Mental Illness in the Workplace

Psychological Disability Management

Henry G. Harder, Shannon Wagner, Josh Rash

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317097327
• Edition: 1
• Topic: Business
• Subtopic: Human Resource Management
• Index: Business

The extent of mental illness concerns in the workforce is becoming increasingly apparent. Stress, depression, anxiety, workplace bullying and other issues are costing businesses billions every year in lost productivity, poor treatments and employee retention. Unless appropriately addressed, issues related to mental illness difficulties will result in stiff financial, organizational, and human costs for organizations.

Drawing on empirical evidence from North America, the United Kingdom, Australia and New Zealand, the book provides a practical guide to identifying, understanding, treating and preventing individual and organizational mental health issues. The authors illustrate how organizations can save money and improve the health and wellbeing of their employees by using a psychological disability management approach in the treatment and accommodation of mental illness issues.

This book will meet the needs of human resources professionals, administrators of employee assistance programs, industrial and organizational psychologists, mental health practitioners, those teaching or studying psychology and disability management, and more generally will serve to enlighten students of business management and practicing managers regarding a major workforce risk factor.

Chapter 1
Introduction

Mental health needs a great deal of attention. It’s the final taboo and it needs to be faced and dealt with.

Adam Ant

On an international scale, treatment of individuals with mental health issues has been a source of historical embarrassment. In decades and centuries past, individuals with mental illness have been segregated, stigmatized, and shunned. Sufferers of mental illness have been exposed to experimental treatments, institutionalized, and in the most horrific of situations have endured physical, mental, and/or sexual abuse. Despite more recent efforts to improve treatment, inclusion, and opportunity for those with mental illness, societies still struggle to adequately and respectfully meet the needs of persons with mental illness. Mental illness also continues to be a source of significant fear and stigma. As a consequence, individuals with mental illness are under-represented in important facets of society such as work and recreation. Further, it is clear that societies have a long way to go in changing perceptions so that individuals with mental illness are viewed as valued members who can contribute fully given appropriate treatment and accommodation.

This textbook specifically addresses the topic of workplace issues for individuals with mental illness. Times are changing. Treatments for mental health concerns have improved drastically over recent decades, as has the understanding that individuals with mental illness can be meaningful, contributing members of occupational environments. Access to more effective treatments along with suitable accommodation strategies have increased the number of individuals with mental illness available to engage in the workforce, providing employers with a new, traditionally undervalued contingent of workers. Improvements in treatment have also allowed workers who may have previously been required to leave the workplace as a result of poor mental health to maintain their working situation. This has, in turn, improved employee retention, and reduced employee turnover and the loss of expertise held by employees with mental health concerns.

Legislative requirements surrounding issues of mental illness in the workplace have also changed. Specifically, many countries around the world are making, or have made, steps to increase legal protections for individuals with mental illness. New legislative environments ensure that employers are responsible to avoid harassment and discrimination related to mental health. Further, requirements to accommodate for mental illness are also common. However, such protections are not without complications. More and more, employers are becoming versed in their responsibilities to employees with respect to avoidance of discrimination and the need for accommodation. They have also continued to increase knowledge and competency regarding the requirement for and the know-how surrounding accommodation for physical disabilities. On the other hand, in the experience of the authors, it seems that employers find mental illness less well defined. They report feeling unsure about issues of assessment, intervention, and accommodation in the area of mental health. Consequently, this text is intended to provide a global review of mental health in the workplace, while, at the same time, providing some practical advice to employers about how to approach the more daunting areas of workplace mental health.

Employer familiarity with mental illness and related approaches in the workplace is integral to a healthy workplace for many reasons. First, individuals with mental illnesses have been, and continue to be, under-represented in the workplace. Similar to individuals with other types of disabilities, individuals with mental illness represent a contingent of working capital whose value has been traditionally underestimated. Second, disability costs related to issues of mental health are known to be among the highest of all types of disabilities, and they are continuing to increase at an alarming rate. In order to be competitive locally, nationally, and internationally, employers will have to acquire knowledge and skills related to the management of issues surrounding mental illness. Third, competency for management of mental health in the workplace will assist employers in maintaining compliance with legislative requirements and avoiding potential litigation related to inappropriate management. Fourth, increased knowledge and skills for employers will lead to better accommodation and treatment of individuals with mental illness in the workplace. Such improvements will lead to better inclusion, access, and accommodation for working persons with mental health issues. Finally, individuals with mental illness will experience the benefits that often result from participation in meaningful work. Increases in self-competency, self-esteem, and social/occupational functioning for individuals with mental health should never be overlooked as a justification for ensuring workplaces are adequately prepared to assist and accommodate where necessary.

