Mental Health Vs Work
Mental Health Vs Work
Mental Health Vs Work
NATIONS
FOR
MENTAL
HEALTH
Mental health
and work:
Impact, issues and
good practices
Publications
To improve the planning and development of services for mental health through:
strengthening the technical capacity of countries to plan and develop services;
supporting demonstration projects for mental health best practices; encouraging
operational research related to service delivery; and developing and disseminating
resources related to service development and delivery.
Nations for Mental Health: An overview of a strategy to improve the mental health of
underserved populations.
WHO/MSA/NAM/97.3. Rev.1
Financial support is provided from the Eli Lilly and Company Foundation, the Johnson and
Johnson European Philanthropy Committee, the Government of Italy, the Government of
Japan, the Government of Norway, the Government of Australia and the Brocher
Foundation.
* These documents have been translated into Russian by the Geneva Initiative on Psychiatry.
Requests for copies in Russian should be directed through Dr Robert Van Voren, General
Secretary, Geneva Initiative on Psychiatry, PO Box 1282, 1200 BG Hilversum, Netherlands.
Tel: 0031-35-6838727. Fax: 0031-35-6833646. E-mail: rvvoren@geneva-initiative.org.
These documents are available from our website:
http://www.who.int/mental_health
NATIONS
FOR
MENTAL
HEALTH
Mental health
and work:
Impact, issues and
good practices
Gaston Harnois
Phyllis Gabriel
ii
Harnois, Gaston.
Mental health and work : impact, issues and good practices / Gaston Harnois, Phyllis Gabriel.
(Nations for mental health)
1.Mental health 2.Workplace 3.Mental disorders - therapy 4.Mental health services - standards
5.Occupational health services - standards 6.Benchmarking 7.Cost of illness
I.Gabriel, Phyllis. II.Title III.Series
ISBN 92 4 159037 8
ISSN 1726-1155
iii
Contents
Preface
vi
Chapter 1
Introduction
1.1 Scope of the problem
Chapter 2
The importance of work to an individuals mental health
2.1 The workplace and mental well-being
Chapter 3
The workplace and mental health
3.1 Promotion of mental health in the workplace
Chapter 4
Mental health an imperative concern
4.1 Issues facing employers and managers
11
12
13
14
14
15
14
16
15
15
16
17
18
iv
Chapter 5
Work as a mechanism for reintegrating persons with serious mental illness
5.1 Size and profile of this group
19
19
5.2.1 Deinstitutionalization
19
21
21
22
23
24
5.4.1 Context
25
25
26
27
28
29
30
31
32
32
33
34
36
37
37
38
39
39
39
40
41
41
42
43
5.8.3 Support
43
43
44
44
44
5.9.3 Costs
47
47
48
48
48
49
51
52
52
53
53
54
54
55
Chapter 6
Discussion
56
Chapter 7
Conclusion
60
References
61
vi
Preface
All of us have the right to decent and productive work in conditions of freedom,
equity, security and human dignity. For persons with mental health problems,
achieving this right is particularly challenging. The importance of work in enhancing the economic and social integration of people with mental health problems is
highlighted in this monograph.
The International Labour Organisation (ILO) has long recognized the importance of documenting the extent of disabilities among the labour force and setting
up effective preventive and rehabilitative programmes. The ILOs activities promote the inclusion of individuals with disabilities in mainstream training and
employment structures. The importance of addressing specific issues related to the
employment of persons with mental health problems has also been recognized.
ILO promotes increased investment in human resource development, particularly
the human resource needs of vulnerable groups, including persons with mental
health problems. Employees mental health problems and their impact on an
enterprises productivity and disability/medical costs are critical human resource
issues. Increasingly, employers organizations, trade unions and government policy-makers are realizing that the social and economic costs of mental health problems in the workplace cannot be ignored.
Because of the extent and pervasiveness of mental health problems, the World
Health Organization (WHO) recognizes mental health as a top priority.
Using instruments that allow us to see not how people die but rather how they
live (1), we now know that the problems of mental illness loom large around the
world. It accounts for 12% of all disability-adjusted life-years (DALYs), and 23%
in high-income countries.
Five of the 10 leading causes of disability worldwide are mental problems (major
depression, schizophrenia, bipolar disorders, alcohol use and obsessive-compulsive disorders). These disorders together with anxiety, depression and stress
have a definitive impact on any working population and should be addressed
within that context. They may also develop into long-term disorders with accompanying forms of disability.
Given the fact that numerous affordable interventions exist, the time has come to
challenge both the low priority given to mental health and the stigma that those
with mental ill-health still endure around the world.
We now know that when essential drugs, if needed, are made available and access
is offered to a psychosocial rehabilitation programme (including the access to
meaningful and realistic employment) many persons will be able to lead more
socially and personally satisfying lives.
WHO has made a renewed commitment to mental health in making it one of its
priorities. Mental health will be the theme of World Health Day 2001 and also
the World Health Report 2001. Given the multifaceted nature of the factors that
contribute to good mental health, WHO is ever mindful of the need to highlight
activities that foster good practices in mental health. In this monograph the issue
of work as it relates to mental health is addressed.
