Businesses Materials for a Mental Health-Friendly Workplace: Workplaces That Thrive: A Resource for Creating Mental Health-Friendly Work Environments
ABOUT THIS RESOURCE
This publication is designed to help look at the benefits of a Mental Health-Friendly Workplace. The benefits accrue to both the bottom line of a business and to the health and well-being of the workforce business's most valuable asset on the balance sheet and in ethical and human terms.
This resource is useful for taking stock of the current level of mental health friendliness and for inspiring new thinking and planning for the future.
Section I is a brief introduction to the status of mental health in the U.S. workplace, including the challenge of overcoming stigma and discrimination toward persons with mental illnesses.
Section II describes the elements of a Mental Health-Friendly Workplace and helps make a preliminary assessment of the current situation in a workplace.
Section III describes, in alphabetical order, a range of policies and practices that are employed in businesses across the country, as well as in many other parts of the industrialized world.
Section IV presents portraits of three thriving Mental Health-Friendly Workplaces across the United States one small business, one medium-sized, and one large each of which illustrates how mental health-friendly policies and practices look and work in real life settings.
Section V provides ready-to-use resources for communicating with employees about mental health in the workplace.
Section VI provides materials for basic supervisory training in some mental health essentials for working with employees who experience mental illnesses.
ACKNOWLEDGMENTS
This document was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by Vanguard Communications, Inc. and the Gallup Organization, under contract number 280-99-0200, with SAMHSA, U.S. Department of Health and Human Services (DHHS). Paolo del Vecchio served as the Government Project Officer. Crystal Blyler, Ph.D., Carole Schauer, Cara Hansen, and Jennifer Bofinger provided subject matter expertise and review.
PUBLIC DOMAIN NOTICE
All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, DHHS.
ELECTRONIC ACCESS AND COPIES OF PUBLICATION
This publication may be accessed electronically through the following Internet World Wide Web connection: www.allmentalhealth.samhsa.gov.
RECOMMENDED CITATION
Substance Abuse and Mental Health Services Administration. Workplaces That Thrive: A Resource for Creating Mental Health-Friendly Work Environments. SAMHSA Pub. No. P040478M. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2004.
ORIGINATING OFFICE
Associate Director of Consumer Affairs, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857
SAMHSA Publication No. P040478M 2004
MFT Continuing Education http://www.aspirace.com--------------------------------------------------------------------------------
CONTENTS
•I. A Mental Health-Friendly Workplace
◦Mental Illnesses Are Common
◦Recovery From Mental Illnesses
◦Social Stigma and Discrimination Toward People With Mental Illness
•II. Elements of a Mental Health-Friendly Workplace
◦Some Indicators
◦The Mental Health-Friendly Workplace Circle
◦Working: Wellness
◦Working: Distress
◦Away: Sick Leave or Disability
◦Return to Work
•III. Policies and Practices for the Mental Health-Friendly Workplace
◦Americans with Disabilities Act (ADA)
◦Confidentiality Safeguards
◦Disability Management
◦Employee Assistance Programs (EAPs)
◦Family and Medical Leave Act
◦Health Insurance (Mental Health Benefit)
◦Health and Wellness Programs
◦Mental Health Employer Consortium
◦Mental Health-Friendly Practices on a Limited Budget
◦Peer Mentor or Buddy System
◦Peer Support
◦Reasonable Accomodations
◦Supervisor Training
◦Supported Employment
•IV. Portraits of Mental Health-Friendly Workplaces
◦Coffee By Design
◦Highsmith, Inc.
◦Quad/Graphics
•V. Resources for Communicating About Mental Health in the Workplace
◦Opportunities for Internal Communication With Employees
◦Communication Tools That Accompany This Resource
•VI. Training Materials: Supervision in the Mental Health-Friendly Workplace
◦About the Training Materials
◦Preparation Steps for Training Delivery
◦Module I: A Mental Health-Friendly Workplace
◦Module II: Supervision in the Mental Health-Friendly Workplace
•APPENDIX
◦A: Sources Used in Developing This Publication
◦B: Resources for Developing Mental Health-Friendly Workplaces
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Section I: A Mental Health-Friendly Workplace: A Place Where People and Business Thrive
Mental Illnesses Are Common
Mental health problems are health conditions involving changes in thinking, mood, or behavior. Mental health and mental illness can be pictured as two points on a continuum with a range of conditions in between. When these conditions are more serious, they are referred to as mental illnesses and include depression, anxiety disorders, childhood and adult attention-deficit/hyperactivity disorder, and other diagnosable illnesses that most often benefit from treatment and support.
These conditions can affect anyone, regardless of age, culture, race, gender, ethnicity, economic status, or location. Mental illnesses are surprisingly common, they affect almost every family in America.
The good news is that effective treatments are available and people recover from mental illnesses. How does recovery happen? A lot of people with mental illnesses work with therapists, counselors, peers, psychologists, psychiatrists, nurses, and social workers, often in combination with some of the most advanced medicines ever developed. They also use self-help strategies and community supports.
It is estimated that about one-third of those with mental illnesses are employed.1 There's a very good chance that you, and every employee in your business, know someone who has a mental illness.
According to one study, nearly a quarter of the U.S. workforce (28 million workers ages 18-54) experience a mental or substance abuse disorder.2 This study found that the most prevalent illnesses in the workplace are alcohol abuse/dependence (9 percent of workers); major depression (8 percent); and social anxiety disorder (7 percent). Further, 71 percent of workers with mental illnesses have never sought help from a medical or mental health specialist for their symptoms.
The National Institute of Mental Health has this to say about the effects of just one of these illnesses depression in the workplace:
This year, more than 19 million American adults (9.5 percent of the population) will suffer from this often misunderstood disorder. It is not a passing mood. It is not a personal weakness. It is a major— but treatable —illness. No job category or professional level is immune, and even a formerly outstanding employee can be affected.