This text gives employers and others interested in learning about mental health in the workplace a single source intended to provide both knowledge as well as recommendations regarding how to approach assessment, intervention, and accommodation. The authors came together as researchers and practitioners in mental health and disability to write a text that could use available peer-reviewed research to supplement a practical guide to mental health in the workplace. With this in mind, we started our text with an overview of the reasons why issues related to mental illness in the workplace can no longer be ignored, as well as an overview of the prevalence, costs, and potential future growth of mental illness in the workplace. Next, we provide four chapters outlining common mental illnesses reported in workplace environments and present a business case for the effective management of these disorders. Specifically, our chapters discuss research and workplace aspects of depression, anxiety, occupational stress, and post-traumatic stress disorder. Finally, in our last set of chapters we pull the specific reviews back into the general and discuss workplace issues and recommendations for action. Important and timely issues discussed include toxic workplaces, worksite reactions, psychological assessment, healthier workplaces, and accommodation for mental health in the workplace. Taken together, the chapters provide a review of mental health in the workplace, and give the reader “hands-on” recommendations for appropriately addressing workplace mental illness. We hope we have achieved our goal and that you find the text both informative and useful.

Chapter 2
The Scope of Mental Illness

To confess ignorance is often wiser than to beat around the bush with a hypothetical diagnosis.

William Osler

Introduction

DEFINITION OF MENTAL DISORDER

The term mental disorder is often used to refer to a disorder of the mind. This, unfortunately, implies that there is a distinction between “mental” disorders such as depression and “physical” disorders such as cardiovascular disease. In reality, this is an artificial dichotomy as the mind and body are inseparable and there is often as much physical anguish in mental disorders as there is metal anguish in physical disorders. Perhaps more appropriately, the term mental disorder is used to refer to a condition that defies typical biomedical explanations (that is, a condition in which the pathophysiological mechanisms are largely unknown). That is, mental disorders often lack the same etiological understanding as do physical disorders. For example, bacteria or viruses cause typical “flu-like” symptoms and are often treated with antibiotics or a flu-shot whereas the causes of depression are still unclear.

In order to propose a pragmatic definition of mental disorder let us first consider the intended purpose of this definition. At the highest level, a definition of mental disorder should help distinguish normal distress from disorder, aid communication between professionals, and inform clinical practice. Five models have been recommended to accomplish this task. The statistical model equates disorder with statistical rarity (Lilienfeld and Landfield, 2008). By this convention, disorders are abnormal because they are infrequent in the general population. Yet, a statistical model provides no guidance as to where to set limits or boundaries on what constitutes disordered behavior. Further, some disorders are relatively rare while others are more prolific throughout society.

The Subjective Distress Model maintains that psychological pain is the core feature distinguishing disordered from non-disordered. According to this model, psychological pain underlies mental disorder analogous to the way that physical pain underlies most physical disorders. Yet, there are disorders that are not accompanied by self-distress. For example, anorexia nervosa is not accompanied by feelings of distress and is considered ego-syntonic, meaning that it is consistent with the individual’s self concept. The subjective distress model cannot account for disorders that are not accompanied by distress.

The Biological Model (Kendell, 1975) stipulates that disorders are characterized by biological or evolutionary disadvantage. This disadvantage may include premature mortality or reduced fitness (for example, a decreased likelihood of reproducing). The biological model fails to account for disorders that do not result in premature mortality or reduced fitness (for example, specific phobias), and is over-inclusive (for example, smoking increases the risk of mortality but is not a disorder).

The Need for Treatment model contends that disorders are a heterogeneous class of conditions that all share one common feature—the need for treatment (Taylor, 1971). Many mental disorders such as schizophrenia, bipolar disorder, and depression are viewed by society as needing treatment. The need for treatment model fails to explain life events that require treatment but are not considered mental disorders, such as pregnancy.

The harmful dysfunction model (Wakefield, 1992) contends that mental disorders are harmful dysfunctions (that is, socially devalued breakdowns of evolutionary systems). For example, panic disorder would be considered a disorder because it is devalued by society and the inflicted individual, and results in activation of the sympathetic nervous system in the absence of a typical evolutionary cue. Yet, the environment is constantly changing and some disorders may be considered adaptive reactions within their environment.

Each of the reviewed models provides useful indicators for mental disorder, but different situations may call for different definitions for defining disordered (Stein, Phillips, Bolton, et al., 2010). For the purposes of this book we will adopt the definition of mental disorder given by the American Psychiatric Association (APA) and refined by the Diagnostic and Statistical Manual (5th Edition) task force: refer to Table 2.1 (APA, 2004; First and Wakefield, 2010; Stein, Phillips, Bolton, et al., 2010). According to this definition, a mental disorder is a behavioral or psychological syndrome that manifests in behavioral, psychological, or biological dysfunction, and results in clinically significant distress or disability, or risk thereof. Further, mental disorders extend beyond reactions to normal circumstances and cannot be explained by adjustment to stressors or loss, culturally sanctioned behavior, or conflicts with society.

Table 2.1 Suggested definition of mental disorder adapted from First and Wakefield, 2010 and Stein et al. 2010

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A. A behavioral or psychological syndrome or pattern that occurs in an individual

B. That is a manifestation of a behavioral, psychological or biological dysfunction in the individual

C. The consequences of which are clinically significant distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning), or substantial increased risk of future distress or disability. Increased risk of distress or disability is not in itself a disorder unless due to a dysfunction.