The publication of this document is particularly important because it has brought
together two large United Nations agencies involved in rehabilitation, namely
WHO and ILO. The document examines the importance of mental health in the
workplace in general, and suggests appropriate management for workers with
mental health problems. In addition, it takes a practical look at strategies to promote and sustain good mental health while highlighting examples of good practices.
The document was written jointly by Dr Gaston Harnois on behalf of WHO and
Phyllis Gabriel on behalf of ILO. Dr Harnois is Director of the Montreal WHO
Collaborating Centre at the Douglas Hospital in Montreal, Canada. He is also
Associate Professor of Psychiatry at McGill University, and former President of
the World Association for Psychosocial Rehabilitation. Phyllis Gabriel MPH, MA
is aVocational Rehabilitation Specialist at the ILO headquarters in Geneva. She
has worked as a Vocational Rehabilitation Counsellor in US community-based
social service agencies as well as in mental health care facilities.
It is hoped that this important document will assist employers and employees in
raising awareness of the benefits of good mental health practices and encourage
the implementation of strategies to maintain a healthy working environment.
Dr Benedetto Saraceno
Director
Department of Mental Health and
Substance Dependence (MSD)
World Health Organization
Mr Pekka Aro
Director
InFocus Programme on
Knowledge, Skills and Employability
International Labour Organization
vii
viii
Chapter 1
Introduction
1.1. Scope of the problem
There is growing evidence of the global impact of mental illness. Mental health
problems are among the most important contributors to the burden of disease and
disability worldwide. Five of the 10 leading causes of disability worldwide are mental health problems. They are as relevant in low-income countries as they are in
rich ones, cutting across age, gender and social strata. Furthermore, all predictions
indicate that the future will see a dramatic increase in mental health problems (2).
The burden of mental health disorders on health and productivity has long been
underestimated. The United Kingdom Department of Health and the
Confederation of British Industry have estimated that 15-30% of workers will
experience some form of mental health problem during their working lives. In
fact, mental health problems are a leading cause of illness and disability (3). The
European Mental Health Agenda of the European Union (EU) has recognized
the prevalence and impact of mental health disorders in the workplace in EU
countries. It has been estimated that 20% of the adult working population has
some type of mental health problem at any given time (4). In the USA, it is estimated that more than 40 million people have some type of mental health disorder and, of that number, 4-5 million adults are considered seriously mentally ill
(5). Depressive disorders, for example, represent one of the most common health
problems of adults in the United States workforce.
The impact of mental health problems in the workplace has serious consequences
not only for the individual but also for the productivity of the enterprise.
Employee performance, rates of illness, absenteeism, accidents and staff turnover
are all affected by employees mental health status. In the United Kingdom, for
example, 80 million days are lost every year due to mental illnesses, costing
employers 1-2 billion each year (6). In the United States, estimates for national
spending on depression alone are US$ 30-40 billion, with an estimated 200 million days lost from work each year (7, 8).
8%
CNS
3%
Tumours
40%
Musculoskeletal
9%
Respiratory disorders
14%
Accidents
7%
Mental disorders
16%
Heart disease
Source: Takala J. (ILO) Indicators of death, disability and disease at work. African Newsletter on
Occupational Health and Safety, December 1999, 9(3):60-65.
DISABILITY
Psychiatric
Social and cultural
exclusion and stigma
Denial of opportunities
for economic, social and
human development
Vulnerability
to poverty
and ill-health
Poverty
Reduced participation in
decision-making, and denial
of civil and political rights
Deficits in economic,
social and cultural rights
Source: United Kingdom Department for International Development. Disability, Poverty and
Development, February 2000 (modified)
attitudinal barriers which cause social exclusion (12). For people with mental illness, social exclusion is often the hardest barrier to overcome and is usually associated with feelings of shame, fear and rejection.
It is clear that mental illness imposes a heavy burden in terms of human suffering,
social exclusion, stigmatization of the mentally ill and their families and economic
costs. Unfortunately, the burden is likely to grow over time as a result of ageing
of the global population and stresses resulting from social problems and unrest,
including violence, conflict and natural disasters (13).
1.3 Using the workplace to prevent mental health problems and provide
solutions for referral and rehabilitation
Globalization and interdependence have opened new opportunities for the growth
of the world economy and development. While globalization has been a powerful
and dynamic force for growth, work conditions and the labour market have
changed dramatically during the last two decades. The key elements in these
changes are increased automation and the rapid implementation of information
technology. Workers worldwide confront as never before an array of new organizational structures and processes downsizing, contingent employment and
increased workload.
Employers have tended to take the view that work and/or the workplace are not
etiological factors in mental health problems. However, whatever the causal factors, the prevalence of mental health problems in employees makes mental health
a pressing issue in its own right (14). Although, effective mental health services
are multidimensional, the workplace is an appropriate environment in which to
educate individuals about, and raise their awareness of, mental health problems.