The good news is that, in more than 80 percent of cases, treatment is effective. It enables people with depression to return to satisfactory, functioning lives. And nearly everyone gets some degree of relief. Treatment includes medication, short-term talk therapy, or a combination of both.
Untreated depression is costly. A RAND Corporation study found that patients with depressive symptoms spend more days in bed than those with diabetes, arthritis, back problems, lung problems, or gastrointestinal disorders. Estimates of the total cost of depression to the Nation in 1990 range from $30 to $44 billion. Of the $44 billion figure, depression accounts for close to $12 billion in lost workdays each year. Additionally, more than $11 billion in other costs accrue from decreased productivity due to symptoms that sap energy, affect work habits, and cause problems with concentration, memory, and decisionmaking. And costs escalate still further if a worker's untreated depression contributes to alcoholism or drug abuse.
Still more business costs result when an employee or colleague has a family member suffering from depression. The depression of a spouse or child can disrupt working hours, lead to days absent from work, affect concentration and morale, and decrease productivity.3
Recovery From Mental Illnesses
Recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms. Science has shown that having hope plays an integral role in an individual's recovery.
Unfortunately, many people with serious mental illnesses do not seek or receive treatment; in 2002 fewer than half of adults with serious mental illnesses received treatment for their mental health problem. The common reasons people do not seek treatment include cost, fear, not knowing where to go for services, and concern about confidentiality and the opinions of neighbors, employers, and community. This fear of what people may think the stigma that surrounds mental illnesses is a serious barrier to treatment and recovery. Fortunately everyone can do something to reduce stigma.
Many people who do not understand mental illness think that there is something shameful about this type of problem. This stigma that surrounds mental illnesses can stop people from getting an education, a home, and a job. In fact, many people do not seek treatment because they fear stigma and discrimination.
Social Stigma and Discrimination Toward People With Mental Illnesses
In spite of increased awareness and openness about mental illnesses, the social stigma and discrimination of mental illnesses remains a significant barrier to well-being and a full life for people who experience these illnesses. Stigma and discrimination often hold applicants back from applying for or being offered employment, despite their qualifications for the job. Stigma and discrimination may deter an employee from seeking help, and he or she may continue to try to work in a state of distress (or be absent from work). If an employee has been away from work during treatment for a mental illness, stigma and discrimination may cause discomfort or even pain for the returning employee, as well as a sea of mixed reactions from supervisors and coworkers who may lack understanding or a comfort level with what to do and say.
Endnotes
1 Kaye, H.S. (2002). Employment and Social Participation Among People with Mental Health Disabilities. San Francisco: CA: National Disability Statistics and Policy Forum.
2 Herz, Rob P., Ph.D., and Christine L. Baker, The Impact of Mental Disorders on Work, Pfizer Facts series, June 2002. This report is an analysis of the National Comorbidity Survey data, 1990-1992, Institute for Social Research, University of Michigan, funded by the National Institute of Mental Health and the National Institute of Drug Abuse, and the W.T. Grant Foundation.
3 National Institute of Mental Health. (Updated June 1999). The Effects of Depression in the Workplace. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.
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Section II: Elements of a Mental Health-Friendly Workplace
There is no single right picture of a Mental Health-Friendly Workplace. Factors that have a bearing on what will work best for any given business include:
•The leadership, goals, and values of the business;
•The culture of the business sector;
•The culture of the community in which the business operates;
•The size of the business; and
•The resources that can be brought to bear from service vendors, the community, and the employees themselves.
Whether your business is looking at its mental health friendliness for the first time or taking stock of how well current programs and practices are working, it is important to come back to these questions:
•What elements of a Mental Health-Friendly Workplace are already in place?
•How are they working?
•What are the long- and short-term goals?
•What are the next priorities and next steps?
•How will the worth or value of taking these steps be assessed?
The remainder of this section paints the Mental Health-Friendly Workplace portrait in broad strokes. Subsequent sections provide greater detail.
Some Indicators
Specific practices and policies in a workplace that values the health of its employees can be observed, including, of course, practices and policies that promote their mental health and well-being. These practices can positively affect productivity, cost-containment of health care, and employee retention in fact, the entire culture of the business. Some observable indicators found in Mental Health-Friendly Workplaces are described on the following pages. Some businesses will recognize many of the indicators as descriptors of their own organizations; others will read them as a list of desirable options or components for building a Mental Health-Friendly Workplace. Any business that thinks of itself as being mental health-friendly will have a number of these elements in place. Think of your own organization as you scan the list.
The Mental Health-Friendly Workplace
•Welcomes all qualified job applicants; diversity is valued;
•Includes health care that treats mental illnesses with the same urgency as physical illnesses;
•Has programs and/or practices that promote and support employee health-wellness and/or work-life balance;
•Provides training for managers and front-line supervisors in mental health workplace issues, including identification of performance problems that may indicate worker distress and possible need for referral and evaluation;
•Safeguards the confidentiality of employee health information;
•Provides an Employee Assistance Program (EAP) or other appropriate referral resources to assist managers and employees;
•Supports employees who seek treatment or who require hospitalization and disability leave, including planning for return to work;
•Ensures exit with dignity as a priority, should it become essential for an employee to leave his or her employment; and
•Provides all-employee communication regarding equal opportunity employment, the reasonable accommodations policy of the Americans with Disabilities Act, health and wellness programs, and similar topics that promote an accepting, anti-stigmatizing, anti-discriminating climate in the workplace.
The Mental Health-Friendly Workplace Circle
The circle on the following page portrays the potential elements of a Mental Health-Friendly Workplace across the life of an individual's employment in a given organization. It shows what an employee (at the heart of the circle) can expect from a Mental Health-Friendly Workplace from the time of recruitment through times of working in health or, perhaps, in times of distress or disability and return to work.