D. The syndrome or pattern must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one), or a culturally sanctioned behavior or belief (for example, trance states in religious rituals)

E. Neither deviant behavior (e.g. political, religious or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual.

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CLASSIFICATION SYSTEMS

Mental disorders are latent constructs that are diagnosed based upon the clustering of typical signs and symptoms within a person. This diagnosis is generally performed in a dichotomous fashion meaning that an individual is either assigned a disorder or not based upon the abundance and clustering of specified symptoms. For example, a major depressive episode is classified based upon the experience of any five of nine typical symptoms in a two-week period so long as one symptom is depressed mood or loss of interest. This method of classification, while effective, can lead to significant heterogeneity in expression and can result in over 70 different combinations of symptoms that meet the criteria for depression.

Two global classification systems have undertaken the task of providing a common language and standardized diagnostic criteria for classifying mental disorders. These are the International Classification of Diseases and Related Health Problem (10th revision; ICD-10) developed by the World Health Organization (WHO, 2011), and the Diagnostic and Statistic Manual (4th Edition; DSM-IV; APA, 2000). In 2013 the DSM-V was introduced amidst substantial controversy. As most readers will have familiarity with earlier versions of the DSM we have presented information as per the DSM-IV as well as the DSM-V. The DSM and ICD classification systems converge with each successive iteration, moving towards a global standard in the diagnosis of mental disorders.

The DSM and the ICD incorporate aspects from many of the previously discussed models for identifying mental disorders. For example, the DSM-IV utilizes a multiaxial coding system designed to assess several domains of information that may help clinicians plan treatment and predict outcome. There are five such axes included in the DSM-IV:

Axis I:	Clinical Syndromes
Axis II:	Developmental Disorders and Personality Disorders
-	Developmental disorders include autism and mental retardation; disorders which are typically first evident in childhood.
Axis III:	Physical Conditions
-	Physical conditions are those such as brain injury or HIV/AIDS which can result in symptoms of mental illness.
Axis IV:	Severity of Psychosocial Stressors
-	Events in a person’s life, such as the death of a loved one, starting a new job, college, unemployment/underemployment, and even marriage can impact the disorders above in Axis I and II.
Axis V:	Highest Level of Functioning
-	A clinician rates a person’s level of functioning both at the present time and the highest level in the previous year.
-	This helps the clinician to understand how the above four Axes are affecting the person and what changes should be expected.

These axes allowed for a clear-cut system of understanding when it comes to mental illness and how they can be categorized by clinical professionals. What is important to note is the difference between each of the axes which highlight the broad range of mental illness and contributing factors across the dimensions.

The DSM V contains important changes to the diagnostic procedures and the reader is referred to the American Psychiatric Association’s online resources such as http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf that clearly identify these changes. In summary, the first three axes have been combined and the fifth has been eliminated in favor of other more specific assessment tools. However, the general diagnostic criteria remain essentially the same.

LIMITATIONS OF CLASSIFICATION SYSTEMS IN OCCUPATIONAL SETTINGS

The use of explicit diagnostic systems in the workplace poses some problems. First, the DSM and ICD contain many nuances that necessitate specialized knowledge and training. Such knowledge and training is costly both in terms of time and financial resources. It takes more than familiarity with a diagnostic system to properly diagnose mental disorders. Similar to medical training, proper diagnosis of mental disorders often takes years of training, and specialty practicum placements. There is no substitute for clinical experience when it comes to proficiency in diagnosis of mental disorders. It would likely be more cost-effective for an employer to “hire-out” the job of assessment to a trained and certified mental health professional.

The second challenge with assessing mental health conditions in the workplace is the typical length of an assessment interview. Structured clinical interviews represent the “gold standard” for diagnosing mental disorders. These are highly structured interviews that contain question algorithms designed to assess nearly every mental disorder in a comprehensive manner. Each classification system has its own structured interview. The Structured Clinical Interview for DSM-IV disorders (SCID) was developed to assess DSM-IV-base...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• List of Figures
• List of Tables
• About the Authors
• Chapter 1 Introduction
• Chapter 2 The Scope of Mental Illness
• Chapter 3 Current Thinking about Mental Illness in the Workplace
• Chapter 4 Depression in the Workplace
• Chapter 5 Anxiety in the Workplace
• Chapter 6 Occupational Stress
• Chapter 7 Post-traumatic Stress in the Workplace
• Chapter 8 Toxic Work Environment
• Chapter 9 Worksite Reactions and Interactions with Mental Health
• Chapter 10 Psychological Assessment for the Workplace
• Chapter 11 How to Create a Healthy Workplace
• Chapter 12 Legislation and Accommodation for Mental Health in the Workplace
• Chapter 13 Why Positivity Matters
• Conclusions
• Appendix A Return on Investment (ROI) Equation Parameters for Depression
• Appendix B Return on Investment (ROI) Equation Parameters for Generalized Anxiety Disorder (GAD)
• Appendix C Return on Investment (ROI) Parameters for Companies Addressing Workplace Bullying
• Index