For example, the workplace can promote good mental health practices and pro-
vide tools for recognition and early identification of mental health problems, and
can establish links with local mental health services for referral, treatment and
rehabilitation. Ultimately, these efforts will benefit all by reducing the social and
economic costs to society of mental health problems.
For people with mental health problems, finding work in the open labour market
or returning to work and retaining a job after treatment is often a challenge.
Stigma surrounds those with mental illness and the recovery process is often misunderstood.
This monograph addresses these issues. It provides a practical guide and resource
for human resource managers, mental health professionals, rehabilitation workers, policy-makers, trade unionists and other concerned individuals.
The central themes of this monograph are:
To examine the importance of mental health problems in the workplace.
To consider the role of the workplace in promoting good mental health practices for employees.
To examine the importance of work for persons with mental health problems.
To discuss the different vocational strategies and programmes for persons with
mental health problems.
To provide examples of good practices. These examples illustrate:
good mental health promotional practices in the workplace by employers;
how to handle an employee who becomes ill with a mental health problem,
such as depression;
vocational rehabilitation models/programmes for persons with long-term
mental health problems.
Chapter 2
Chapter 3
The organization assists in preventing mental ill-health by giving people a good working
environment and a clearly defined job. Following absence, it is often essential to be able to
modify working hours during the rehabilitation period and to provide a gradual return to
usual working practices through a good sick pay scheme. Financial support at this time
allays anxiety and encourages a speedier return to work.
Regular honest appraisals are important and problems in performance should be discussed
when they occur, with an opportunity to follow up and review progress. People should feel
able to contribute to their development and feel accountable for their jobs.
On-site counselling facilities from personnel or health professionals are available, reducing
time away from work (17).
There is growing global concern about the impact of job stress, including issues
related to gender, ethnicity, sexual harassment, violence and mobbing at work,
family, and underemployment (22). Job stress is one of the most common workrelated health problems in EU countries. The Second European Survey on
Working Conditions indicated that 28% of workers reported that their work causes stress. In Japan, the proportion of workers who report serious anxieties or
stress in relation to their working life increased from 53% in 1982 to 63% in
1997. In developing countries, there is increasing concern regarding the health
impact of job stress. For example, an increased risk of work-related illnesses and
accidents has been observed in South-east Asian countries that have experienced
rapid industrialization (23).
In most countries there is no specific legislation addressing the impact of job
stress. Most countries have at least minimum standards for safety and health features of the workplace. These standards tend to focus on the physical aspects of
the workplace and do not explicitly include the psychological and/or mental
health aspects of working conditions. Notable exceptions include the
Netherlands and the Nordic countries (24).
Absenteeism
increase in overall sickness absence, particularly frequent short periods of
absence;
poor health (depression, stress, burnout);
physical conditions (high blood pressure, heart disease, ulcers, sleeping disorders, skin rashes, headache, neck- and backache, low resistance to infections).
Work performance
reduction in productivity and output;
increase in error rates;
increased amount of accidents;
poor decision-making;
deterioration in planning and control of work.
Relationships at work
tension and conflicts between colleagues;
poor relationships with clients;
increase in disciplinary problems.
Workers health is a separate goal in its own right. Addressing mental health
issues in the workplace means incorporating social responsibility in a firms everyday practices and routines.
10
Role in organization
Career development
Decision latitude/control
CONTENT
Task design
Workload/work pace
Quantities and quality
Work schedule
Consensus from literature outlining nine different characteristics of jobs, work environment
and organization which are hazardous.
Source: HSE Contract Research Report No. 61/1993. Cox T. Stress Research and Stress Management: Putting
Theory to Work.
Chapter 4
Mental health:
an imperative concern
4.1 Issues facing employers and managers
Although our knowledge of mental health issues has increased over the past few
decades, employers and enterprises have lagged behind in their understanding
and acceptance of the pervasiveness, treatment and impact of mental health problems on organizational life (29). Most human resource management and public
administration training programmes do not cover adequately the area of mental
health and employment. Recognition of mental illness in the workplace is often
difficult for there is often a psychological component to physical symptoms and
physical ailments may be present in some mental disorders (30). Whatever the
original cause, employers and managers are faced with three main issues as they
attempt to address the mental health needs of their employees:
11
12
Key components
Formation of a Stress Management Group (SMG). The SMG managed the programme. It
was usually led by the human resource director with the full support of the chief executive.
The Listening Group. This was a two-day event for 25-30 people representing all sections
of the organization. The Listening Group was led by the consultants to the programme.
Its aim was to develop a preliminary analysis of the nature and extent of organizational
stress by listening to the views of the staff.
Post -Listening Group action. Following the Listening Group, the SMG worked with consultants to plan the Organizational Stress Workshop on the basis of the findings of the
Listening Group.
The Organizational Stress Workshop. This was a second two-day event for 30-60 people
who had a particular involvement in the findings of the Listening Group. Their role was
to draw up action plans.
The Action Groups. A number of groups were formed, coordinated by the SMG, to see
through the action plans over a period of months or even years.