The programs and practices enumerated in each segment of the circle support both the employee and his or her manager or supervisor. The lists of elements in each segment of the circle are suggestive, not exhaustive. It is unlikely that any single workplace will contain all of these elements.
If you are a human resources professional, a person playing a similar role, or a manager, this circle is meant to help you look at your organization (1) through the eyes of an employee and his or her work life in your organization, and/or (2) through the eyes of a supervisor who has an even closer daily connection with employees in times of health and in times of distress. This view of work life may suggest opportunities to strengthen communication, guidance, and support for supervisors and employees as well as stimulate thinking about how well your mental health-friendly practices are meeting the needs of employees in all phases of their work life. The text, which follows the circle, briefly describes each segment of the diagram. Policies or practices noted in the descriptions in italic type are discussed in greater detail in Section III.
The Mental Health-Friendly Workplace Circle
Recruitment/Orientation
The activities carried out during this segment of work life bring the job applicant or new employee in contact with many of the policies, practices, and procedures of the business. Regardless of how well-qualified the applicant is for the job, the person who has experienced a mental illness is likely to be quite reticent to self-disclose and risk the stigma and discrimination associated with mental illnesses. There are ways a business shows its mental health friendliness up front:
•When a prospective employee learns that the benefits package treats mental health as a part of overall health, it sends a clear indication that the workplace is likely to be a welcoming environment.
•As most employers know, the Americans with Disabilities Act (ADA) makes it unlawful to discriminate against a qualified applicant or employee with a disability.
•Hiring managers and/or supervisors need to be oriented to mental disability as a dimension of equal employment opportunity and diversity in the workplace. They also should become familiar with the provisions of the ADA to respond appropriately to questions a job applicant may raise regarding reasonable accommodations or supported employment.
•Programs such as peer mentoring or buddy systems to help new employees adapt to the workplace culture also say, This is a mental health-friendly environment.
Working: Wellness
This segment of the circle represents the state in which every employer and employee wants time to be spent. Many employers have instituted health and wellness programs, which can provide work-life balance activities and lifestyle change incentives to strengthen employee resilience and business loyalty. Some companies are documenting the simultaneous benefits to the organization in terms of health cost containment, employee retention, and attendance. These may sound like programs that only large Fortune 500 companies can undertake; however, many health promotion strategies can be undertaken on a limited budget. (See Mental Health-Friendly Practices on a Limited Budget, Section III.)
Strong supervisor-employee and employee-employee working relationships are critical to maintain wellness. Workplace-sponsored professional growth opportunities, such as skill development in conflict resolution, effective interpersonal communication, team-building, and/or the application of strength-based supervision techniques, are examples in this area. Supervisor training in mental health-related supervision is another important part of fostering a mental health-friendly atmosphere.
Internal employee communication e-mail, newsletters, bulletin boards, and face-to-face meetings are all useful tools to encourage healthy lifestyles among the workforce. Annual health fairs and the observance of events such as National Mental Health Awareness Month (May) are opportunities for communication. They also present occasions to bring community resources into the workplace from such organizations as State and local affiliates of the National Mental Health Association (NMHA) or the National Alliance for the Mentally Ill (NAMI). These organizations can provide education and awareness-raising presentations, or even special services such as confidential online depression screening for employees. (See Section V for more on the topic of employee communication.)
Working: Distress
Most employees experience a day now and then when they would describe themselves as being distressed unhappy client, unhappy boss, too much work, too little time. The resilience-building techniques learned in the business's health and wellness program may help offset the negativity and the employee may soon feel more in equilibrium.
However, there are more extended, more serious times and signs of distress or illness. Supervisors need to know how to respond to signs of employee distress in a timely way. Often no action is taken. Reasons can include the supervisors:4
•Fear of the consequences;
•Lack of confidence in his/her own assessment;
•Concern about interfering;
•Hope that the problem will go away on its own; or
•Personal history, which echoes a similar situation in his/her own life past or present that produces inaction.
Failure to respond sets a destructive dynamic in motion:
•Relationships between the employee and supervisor become strained;
•Coworkers feel confused and assume a sense of responsibility for the employee;
•In an effort to help, different people take over first smaller, then larger, tasks of the affected employee;
•Coworkers try to offer advice to the affected employee, whose response is not usually receptive or positive;
•Coworkers begin to feel angry;
•Morale deteriorates;
•The problem that is the affected employee becomes the primary focus of workgroup attention;
•Everyone's ability to function is affected;
•Coworkers try to distance themselves from the affected employee; and/or
•Feelings of resentment, hopelessness, and emotional exhaustion develop in the workplace.
Frequently supervisors try to intervene near the end of the cycle by firing the affected employee. The better approach for everyone in the workplace is to intervene early.
Many businesses, especially large corporations, retain the services of employee assistance professionals whether in-house, through a vendor, or through other arrangements. These professionals provide a consultation resource to managers and supervisors (e.g., to help them learn to pick up on workplace behaviors that may indicate there is a problem or to help them develop workable solutions to prevent termination and encourage productivity). They also are a direct resource for employees for their own self-referral for diagnosis, intervention, treatment, and other appropriate care.
Reasonable accommodations can be most critical in times of distress and can help maintain employee wellness. For example, flexibility in scheduling and leave policies can help employees maintain their mental health by allowing them time to attend mental health appointments or to manage stress.
A small business that feels it cannot afford employee assistance services still can provide training for supervisors on recognizing and being aware of the options available to cope with employee distress:
•Through the business's health insurance plan, an arrangement might be worked out for referrals to a mental health provider for intervention;
•Many companies also are promoting employee access to online mental health information resources such as national health (including mental health) information clearinghouses, screenings for depression and other common illnesses, and referral information; and/or
•Where no health insurance is available, employers should become knowledgeable about mental and behavioral health resources in the community and make that information available to all employees.
