Mental health training for managers? A case of caveat emptor
8 Aug 2019
Stephen Bevan, Head of HR Research Development
Sally Wilson, Senior Research Fellow
Compared with only a decade ago, the ease with which most modern workplaces now embrace serious and empathetic conversations about mental health is a cause for celebration. This is not to declare the struggle against ignorance and stigma to be over, by any means, and there is so much more to do. However, the work of campaigners, third sector bodies, prominent individuals and - dare we say it – the steadfast work of certain research organisations which have sought to build a solid evidence base, have all contributed to mental health at work edging its way towards being a mainstream topic for business.
One of the things we have all learned during this time is that mental illness among working age adults is a complicated topic. The range of mental health challenges which confront people and the causes of their illness are varied and multifactorial. Also, the way mental illness affects people and their ability to sustain work throughout their lifecycle varies considerably between individuals. A big lesson over the last decade is that this complexity and variability means that there are no simple or binary solutions – interventions at work to support people living with mental illness must be personalised and flexible, and no single intervention can ever work for everyone.
Moreover, at IES our research has shown that rather too many of the interventions to support employee wellbeing have a weak or even non-existent evidence base. This means that we are in danger of mental health stigma at work reducing at a faster rate than our ability to harness proven interventions to support it.
Despite this, there is a welcome momentum behind the idea of raising awareness of mental illness at work, reducing stigma and raising the confidence of managers and others to offer support and signposting to expert help. But even this ‘space’ in the mental health at work terrain is contested. Some voices, including our own, are becoming increasingly concerned that – in the understandable rush to find solutions - too many eggs may be being put into the Mental Health First Aid (MHFA) ‘basket’ to the exclusion of other approaches and modes of delivery which do just as good a job and which might have more flexibility in meeting the needs of some managers in a range of working environments.
One sign of this is the attempt earlier this year to get UK Health and Safety legislation changed to make MHFA a requirement in all workplaces in an attempt to give mental health ‘parity of esteem’ with physical health. Our view at the time, and it remains our view, was that this move had laudable motives but was seriously misguided because it presumed that MHFA was the only intervention with any merit.
While investing in MHFA interventions looks like a simple, decisive and visible way of taking the mental health issue seriously – and the government’s £15 million investment to get up to 1 million people trained in basic MHFA skills is one prominent example – it too suffers from a worryingly weak evidence base. We concluded this after conducting a review of the evidence on line manager training on mental health in a study we conducted for the Rail Safety and Standards Board (RSSB). This found that MHFA performs no better than many of the alternative approaches and our conclusions are confirmed by several others who have also scrutinised the results achieved by MHFA.
For example, launching a research report on the effectiveness of MHFA, Professor Alison Drummond of Nottingham University said ‘we became interested in this topic as we were aware of the amount of publicity and resources being put into Mental Health First Aid training despite very little research to support it’.
The Health and Safety Executive (HSE), concluding a review of MHFA and its impact, remarked that ‘there is consistent evidence that MHFA training raises employees’ awareness of mental ill health conditions. There is no evidence that the introduction of MHFA training in workplaces has resulted in sustained actions in those trained, or that it has improved the wider management of mental ill-health’.
In a column for the British Medical Journal (BMJ) GP Margaret McCartney said, perhaps more controversially, ‘what about side effects? If we encourage people to seek professional help, could this lead to over-diagnosis and the medicalisation of human distress? And might such medicalisation inappropriately and harmfully trump sensible and kind human care? Hunt says that we can avoid this by teaching “resilience and self-help” as a first step. I think that we’re in an evidence-free zone. The risk is that huge sums may be spent with great flourish but with little benefit to the people who are affected most.’
Hugh Robertson of the TUC has also expressed concern about MHFA and the way it is implemented by employers. He remarked that ‘any employer who thinks they can deal with mental health concerns just by introducing MHFA, offered to a few handpicked ‘Mental Health Champions’, is very much mistaken. MHFA is not going to change the workforce on its own and should be seen as one of a range of initiatives that employers need to introduce’.
Mr Robertson correctly points out in the same article that there is good evidence from several studies that MHFA training ‘increases participants' knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward individuals with mental health problems.’ But these positive outcomes are focused on the immediate, post-training responses of participants with very little or no data on the sustainability of these positive feelings or of their medium-term impact on workplace health, attendance or productivity.
This criticism is tacitly acknowledged by MHFA itself. In their recently published ‘Impact Report’ they highlight both their ‘reach’ and their impact but wisely make no claims about the longer-term impact of MHFA training on the psychosocial work environments where their training has been implemented. IES agrees that line managers are an important link in the chain if we want to improve mental health at work and we have championed this cause in webinars, events and articles.
However, our research and our practical experience suggests that education, awareness-raising and stigma-reducing interventions are a necessary but not sufficient condition of success in this domain. For example, we and others are concerned that MHFA places too little emphasis on preventative measures such as risk assessment and job design. Similarly, interventions raising mental health awareness among managers and others need to have clear supervisory support and even clinical governance protocols in place if those being trained are not to be exposed to an elevated risk of psychological distress. We are not expecting line managers to be clinical psychologists, but ‘empowering’ them through awareness training places an obligation on employers to protect and support them.
With the government consulting on a number of proposals to improve employer action on workplace wellbeing, especially in SMEs, there have already been calls for HM Treasury to offer employers tax breaks on a range of workplace health interventions. The John Lewis Partnership-led Working Well Coalition is the most recent of the voices calling for such concessions and, as with those making such calls before them, will need to supported by arguments to counter concerns about ‘deadweight’ (ie offering tax breaks – effectively a subsidy - to those employers already investing in workplace health). We also think there is a duty on the government to resist calls for tax incentives on interventions which, despite an appealing ‘face validity’, cannot demonstrate a sufficiently strong evidence-base to support their widespread use – especially if this risks the ‘crowding out’ of other interventions for which a more compelling evidence-base exists.
MHFA is one of many useful tools available to promote greater awareness of mental illness at work. Other interventions vary in the way they are delivered (eg online, individual rather than group-based) and in the focus of the intervention (eg prevention, looking at psychosocial risk, matching job demands to the resources of the individual, creative job design tools). Later this year we will publish the findings of a randomised control trial for the RSSB which compares impacts of different modalities of line manager mental health training. This includes ‘first responder’ training as one element as well as proactive approaches to risk management, ‘soft skills’ for conducting effective one-to-one meetings and workplace adjustments for employees requiring support. We will report on medium-term changes in line manager behaviour as well as the organisational facilitators and barriers that can arise when applying new knowledge on this topic.
MHFA has an important part to play, but only a part. Our concern is that, as its profile and the resources directed towards it grow, the evidence to support MHFA remains weak. At the same time there is a risk that investment in other upstream and downstream practices which may suit the needs of some organisations better is lower because too many mistakenly think that a MHFA programme will meet all of their needs.
It is important that policy makers and employers maintain an open mind about the interventions that work best in this area, as we endeavour to do as researchers. We are watching relevant debates in the education and health sectors with interest, in recognition that different professions have specific needs and there are unlikely to be preventative or reactive measures that work for all employees at risk, everywhere.
Any views expressed are those of the authors and not necessarily those of the Institute as a whole.