Outcomes/effectiveness
Sickness absence in the Mental Health Trust
1993-4
1994-5
1995-6
6.17%
5.72%
5.59%
13
1996-7
5.6%
1997-8
4.79%
1997-8
16.8%
14
15
16
Results: After 2 years, 85% of the employees who took the programme have returned to
their jobs and are still in them.
Cost: The programme costs Cdn.$ 2600 (US$ 1700) for 12 weeks.
Charbonneau, C.: Accs Cible S.M.T. Dix ans faire renatre la confiance. November 1998.
17
18
19
Chapter 5
The unemployment rate of this group is around 90% in contrast to that of persons with physical or sensorial disabilities, which is approximately 50%. Again,
expressed differently, only 10% of persons with a serious psychiatric background
who wish to work and are judged capable of working are in fact working. Women
fare less well than men.
It has long been known that severe mental illness often impairs dramatically ones
capacity to work and to earn a living. It can lead to impoverishment, which in
turn may worsen the illness. Thus, all efforts to find employment for these persons are essential since they improve quality of life and reduce both impoverishment and the high service and welfare costs engendered by this group (44).
5.2.1 Deinstitutionalization
Until the early 1950s we had to resort to long-term hospitalization, usually in a
psychiatric hospital, since few very effective treatments were available. The negative side of prolonged hospitalization was that patients not only had the signs and
symptoms of their illness but also had a tendency to lose the social skills which
they possessed that are required in order to live in society (such as the ability to
20
Economically
active
57 000
In employment 12%
Looking for work 4%
Economically
inactive
20 000
398 000
Not actively looking for work 84%
Source: Labour Force Survey, Spring 1998. United Kingdom Educational and Employment
Committee, Opportunities for Disabled People
dress and to feed oneself appropriately, to relate to other persons, to take the bus,
or go to the bank, etc.). This phenomenon, referred to as institutionalization,
became more evident when the first neuroleptic drugs (tranquillizers) were discovered in the 1950s. These had the capacity to control symptoms such as
thought disorder, hallucinations, restlessness and agitation. Their discovery had a
dramatic impact on the life of many long-term psychiatric patients who could
then be discharged much more rapidly and also benefit from other treatments
such as psychotherapy. However, a good number of patients whose active symptoms were well looked after with the first and successive generations of neuroleptic medication were still showing other symptoms such as withdrawal, lack of
motivation, a certain degree of apathy, and the so-called negative symptoms of
major psychiatric illness, most notably schizophrenia. It is only since 1985 that
we have medications available (so-called atypical neuroleptics) that can significantly impact on negative symptoms.
All the above medications are powerful and they must always be carefully prescribed and monitored. Several can cause secondary effects such as thirst, involuntary movements and problems with vision, although this is less frequent with
the newer molecules.
The other categories of illnesses normally included under the term severe mental illness are the major depressions, be they unipolar or bipolar (manic-depressive illness). Tricyclic antidepressants and MAO inhibitors are used for the
former and mood stabilizers (mostly lithium carbonate) for the latter.
21
22
23
24
last few years: this has revived the demand for a great variety of workers in many
spheres of economic activity (56).
Supporters of both viewpoints seem to agree that the organization of work is
becoming more intangible and that regular 8 to 5 jobs may be less common, to
be replaced by flexible schedule, increased part-time work, short-time contracts,
often done in the employees own home
There seems to be agreement that the newer jobs will be in the following sectors:
handling information and knowledge;
information technology;
the health sector;
the leisure economy.
Whenever they have been successful in finding a paid job in the past, persons with a
backgound of serious mental illness tended to work either in the traditional industrial sector or in service areas that did not require high technological capacity.
While it is too early to predict what will happen in the 21st century, it is obvious
that work programmes for these persons will have to take into account the
changes in the nature of work. This will include the need for a better education
and the development of professional skills in keeping with the requirements of
the new jobs.
5.4.1 Context
Shorter periods of hospitalization when needed and appropriate follow-up in the
community prevent people from losing the social skills that are essential to adequate living in the community. The approach is also somewhat less costly to governments. However, we find that, while they are saving millions of dollars by
closing psychiatric beds, at least in most developed countries, few governments
have promulgated policies and developed community resources necessary to
ensure the social integration of these patients. It takes greater political will and
skills to put in place the conditions and programmes that will permit the meaningful return to life and society (including work) of persons with serious mental
illness than it does to close a psychiatric hospital.
In the past, policies and programmes have tended to lump together the requirements of persons with mental retardation and those of persons with serious mental illness. Whereas they can have several needs in common, it has to be realized
that the requirements for both groups are vastly different when it comes to reasonable accommodation.
It is useful to review how to overcome the main obstacles that impact on the ability of persons with serious mental illness to have access to work.
25
26
In the past, and still today, many persons with psychiatric backgrounds have had
to lie to a potential employer about their illness. Some of the most successful programmes are those where a mutual trusting and respectful attitude has been
developed so that issues that may arise are easier to address.