Away: Sick Leave or Disability
This segment of the Mental Health-Friendly Workplace circle is the least frequently visited, by both employer and employee. An employee may require only a few days away to re-establish equilibrium and then return to his or her job. For some, a longer respite may be required.
From a supervisor's standpoint, knowing how best to remain in touch with and supportive of an employee during this time period is very important. Likewise, from the employee's standpoint, being able to stay in touch in the mode preferred by the employee may be the link that keeps hope alive during a difficult season. If the employee is open to it, communication with coworkers can be therapeutic as well. Maintaining confidentiality safeguards is very important during this time period.
Case studies and reports of employees whose mental illnesses forced them to be away from work for a time underscore the importance to the employee of the continued support and compassion of a supervisor. The degree of involvement during that time period is, of course, primarily at the discretion of the person who is away ill.
One of the most encouraging and hopeful activities that a supervisor and employee can undertake during the recuperation period is planning for the return to the job. Employer flexibility is key. For example, it may be best that the employee start back on a reduced schedule. While the transition usually is most successful if the employee is returning to his or her old job, there may be aspects of the job that could be reshaped to meet both employee and workplace needs. An employee assistance professional or health care provider can be very helpful in suggesting ways to make the planning process work well, and indeed they may be able to participate with the employee and the supervisor in this planning activity. If an appropriate peer support match is available from the workplace, this planning/transition period is a favorable time to introduce the possibility. Ideally, a conversation or meeting between the two employees would take place prior to the return to work.
Return to Work
As pointed out in the previous segment, the ongoing work of maintaining communication and planning for return to work is very important to a smooth return. The supervisor should be well versed in the returning employee's wishes regarding what information is shared with coworkers. Depending upon the specific circumstances, there may be necessary adjustments or reasonable accommodations upon return. The stronger the supervisor-employee relationship, the easier the adjustment will be. If the business has a coworker peer support program, this component can augment the supervisor's role in easing the readjustment to the work environment.
Another important contingency deserves forethought and planning. Sensitivity to mental health issues and attention to supervisor training regarding workplace problem-solving and reasonable accommodations generally preclude the need for termination. In the rare event these efforts fail, and an employee's departure becomes necessary, the business (top management, human resources or other personnel administrator, supervisor, and coworkers) should ensure that the employee's exit is carried out with respect and care for his or her human and professional dignity. Exit with dignity policies and practices are equally important for the departure of any employee. Thoughtful, respectful gestures include deference to the employee's wishes about what is said to coworkers or clients, whether or not future contact would be welcomed by the departing employee, and whether or not a farewell event would be comfortable.
Endnotes
4 Handrich, Rita R., Ph.D., Responding Effectively to Mental Illness in the Workplace. Presentation at Can Health Services Research Influence Public Policy and Private Actions?, a conference jointly sponsored by the Association for Health Services Research and the National Alliance for the Mentally Ill and supported by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, the National Institute for Mental Health, Eli Lilly and Company, and Merck & Co., Inc., December 8-9, 1999.
5 The Mental Health-Friendly Workplace Circle was inspired by Chart 1: An holistic approach to managing an individual, in Line Managers' Resource: A Practical Guide to Managing and Supporting Mental Health in the Workplace, London, UK: mindOUT for mental health campaign, Department of Health, p. 8.
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Section III: Policies and Practices for the Mental Health-Friendly Workplace
This section amplifies some of the policies and practices noted in the Workplace Circle in Section II. The descriptions are intended to show a range of practice variations and point toward resources for more information or technical assistance. Items are arranged in alphabetical order for easy reference.
Americans with Disabilities Act (ADA)
Title I of the Americans with Disabilities Act of 1990, which took effect July 26, 1992, prohibits private employers, State and local government, employment agencies, and labor unions from discriminating against qualified individuals with disabilities in job application procedures, hiring, firing, advancement, compensation, job training, and other terms, conditions, and privileges of employment. An individual with a disability is a person who:
•Has a physical or mental impairment that substantially limits one or more of his/her major life activities;
•Has a record of such an impairment; or
•Is regarded as having such an impairment.
With the passage of the ADA, employment of qualified individuals with disabilities became a civil right, enforceable by legal action. A qualified employee or applicant with a disability is an individual who, with or without reasonable accommodation, can perform the essential functions of the job in question. Any person has the potential need to be accommodated, on a temporary or permanent basis, which makes it a persuasive option as well as the right thing to do.
Reasonable accommodations are . . .modifications to the job application process, the work environment, or job that will enable the qualified individual with a disability to perform the essential functions and enjoy equal benefits and privileges of employment. Employers do not need to provide accommodations if they can demonstrate that doing so would result in an undue hardship.6 See Reasonable Accommodations for examples. (See also Disability Management.)
The U.S. Equal Employment Opportunity Commission (EEOC) has responsibility for enforcing several different discrimination laws, including Title I of the ADA. The provisions of the ADA apply to all employers with 15 or more employees. The Web site www.eeoc.gov provides very practical, plain-English facts and guidance for employers about compliance with the ADA.
Confidentiality Safeguards
Protection of an employee's right to privacy is a key policy element of any Mental Health-Friendly Workplace. Two major factors guide that policy: the protections ensured by the Health Insurance Portability and Accountability Act (HIPAA) and similar State legislation, as well as the specific wishes of the employee about how much information to share with his/her supervisor and coworkers.
State and Federal laws require a specific level of confidentiality for health information issues. In general, these laws stipulate that information regarding treatment even the fact that one is receiving treatment can only be released with the patient's (employee's) written permission.
To receive the protections of the Americans with Disabilities Act as reasonable accommodations, the employee must be willing to disclose to the employer that he or she has a disability. The congruence between the formal statements of the business and the informal climate of the workplace with regard to its mental health friendliness plays a significant role in an employee's willingness to self-disclose to request a reasonable accommodation. Interviews with employees who have self-disclosed reinforce the importance of flexible workplace practices, and supervisor and coworker support.
