or unfair treatment based on factors such as race, gender, sexual orientation, and social class. Some potential bases of discrimination such as age, sexual orientation, social class, citizenship, disability, and “appearance discrimination” can affect long-term depressed mood and may have a greater impact on mental health when these factors are present together (Han et al., 2022). For instance, according to Han et al. (2022), the association between race and gender discrimination in the work environment and depression fluctuates with age, with a small effect on depression among workers aged 21-26 years, but a large effect on depression among workers aged 33-37 years, and then a significantly weaker effect of discrimination on mental health at ages 45-46 years.

On the other hand, workers who experience discrimination or stigmatization in the workplace are more difficult to return to work. It is often difficult for employers to gauge the mental health needs of their employees because of the continued stigma associated with mental health conditions. Stigma often creates psychological barriers that prevent employees from speaking up or seeking help (Wu et al., 2021). There are many effective ways to help employees who have experienced stigmatization return to work. Examples include alternative work assignments or workplaces, the use of return-to-work coordinators, early and thoughtful contact with employees while they are on leave, and establishing good lines of communication between the workplace and health care providers (Kelloway, 2017). But as with other “invisible” injuries, concerns about stigma may lead workers not to request or take advantage of these arrangements, as the stigma experienced by injured workers can be “anti-therapeutic” and lead to a lack of return to work and chronic disability (Kelloway, 2017).

In this section we have reviewed the key limitations in workplace mental health. Due to stigma and preference for research on individual workers, gaps are present at various organizational levels.

8.3 FUTURE RESEARCH DIRECTIONS

The shocking reality that half of workers do not return to work after being on disability leave for six months reminds us of the importance of future research on long-term absence and risk factors at multiple levels of an organization.

Noting these evidence gaps is particularly important so that future research can be tailored to support workplace mental health. Continued research needs to be a priority due to the risk of long-term absence from work following mental illness (Blank et al., 2008). Return-to-work outcomes are significantly diminished after a period of 6 months absence, with 50% of employees being unable to return to their jobs (Blank et al., 2008). Lengthy absences from work can affect social status, income, relationships, and increase other risk factors, which can create secondary negative psychological effects in an employee beyond the cause of their initial absence (Harder, 2003). Therefore, identifying risk factors in the workplace for developing mental health issues needs to be a priority future research direction (LaMontagne et al., 2014). As mentioned previously, these risk factors must account for the effects of stigmatization (Kelloway et al., 2023). This is not only to account for the stigmatization of mental health issues that occur, but also to identify the specific risk factors of marginalized groups (such as members of LGBTQIQA2S+ and BIPOC communities, older adults, and those with disabilities); because current workplace mental health research is generalized, context within specific employee populations is critical (Kelloway et al., 2023).Additionally, more evidence is needed on the role of leadership on mental health in the workplace (Kelloway et al., 2023). Evidence to support the role of leadership in workplace mental health will support research into effective strategies focused on positive leadership. However, strategies should not be limited exclusively to the role of leadership in making positive mental health workplaces. Future research needs to support strategies at all intervention levels, including individual, leader, and organizational level resources (LaMontagne et al., 2014; Nielsen et al., 2017). Because most research focuses on individual approaches, there is an increased need for integrated approaches that address multiple domains (LaMontagne et al., 2014). Examples of resources to explore include building social capital, building employee autonomy, increasing problem-solving skills, and transformational leadership (Nielsen et al., 2017). Key priority areas must also include improving working conditions, surveillance, information, and improved mental health services; these also must be integrated within approaches rather than being implemented as stand-alone items (Sauter et al., 1990). Unfortunately, there is some indication that management prioritizes mental health strategies lower than employees do. Future research should emphasize the need to mitigate this by encompassing consensus building regarding the importance of all interventions used (Reavley et al., 2014). Once evidence and strategies are developed, research will need to continue to evaluate these resources to help inform future research directions, policy, and workplace mental health practices. Evaluation will help determine the effectiveness of interventions within workplaces, as well as the economic benefits to organizations to promote ongoing uptake (Kelloway et al., 2023). Additionally, this would support the development of standards and recommendations for implementation across diverse organizations (LaMontagne et al., 2014). Developing evidence and strategies to support mental health in the workplace will involve many different disciplines; if research is to provide sufficient evidence, strategy, and evaluation to be useful in this context, there will need to be an emphasis on common definitions and terms to avoid subjectivity (Blank et al., 2008; Kelloway et al., 2023). For example, Blank et al. (2008) noted that poor mental health was sometimes described in terms of morbidity and illness versus as part of the positive mental health continuum used in psychology.

In this section we have learned about the importance of researching the use of program resources, and taking integrated approaches that focus on multiple domains.