27
28
disability rights movement and to the attention of the public. At the international
level, advocates are combining three themes to attract media coverage: redefining
the bottom line as a universal human rights issue, subjecting residential institutions to worldwide exposure, and building support for community based services
(66). Ultimately, this type of advocacy can ameliorate negative myths and stereotypes and, in turn, can impact and influence work opportunities for individuals
with mental health problems.
Another important way to fight stigma is to inform the community of good
practices and of programmes that work.
29
30
31
32
Professionals and workers in the disability field must remember that employers are
not social agencies and are traditionally reluctant to hire persons with a background of serious mental illness. Employers are concerned that there will be a loss
of productivity and this concern has to be addressed.
33
34
35
36
37
38
substantial time is spent talking with other service providers trying largely to increase
their optimism about the clients chance of finding and keeping work in the hope that
they will be supportive throughout what can be a difficult process for the job-seeker;
an emphasis is placed on the staffs own mental health in the workplace with a very
strong sense of community and mutual support and emphasis on training and further
education for staff.
Source: Exel L. Vocational rehabilitation of people who have a psychiatric disability: the
Australian experience. Proceedings of the Asia and the Pacific Regional Conference
Campaign98 for Asia and Pacific Decade of Disabled Persons 1993-2000, Hong Kong, 2328 August 1998.
5.6 Rights of persons with serious mental health problems with respect
to access to work
While access to paid work for persons with serious mental health problems can be
influenced by a number of contingencies such as low level of development, traditions, culture, and high level of unemployment, we fully share the viewpoint
expressed in the ILO Convention and in many countries legislation that disability, including mental health disabilities, cannot be used as an excuse to refuse
access to employment to someone who wishes to work and is capable of working.
We therefore believe that:
work represents a most important value in society;
work represents for a person a privileged way to exercise a role in society;
persons with serious mental health problems have the right to exercise the
same social roles as other citizens;
work is a right for these persons to the extent that they desire to exercise this right;
services must be developed to answer the work needs of these persons.
39
40
tional skills. There have been insufficient resources available to assist individuals
with psychiatric disabilities in vocational rehabilitation efforts so they may compete and succeed in the job market.
In rural areas, for economic and pragmatic reasons, there are strong pressures to
involve the mentally ill individual in the field. If community leaders have been
sensitized and the individual receives adequate medication and support, this may
lead to quite productive employment.
In Viet Nam, we have seen a few examples of women being involved in cultivating rice after discharge from the psychiatric hospital. This was not systematically
used, but was always more successful when the Peoples Committees representatives were involved in the process (82).
In some countries of Africa (Kenya, Nigeria), there exist so-called psychiatric villages where many former patients live with members of their families. In these
enclaves, which are quite well accepted by the community at large, the former
patients can be reintegrated to a useful role and involved in the production of
goods which are then purchased by the community at large. In Abeokuta,
Nigeria, we have seen former patients making and selling candles for a reasonable
profit from which they derive much of their subsistence.
In large, fast-moving urban areas, with crowded living space and no alternative
accommodations available, the situation is often quite difficult.
Success stories, nevertheless, exist.
Programmes must be culture-relevant and culture-sensitive. While a sharp division often exists between rural and urban settings, the family remains at the core
of provision of services and the main link towards involvement in natural community support.
Currently, in Poland there are occupational therapy workshops and centres for
work activities for people with moderate and severe mental health disorders. The
primary aim of therapy workshops is to promote the social skills necessary for
independent living, including work. There are approximately 300 occupational
therapy workshops in Poland which ensure temporary employment for people
with mental illness who have lost their jobs. They receive a small stipend for their
work. There is one experimental Centre for Work Activities, in which the staff
consists of people with severe mental illness. This centre is supported financially
by the State Fund for Rehabilitation of the Disabled (81).
41
42
Job modifications
Arranging for someone who cannot drive or use public transportation to work at home.
Restructuring a receptionist job by eliminating lunchtime switchboard duty normally
handled by someone in this position.
Exchanging problematic secondary tasks for part of another employees job description.
Schedule modification
Allowing a worker with poor physical stamina to extend his/her schedule to allow for
additional breaks or rest periods during the day.
Allowing a worker to shift his/her schedule by 1? hours twice per month to attend psychotherapy appointments.
In the United States until recently recipients of social security lost cash and medical benefits if they earned US$ 500 per month. This has now been raised to US$ 700 per month in
order to create an incentive for social security recipients to go back to work.
5.8.3 Support
One needs to emphasize once again the necessity of providing continuing support to
both the individual and, most often, to the employer, in order to establish a working relationship based on known expectations, cooperation and partnership.
Trial periods on the job site have been found to be very successful and predictive
of the employers capacity to integrate the job.
43
44
45
46
5.9.3 Costs
There are few complete evaluations of the costs of programmes and services,
including subsidies and parity in mental health insurance, as well as the savings
accrued to governments from not having to pay social benefits to this clientele.