An employee assistance professional can be a consultant/resource for helping to create workplace policy and for training supervisors on Federal and local confidentiality requirements.
Disability Management
Disability management is the process of working effectively with employees who become disabled. Disability management includes the use of services, people, and materials to 1) minimize the impact and cost of disability to the employer and the employee; and 2) encourage return to work of an employee with disabilities.7
Although the term disability management may not be in general use in the workplace, in practice, all businesses are managing employee disability to greater and lesser degrees of effectiveness.
This resource is designed to help move business practice toward more effective use of services, people, and materials to prevent or minimize the impact and cost of disability to the employer and the employee. The Mental Health-Friendly Workplace Circle in Section II depicts the major elements of employee work life that must be managed and supported by mental health-friendly policies and practices if all employees including those with disabilities are to thrive. The return to work of an employee with disabilities is also envisioned in the Mental Health-Friendly Workplace circle (see the Recruitment/Orientation, Away, and Return to Work segments).
Traditional disability management is thought of as rehabilitation for people with physical disabilities, and that is primarily the domain of vocational rehabilitation practitioners. The inclusion of mental or invisible disabilities in the provisions of the Americans with Disabilities Act has called for some new thinking about disability management.
One approach to disability management in the United States is to reduce the costs of disability insurance through activities designed to prevent disabilities from occurring and/or to minimize their impact on workers and employers. In this aproach activities include: safety (prevention) programs, employee health and assistance programs, and return-to-work programs.8
Another approach to disability managment centers on collaboration among employers. See Mental Health Employer Consortium, which describes the Maine Medical Center approach to disability management a community-wide approach to managing the return-to-work aspects of disability management.
Employee Assistance Programs (EAP) 9
EAPs are resources provided by an employer either as part of or separate from employer-sponsored health plans. EAPs typically provide preventive care measures, various health care screenings, and/or wellness activities.
EAPs have been around for several decades. Initially they were occupational alcoholism programs, but they soon evolved to include drug abuse and mental health. Now a broad range of work-life service options are available:
•Information and referral services for mental and behavioral health services;
•Individual in-person and telephone counseling;
•Grief, marital, or family counseling;
•Financial or job-related problem counseling;
•Training for supervisors in identification and referral for work-related behaviors that may be indicative of a mental or behavioral health problem;
•Assistance for supervisors in techniques of problem-solving and providing reasonable accommodations to head off problems and prevent termination; and
•Consultation with corporate executives on EAP needs and program design.
It is estimated that more than 70 percent of the largest employers have EAPs. Smaller employers may arrange for some of the same functions and services (e.g., information and referral) through a managed care or other health care provider agreement.
Employee assistance programs in large corporations often are operated onsite as part of an employer-sponsored health plan. Some corporations with their own onsite health facilities still retain the services of an offsite employee assistance professional to work with the corporate human resource personnel and top executives to develop appropriate health and wellness strategies to meet corporate goals.
In addition to providing services to employees, EAPs can provide valuable training and consultation for supervisors to help them be aware of and pick up on the workplace behavior cues that may indicate an employee is experiencing distress. Most important, EAPs can help supervisors problem-solve with the employee and to arrange reasonable accommodations to head off problems, prevent termination, and increase workplace productivity. Consultation with the EAP on how to support and plan for the return of an employee who is away from work due to mental illness is also an invaluable resource.
Communication with employees about the EAP and other related benefits should be clear and frequent. EAP or community resource phone numbers, or Web site URLs should be posted on the company Intranet, in its newsletter, and on bulletin boards. Brochures should be kept in break rooms and other areas frequented by employees.
Family and Medical Leave Act of 1993 (FMLA) 10
The FMLA, administered by the U.S. Department of Labor, applies to most employers of more than 50 employees. A covered employer must grant an eligible employee up to a total of 12 work weeks of unpaid leave (for covered conditions) during any 12-month period. Among the reasons eligible employees are entitled to leave are the instances in which an employee is unable to work because of a serious health condition. Serious health condition is defined as an illness, injury, impairment, or physical or mental condition. For details of the FMLA, frequently asked questions, employer coverage and employee eligibility criteria, and other provisions of the law, go to www.dol.gov/esa.
Health Insurance (Mental Health Benefit)
Investment in a mental health benefit is an employer action that speaks louder than words about the mental health friendliness of the business. Ideally the insurance investment will include appropriate coverage for treatment, prevention, and educational programs. It should be confirmed that the treatment and services provided are indeed available through an adequate network of providers. Employees need to be well-informed of the specifics with regard to their mental health coverage when choosing among health insurance options. Different States have different policies and/or laws with regard to mental health parity; therefore, it is very important that human resource managers adequately describe the differences in mental health care coverage if various health insurance plan options are offered.
Among the onsite programs that can be provided by health insurers are the following:
•Onsite screening and preventive health care programs, coupled with incentives for participation, including stress management and depression screenings;
•Educational seminars on mental health topics;
•Supervisor education on detecting mental illnesses in the workplace; and
•Rapid response teams for crisis intervention.
A health insurer's toll-free information access line should be well publicized to supervisors and employees. Persons who are experiencing distress or simply want to learn more about symptoms of specific mental illnesses should have the phone number and Web site URL for reaching this resource close at hand.
(See also Employee Assistance Programs and Health and Wellness Programs.)
Health and Wellness Programs
These programs focus on maintaining a state of health and well-being through health promotion. Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior, and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change.11
Many wellness programs are started in an attempt to hold down skyrocketing health care costs (see the Highsmith Inc. business portrait in Section IV) or to reduce or ameliorate the effects of stress in the workplace. In recent years, many employee assistance programs have incorporated work-life balance and other wellness dimensions.