In the United States, the cost of equal health insurance coverage for mental and
physical health services has been one of the most hotly debated issues at national
and state levels. Despite vehement opposition by special interests who claimed
that parity would be too costly for businesses, the Federal Mental Health Parity
Act was passed in 1996, requiring the level of insurance coverage for mental illness to be similar to that for physical illness. Multiple studies show that the cost
impact is minimal and that many employers (those with over 50 employees) are
instigating policies to provide parity for their workers. The introduction of parity
in combination with managed care results in, at worst, very modest cost increases. In fact, lowered costs and lowered health insurance premiums were reported
within the first year of the Mental Health Parity Act2 (92).
A recent Canadian study (93) found that, over a period of 10 years, 240 persons
with serious mental health problems have been able to keep a job, largely owing to
the work reintegration programme. Using conservative figures, these persons
earned $5 million (all figures in Canadian dollars), paid $1.3 million mostly in
income tax, and saved the government an estimated $700,000 in social costs
which they would have received had they been unemployed. The net result is
therefore an increase in collective wealth of the order of $2 million.
A recent survey by the US General Accounting Office found that 14% of employers
in 26 states were not complying with the federal standards. Most of those companies
had lifetime limites on mental health benefits of $100.00 or less but set higher
ceilings for medical and surgical benefits. (Many employers found to violate law
requiring parity for mental health coverage. New York Times, 18 May 2000.)
47
48
5.10
5.10.2 Finding a job on the regular market (the work integration contract)
In order to foster the progressive reintegration of persons in the job market, individual work integration contracts may be used. The employers tend to be small
to medium-sized businesses or community agencies.
The contracts, which vary in duration (many do not have any time limits), all
receive government support in a decreasing proportion. For instance, in Quebec,
Canada, the government will give the employer a grant of up to 85% of the persons salary for the first year and of up to 75% in subsequent years. The grant will
also pay for special needs such as access to worksite, accompaniment, evaluation
of capacities, and medical treatment, in a proportion ranging from 50% to 100%.
In one such programme, (94) 300 of the 3000 persons with work integration contracts have a background of serious mental health problems and the state contributes (after several years) 40% of their salary.
49
50
There are some key differences between social firms and regular businesses:
First of all it is the mission of a social firm to create jobs for people with disabilities
and disadvantaged people. Social firms have a social and a commercial mission.
One of the most important characteristics of a workplace in a social firm is the
empowering atmosphere for their employees with disabilities. While in a regular business people with disabilities might be considered as a disturbing factor,
social firms do actively recruit from this target group and provide the necessary
reasonable accommodations.
The emphasis is on the potential and abilities of the worker rather than on potential
problems and barriers. With this flexible approach work tasks can be arranged and
adjusted to accommodate worker needs. This often results in the job being accomplished as quickly and to as high a standard as in any other workplace (98).
All social firms initially receive support from the state. In the most advanced firms,
a full market analysis and business plan must be developed prior to receiving the
go-ahead.
Several firms, once established, reach 85% self-financing. All firms employ, side-byside, handicapped and non-handicapped workers. All are paid the regular rate for
the sector of employment in which they work.
While the majority of workers are permanent employees, approximately 25% may
use the firm as transitional work while 10-15% receive qualifying training. A
good majority of workers are trained on site and all of them receive ongoing support as necessary.
The firms are involved either in the provision of services (office work, recycling,
restaurant, catering, landscaping, etc.) or in manufacturing (textiles, computer
hardware, furniture, etc.).
Social firms
Approx. 300
Approx. 1,600
Employees
Approx. 6000
Approx. 40,000
Disabled employees
50%
40%
8
72*
8
340
370
200
50%
36%
50-60%
Approx. 2000
Approx. 47,000
40-50%
Spain (Andalusia)
United Kingdom
Austria
(Carinthia & Styria, 1999)
Total
51
52
53
54
A quality provision
This success is due to a number of factors. One clearly relates to the encouragement and
training provided to the trainees. The organizations efforts have obtained regional and
national recognition in the United Kingdom National Training Awards competition in 1997
and 1999. The other has to do with the strong links which have been established with over
300 of the largest employers in Northern Ireland. Indeed, since its earliest days the work of
the organization has been led by businessmen helped by health professionals.
Partnership working
Great importance is attached to maintaining ongoing links with employers and this is promoted
on two levels. One had been secured as the result of the organization being successful in attracting subcontract work based on quality, price and time delivery from a range of companies.
The other is due to the personal links established with human resources departments by the
employment service officers.This has helped to overcome the stigma which is still attached to
mental illness and, more importantly, has ensured that ongoing help is available to both the
employer and the trainee once a job placement has been secured.A range of organizations from
many parts of Europe has studied the methods employed by this NGO.
55
56
Chapter 6
Discussion
The issue of work and mental health has been explored from two different perspectives. The first emphasized mental health problems that may arise in employees who have an employment history. The second addressed the issue of making
employment accessible to persons who never had a job, or have lost it due to serious mental illness.
The magnitude of mental health problems in the general population and in the
working population tends to be highly underestimated. The percentages of the
population that admitted having had any psychiatric disorder during their life
were: Brazil (36.3%), Canada (37.5%), Netherlands (40.9%), USA (48.6%),
Mexico (22.2%) and Turkey (12.2%) (107). It was also found that the highest
prevalence rates occurred amongst the youngest age group with the lowest socioeconomic status. Further, most individuals with mental health problems do not
receive professional help.
With respect to the impact of mental health problems at work, a major study (108)
suggested a prevalence of 18.2% for any mental health problems. Work impairment
is always higher in workers with comorbid psychiatric disorders (more than one
disease at the same time). The average number of psychiatric work days loss was 6
days per month per 100 workers, and the average number of psychiatric work cutback days was 31 days per month per 100 workers.
Loss of productivity is often substantial,
especially since absenteeism caused by
Clinical depression is a major
mental health problems can be proworkplace health issue.
longed, the more so if it is not officially
Employers are beginning to recognize
recognized and adequately addressed as
its implications for productivity and,
part of the health coverage benefits availfortunately, there are effective
able to the employee. There will be
treatments which lead to positive longinstances in which mental health probterm results.
lems appear to be mostly related to difficult working conditions. In other cases,
the illness may appear regardless of the nature of the work environment. Whatever
the etiology, the issues must be addressed adequately.
Employers of all sizes are beginning to recognize that depressive disorders often
constitute their single highest mental health (medical) and disability cost.
Employers experience expensive consequences of depression through absenteeism,
lower productivity, disability, accidents and the inappropriate use of medical services (109). A large percentage of employers understand the relationship between
health and productivity and are improving their management strategies by developing and implementing programmes supportive of work/family/life issues, such
as flexitime, part-time schedules, child care benefits, personal leave, wellness health
programmes, and family counselling. Innovative employers have developed prac-
tices in conjunction with their health and human resource systems for managing
both the direct and indirect cost consequences of mental illness in general and
depressive disorders in particular. To recap briefly, these employers are encouraging early recognition, appropriate and cost-effective care management, accommodations, and timely return to work. This is especially evident with the larger
employer (over 1000 employees) who is more apt to have the resources in terms of
time, staff and capital expenditure. It is important to note, though, that smaller
enterprises (under 50 employees) can partially implement aspects of these programmes without incurring financial costs.
Access to sustained employment for individuals with serious mental health problems is a more difficult issue to address.
Serious mental illness affects approximately 2% of the worlds population. It results
in persons having much difficulty in fulfilling the role which they may have set for
themselves in life. Those individuals no longer live in institutions for long periods
of time; the vast majority are in the community where they often receive inadequate follow-up.
Even though more than 70% of these people would like to work, only 10-12% do
in fact work, all too often in jobs that do not correspond to their liking and capacities. In contrast, the employment rate of other forms of disability is in the vicinity
of 50%.
Most countries have legislation which basically states that disability does not constitute valid grounds to deny someone the right of access to equal opportunities,
including that of competitive employment.
Within the realm of disability, persons with serious mental illness are particularly
vulnerable. We have reviewed how one can overcome obstacles related to ignorance, prejudice and stigma. The concept of rights to equal opportunity fully justifies taking all measures to facilitate access to paid work for those who wish it and
are capable of it. Globalization, privatization and downsizing are not valid excuses
for social and economic exclusion of individuals with mental health problems.
The users themselves now increasingly
utilize empowerment strategies to
demand proactive policies and coordinated action.
57
58
The ongoing creation of social firms (enterprises) testifies to the fact that it is possible to function in an entrepreneurial manner and to be competitive, while at the
same time not sacrificing the social needs of persons with serious mental illness on
the altar of unrestricted profitability. Data now prove that successful employment
programmes not only exist but that they can be very cost-effective.
Given the magnitude of the problem, it is expected that government-supported
initiatives will remain the rule rather than the exception. We have noticed with
approval the active involvement of the EU in support of the development of
model programmes in 11 countries. Many of these programmes now function
in a largely autonomous manner.
Once an employer recognizes that mental health problems are probably the single
most important factor responsible for the disability of employees, it makes sense to
recognize mental health as a legitimate concern of the organization.
We now know that there are effective preventive and promotion programmes as
well as those for treatment and rehabilitation.
The promotion and prevention programmes will attempt to create a climate that
fosters motivation and commitment, reduces obvious stressful agents and promotes harmony among co-workers. The good practices in this monograph illustrate the importance of health education in order to increase awareness of factors
affecting mental health and well-being; screening programmes to detect risk factors or early signs of stress-related illness; and communication, clear work goals
and participation of employees in this process. In addition, occupational health
services and employee assistance programmes are instrumental in implementing
promotion and prevention activities.
Treatment programmes should include the capacity for correct diagnosis, remembering that often mental illness hides behind physical signs and symptoms.
Quick access to and intervention by competent medical and professional staff will
be called for. Integral to quick access and early intervention of appropriate medical
treatment for individuals is reducing the stigma and shame associated with mental
health problems. As discussed, often an individual will not seek treatment or will
delay seeking it because of the stigma associated with mental illness. Furthermore,
there is a need for more easily accessible mental health treatment programmes.