See Appendix B for resources that can help in creating wellness programs.
Mental Health Employer Consortium 12
An employer consortium is formed in a community for one or more of the following purposes:
•To educate employers in the community about mental illnesses and their effect on employment;
•To develop strategies and supports among employers to use when persons with known mental illnesses require some form of assistance to preserve their job;
•To increase the ability of the member employers to support a diverse workforce in general;
•To help employers determine what workforce accommodations are appropriate for persons with mental illnesses;
•To increase the number of people hired who are known to have mental illnesses; and/or
•To provide a forum in which employers can seek and attain support from one another to address issues and concerns that may arise.
A local employer, such as a hospital or university, may decide that it is willing to sponsor a consortium. This organization brings special psychiatric and vocational expertise. The sponsor may seek seed money from a local foundation or a community betterment fund within its own organization. The sponsoring organization identifies local employers to approach.
Employers who have participated in the development of a consortium report that the process of joining, as well as hiring people with known psychiatric disabilities, changed them as individuals and changed their companies. Changes included:13
•Reduced fear and stigma;
•Increased comfort with and trust of persons with mental illnesses;
•More willingness to work toward positive solutions;
•More knowledge about how to handle problems;
•More detailed understanding of accommodations; and
•Better management of people with mental health issues who were not identified in the past.
The Maine Medical Center, with support from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, documented and published a record of the experience of developing a Consortium. The 83-page booklet, Business Partnership, Employment Outcomes: The Mental Health Employer Consortium, is available from the Maine Medical Center, Department of Vocational Services, 22 Bramhall Street, Portland, ME 04102; Telephone: (207) 871-2088.
Mental Health-Friendly Practices on a Limited Budget
Even with limited resources, smaller companies can create Mental Health-Friendly Workplaces in which employees with mental illnesses are valued and the workplace climate is accepting and supportive of good health, including mental health. To begin, here are a few examples that every business can have:
•Formal and informal policies about workplace conduct and how coworkers treat each other;
•Speakers on mental health topics from local mental health organizations;
•Resilience-building activities that protect against the effects of workplace stress, perhaps led by an employee with special expertise or interest, such as yoga, tai chi, or lunchtime fitness walks (employees training employees) or workshops on problem-solving, effective communication, and conflict resolution;
•Training in what every supervisor needs to know to help create and support a mental health-friendly environment (initial resources for training provided in this resource);
•Brochures from local community mental health organizations about how to access services; and
•Mental Health Awareness Month or other visible mental health-friendly events/activities and education/information materials (see Section V of this resource).
The Coffee By Design business portrait in Section IV vividly illustrates the old adage: where there's a will there's a way. Even small business can find resources in the community that can help provide education, information, treatment, and supervisory training. FREE mental health education materials and information about services are readily available from highly reliable sources such as the Substance Abuse and Mental Health Services Administration and the National Institutes of Health, both of the U.S. Department of Health and Human Services via their Web sites. (See Appendix B, Resources for Building Mental Health-Friendly Workplaces.) Within your State, county, or city public agencies and mental health organizations can provide services and information. These can even be accessed through some of the national Web sites listed in Appendix B.
Peer Mentor or Buddy System
This is an idea that is equally useful for all employees entering a new corporate environment. It is especially beneficial for someone who is entering the workplace with fears of being stigmatized or avoided by other employees. Peer mentors or buddies are a personal adjunct to the business's more formal orientation activities.
The goal of this kind of mentoring or buddy system is to help the new employee become fully integrated into the work group and the culture of the workplace as quickly and comfortably as possible. Peer mentors or buddies could be a group of employees who volunteer to serve in that capacity, or they could be appointed to the role as an acknowledgment of their good interpersonal skills and corporate citizenship abilities.
Mentors or buddies need to be oriented to the business's desired outcomes for the activity and to the essential aspects they should cover, such as organizational values, informal policies, and norms for how people work and communicate with each other. Mentors need to be good listeners, as well. As they get to know the new employee, they can facilitate introductions to individuals and activities that are likely to be enjoyable. (See also Peer Support.)
Peer Support
This is a variation on the peer mentor or buddy concept. Here, the peer connection is to another person or group of persons (sometimes called self-help groups) who also have experienced mental illnesses. Identifying peers for this purpose requires all persons involved to be willing to self-disclose. The idea is that the returning employee's transition is much smoother and more comfortable when an understanding buddy (or group of coworkers) is willing to share the journey and support another's return to full employment. Peer support groups also can be found outside the workplace. Employee assistance programs may keep lists of local peer support groups. Local chapters of national advocacy organizations such as the National Mental Health Association (NMHA), the National Alliance for the Mentally Ill (NAMI), and others listed in Appendix B, are a resource for finding information about local self-help groups (peer support groups). In addition, the health section of local newspapers often lists local support groups for persons with different mental illnesses. (See also Peer Mentor or Buddy System.)
Reasonable Accommodations
The need for reasonable accommodations for a person with a mental illness usually is requested by the employee in discussion between employer and employee. EEOC regulations (pertaining to the Americans with Disabilities Act) specify that the employer should take into account, but is not obligated to abide by, the employee's preference within the range of effective accommodations. The employer is not required to provide accommodations that would pose an undue hardship on the operation of the business. Similarly, workers cannot be forced to accept accommodations that are neither requested nor needed. From time to time, laws and court decisions change policies and requirements. It may be important to check for updates at www.eeoc.gov.
One study of employers who have made reasonable accommodations for employees indicated that employers had not made these accommodations to comply with the law. Rather they cited other reasons specifically:
•It made good business (i.e., financial) sense;
•Such modifications are made for any employee who needs them;
•They had come to value the worker over time (e.g., for his/her skills or reliability); and
•They had empathy for the worker's needs and considered the accommodation fair or humane.14
Examples of reasonable accommodations for persons with mental disorders, as required by the Americans with Disabilities Act, could include:
•Schedule modification
◦Allowing workers to shift schedules earlier or later
◦Allowing workers to use paid or unpaid leave for appointments related to their mental disability
◦Allowing an employee to work part-time temporarily (e.g., when first returning from an absence)
•Job modification
◦Arranging for job sharing
◦Reassigning tasks among workers
◦Reassigning the employee to a vacant position
•Modifications to the physical environment
◦Providing an enclosed office
◦Providing partitions, room dividers, or otherwise enhancing soundproofing and visual barriers between workspaces
•Changes in policy
◦Extending additional paid or unpaid leave during a hospitalization
◦Allowing an employee to make phone calls during the day to personal or professional supports
◦Providing a private space in which to make such phone calls
◦Allowing workers to consume fluids at their work stations throughout the work day (e.g., if needed due to medication side effects)
•Provision of human assistance
◦Allowing a job coach to come to the work site
◦Participating in meetings with the worker and his/her job coach or other employment service provider
•Provisions of assistive technology
◦Providing a portable computer to enable an employee to work at home or at unusual hours
◦Providing software that allows the worker to structure time and receive prompts throughout the work day
•Supervisory techniques
◦Offering additional supervisory sessions
◦Offering additional training or instruction on new procedures or information
Supervisor Training
It is reported that many supervisors (as well as other employees) are not well informed about mental illnesses, skilled in managing employees with mental illnesses, or well versed about the requirements or protections of the Americans with Disabilities Act (ADA).15
To invest in other mental health-friendly policies and practices, and to overlook the training of supervisors would be short-sighted, indeed. It is understood that supervisor time for such activity is costly for an organization, and therefore limited. Employee assistance programs often provide supervisor training as a part of their service, and they usually are available for supervisor consultation on how to handle difficult situations.
Some introductory supervisor training materials are provided as a part of this resource (see Section VI). They provide a starting point to engage supervisors in the creation of a more accepting, stigma- and discrimination-free, Mental Health-Friendly Workplace.
Supported Employment (SE)
Supported employment is a service provided for persons with severe mental illnesses and their employers. SE programs help persons with severe mental illnesses find and keep jobs.
A review of effective SE services identified six critical goals for SE:16
•Pay is at least minimum wage but, preferably, at the prevailing wage rate;
•People with and without disabilities work together in an integrated setting;
•Support is ongoing and provided as needed;
•Services are individualized;
•Job selection is based on a person's preferences and skills; and
•Competitive employment is the goal.
SE program services vary across the country. The job coach is one popular model: A prospective employee is assigned a job coach to assist with finding a job and to provide vocational support either on or off the job site. Most support is provided in the community rather than in a mental health or other treatment center. The job coach may work with the employee, employer, and others (e.g., coworkers or family members) to promote a successful work experience.
Employers should be aware that employees with severe mental illnesses may receive Federal or State benefits such as Medicaid or Medicare or Social Security Disability Insurance benefits. While these benefits may supplement those provided through employer-sponsored benefit programs, they also may complicate decisionmaking for employees who are striving to protect access to these important benefits. Receipt of such benefits, for example, often limits how much an employee can earn before being removed from the benefit rolls. Such work limitations may lead employees to engage in counterintuitive behaviors, such as as refusing promotions, increases in work hours, or pay raises.
Employers must recognize that these behaviors do not indicate a lack of interest in or dedication to the job. Employees in such circumstances may need assistance to help determine how their public benefits will be affected by their work situation. The Social Security Administration supports benefit planning assistance and outreach centers that can be of great use to such employees (see www.ssa.gov/work or www.jan.wvu.edu/). Supported employment programs are also well versed in such issues.
SE programs are funded by a number of Federal and State government agencies, including State offices of vocational rehabilitation (VR) and State mental health authorities. Medicaid rehabilitation funding is available for some aspects of SE in some States. The Social Security Administration's Ticket to Work and Work Incentives Improvement Act of 1999 established a new initiative to provide greater access and choice for employment services in the community (see www.ssa.gov/work).
Endnotes
6 Work as a Priority: A Resource for Employing People Who Have Serious Mental Illnesses and Who Are Homeless(Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2002), p. 71.
7 Gabriel, Phyllis and Marjo-Riita Liimatainen, glossary to Mental Health in the Workplace (Geneva: International Labour Office, 2000).
8 O'Reilly, Arthur, The Right to Decent Work of Persons With Disabilities: IFP/Skills Working Paper No. 14 (Geneva: International Labour Office, 2003), p. 69.
9 The acronym EAP is also used to refer to an employee assistance professional and/or an employee assistance plan. In this document, unless explicitly noted otherwise, it is used to mean employee assistance program.
10 Information on the Family and Medical Leave Act of 1993 was taken from Fact Sheet #28: The Family and Medical Leave Act of 1993, U.S. Department of Labor, www.dol.gov/esa(April 22, 2004). 11O Donnell, Michael P., American Journal of Health Promotion, 3, no. 3 (1989): 5.
12 Information on employer consortiums is drawn from Richard Balser, Helaine Hornby, Karen Fraser, and Christine McKenzie, Business Partnerships, Employment Outcomes: The Mental Health Employer Consortium(Portland, ME: Maine Medical Center, 2001).
13 ibid., p. 51.
14 Mancuso, Laura L., M.S., C.R.C. Case Studies on Reasonable Accommodations for Workers With Psychiatric Disabilities. In Case Studies on Reasonable Accommodations for Workers With Disabilities(study funded by the Community Support Program, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, June 1993). Available online at www.mentalhealth.samhsa.gov/publications/allpubs/CS00-0008/default.asp.
15 For example, in qualitative research conducted by Greenberg Quinlan Rosner, June-July 2002, and in focus groups of business community managers conducted by The Gallup Organization, April 2003.