Rehabilitation programmes will emphasize the requirements for a prompt return
to work by focusing on necessary accommodations to the work situation, as well as
required support to the individual. The good rehabilitation practices highlighted
in the monograph encourage high levels of client participation in all aspects of the
rehabilitation process. This also includes the participation of an individuals support system such as family members, a mental health professional, case manager,
vocational counsellor and work supervisor. A successful timely return to work and
the identification of necessary accommodations needs to involve the client as well
as his/her support system.
59
60
Chapter 7
Conclusion
The central themes of this monograph were: to address the importance of work
for people with mental health problems; to discuss the different vocational strategies and programmes for people with a mental health disorder; and to consider
the role of the workplace in promoting good mental health practices for employees. Integral to these themes is the identification of good practices by employers
as well as vocational rehabilitation agencies and professionals.
It is clear that there are many factors involved in addressing the importance of
work for people with mental health problems, as well as identifying effective practices that encourage employment, re-employment and retention. Social support
systems, mental health professionals and employers all have a significant role in
helping individuals define options, make choices, learn to manage potentially disabling conditions, and avoid long-term hospitalization. The ultimate goal is for
individuals to obtain and/or return to gainful, worthwhile activity, such as meaningful work (113).
Access to satisfying work remains one of the most sought-after goals of the adult
population of most countries. Employers, employees and unions are starting to
realize that, for this population, mental health problems are the single most important cause of disability responsible for a global burden of disease larger than that
due to infections, AIDS, cancer and physical accidents. The impact of mental
health problems on absenteeism, productivity and job satisfaction is only starting
to be realized.
Given the importance of work, and due to advances made in the prevention, treatment and rehabilitation of persons with mental health problems, it makes eminent
sense to address all aspects of the mental well-being of employees.
For the same reasons, the disability associated with severe mental health problems
can no longer serve as an excuse to deny those who so wish reasonable access to
competitive employment. It is a precondition to full citizenship.
References
1.
Brundtland GH. Mental health in the 21st century. Bulletin of the World Health Organization,
2000, 78(4):411.
2.
Ibid.
3.
Mental illness: key area handbook. The health of the nation. London, UK Department of Health,
1993:11-24.
4.
STAKES. Introduction to mental health issues in the EU. Helsinki, Finnish Ministry of Social
Affairs and Health, 1999 (www.stakes.fi/mentalhealth).
5.
Strategies, employment, mental illness: strategies to secure and maintain employment for people with
long-term mental illness. United States National Institute on Disability and Rehabilitation
Research (NIDRR), 1993, XV(10).
6.
The cost of mental health problems. The fundamental fact. The Mental Health Foundation, UK,
2000 (www.mentalhealth.org.uk//ffcost.htm).
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8.
Managing the impact of depression in the workplace: an integrated approach. Washington Business
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9.
Lahtinen E, Lehtinen V et al. (eds). Framework for promoting mental health in Europe. STAKES
National Research and Development Centre for Welfare and Health, 1999.
10. Disability, poverty and development. Issues papers. UK Department for International
Development, 2000:4-9.
11. Ibid., p. 7.
12. Ibid., p. 8.
13. Ibid., p. 9.
14. Jenkins R. Mental health at work Why is it so under-researched? Occupational Medicine, 1993,
43:65-67.
15. National Alliance for the Mentally Ill (NAMI). Fact sheet. Facts about mental illness and work.
August 1999 (www.nami.org). (NAMI is a United States non-profit self-help advocacy
organization.)
16. Warr PB. Work, unemployment and mental health. Oxford, Oxford University Press, 1987.
17. Miller D. Work problems caused by mental ill health and their management. In: Jenkins &
Coney, Prevention of mental ill-health at work: a conference. 1992.
18. US National Institute for Occupational Safety & Health (NIOSH). Stress at work. 1998.
19. UK Trades Union Congress (TUC). Stressing the law. 2000.
61
62
63
64
65
66
Publications
To improve the planning and development of services for mental health through:
strengthening the technical capacity of countries to plan and develop services;
supporting demonstration projects for mental health best practices; encouraging
operational research related to service delivery; and developing and disseminating
resources related to service development and delivery.
Nations for Mental Health: An overview of a strategy to improve the mental health of
underserved populations.
WHO/MSA/NAM/97.3. Rev.1
Financial support is provided from the Eli Lilly and Company Foundation, the Johnson and
Johnson European Philanthropy Committee, the Government of Italy, the Government of
Japan, the Government of Norway, the Government of Australia and the Brocher
Foundation.
* These documents have been translated into Russian by the Geneva Initiative on Psychiatry.
Requests for copies in Russian should be directed through Dr Robert Van Voren, General
Secretary, Geneva Initiative on Psychiatry, PO Box 1282, 1200 BG Hilversum, Netherlands.
Tel: 0031-35-6838727. Fax: 0031-35-6833646. E-mail: rvvoren@geneva-initiative.org.
These documents are available from our website:
http://www.who.int/mental_health