16 Supported Employment for Persons With Psychiatric Disabilities: A Review of Effective Services, developed by the National Mental Health Association as part of the Targeted Technical Assistance project of the National Association of State Mental Health Program Directors (NASMHPD) and the Division of State and Community Systems Development (Mental Health Block Grant) of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services (no date), p. 3. Available at www.mentalhealth.samhsa.gov (search site by document title).
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Section IV: Profiles/Portraits of Mental Health-Friendly Workplaces
The following vignettes illustrate successful Mental Health-Friendly Workplaces. These businesses have implemented policies and procedures that benefit not only the morale and well-being of employees, but also their own bottom line. The first profile is of Coffee By Design, a small business employing 34 people. Next is Highsmith, Inc., a mid-sized firm with about 200 employees. The final profile is of a large corporation, Quad/Graphics, a 12,000-employee organization. These Mental Health-Friendly Workplaces are forward-thinking in their approaches to their employees health and well-being which is key to their overall success.
Coffee By Design
Portland, Maine
Coffee By Design (CBD) is a 10-year-old, locally owned and operated coffee chain and wholesaler in Portland, ME. Husband and wife owners, Alan Spear and Mary Allen Lindemann, co-own the business. They describe their corporate interest as focusing on long-term relationships with the people with whom we work both employee and vendor as well as with those we serve. We hope to create an environment that is pleasant, professional, and rewarding for our customers and 34 employees.
CBD also has a long-term commitment to the local community and has been an active participant in the revitalization of downtown Portland. In addition, CBD strives to protect the environment, recycling and using recycled products whenever possible and working with vendors and suppliers who share their commitment to the environment and a better world. Not only is CBD committed to the Portland arts and business community, but to the State of Maine as well. Lindemann is the current president of Maine Businesses for Social Responsibility.
Inspiration
Shortly after opening the coffee shop a decade ago, Lindemann was inspired by a television report describing a European village that took responsibility for the mental health needs of its residents. At the same time, she said she had read about Maine's transition from a centralized residential/institutionbased mental health system to a community-based one. These experiences led to a simple, yet profound epiphany for Lindemann: One person at a time, we can make a difference.
CBD's emphasis on and commitment to mental health emerged when Maine made that transition. Under the new, community-based, mental health system, many people who had been institutionalized for serious mental illnesses were encouraged to re-enter society. The public simply did not understand this change overnight and, as Lindemann explained, we had to work at it.
Support in Times of Distress: Employee Story
While CBD was working to become more mental healthfriendly through its customer service, a staff member began showing symptoms of a mental health problem. This young woman was an exemplary employee whose behavior suddenly changed. We realized internally that we were all faced with mental illness and, instead of her, it could be any one of us. Earlier, the employee had called a number of her coworkers and asked them to meet her to talk. In retrospect, they felt that, had they known then what they learned later about signs and symptoms, they would have recognized that this coworker was reaching out.
Distress
On the day the young woman experienced a change in behavior suggesting she needed immediate assistance, Lindemann personally took her to a psychologist. Eventually, the young woman was admitted to a residential facility, but not without her family's consent. Lindemann said, Calling her parents was the hardest thing to do. I had to tell them this situation was so bad that I was afraid this woman might hurt herself. Later, they learned that the woman had recently experienced a traumatic end to a relationship.
Away
Once the employee was admitted to a residential facility, CBD began a campaign to make her feel welcome to return to work when she was ready. Lindemann visited the employee regularly, as did many of her coworkers. When the woman returned home to her parents in Connecticut, they wrote letters and e-mails as often as possible. CBD, unwilling to deliver a second blow to a family in crisis, continued the employee's insurance at their own cost until she was stabilized and could transfer to COBRA. The stability of our coverage was far more important than the cost, said Lindemann.
During this time, the entire corporate team began asking, What can we do now to help and support our coworker? In response, CBD took the entire staff to speak with a psychologist who was a regular customer. At her office, staff members discussed their feelings and learned about the signs of mental illnesses. The lessons learned from this event were, It happens here. Mental illnesses are all around us and it could be any one of us.
Shortly thereafter, other staff members began disclosing their own battles with mental illnesses, including depression and bipolar disorder, and CBD immediately mobilized efforts to address the question of how to make CBD a comfortable workplace for someone with a mental illness. Lindemann began making phone calls to a number of organizations and businesses already addressing these issues, and quickly learned tips from them. For example, she was told the stress of an 8-hour shift may be hard for someone experiencing bipolar disorder. To learn more, Lindemann contacted one of CBD's wholesale clients Manic Designs a coffee house born out of a for-profit mental health organization that is run entirely by people with mental illnesses. Lindemann spoke directly with several of their employees to get tips and testimonials about what works best in the workplace when you have a mental health problem.
Return to Work
After a year-and-a-half of recovery, the woman returned to CBD. Her first day on the job was moving for both employer and fellow employees. Her employer was deeply impressed by the progress she'd made and by her courage to return to work. At the same time, many employees who knew her previously were still upset about what had happened. Rather than make an issue of the reintegration process, Lindemann and the returning employee had informal discussions with the other employees about it. The employee chose not to disclose an exact diagnosis, but did not hide her struggle with mental illness. CBD emphasized that, in its workplace, disclosure of a diagnosis is unnecessary, but honesty is of the utmost importance. Her willingness to disclose helped her fellow employees accept what had happened and work together to support her through her transition. Once other workers began self-disclosing, very quickly they were reassured by coworkers that they were not crazy, and that these illnesses would not keep them from leading a regular life.
Lindemann said of the experience, We learned that, as a business and as human beings, we need to be aware and listen when someone calls to talk or get together. They may be in need of mental health assistance, and if we're all talking honestly about it, we can help that person get the help that he or she needs.
Employee Empowerment
As the transition from institutional care to community-based care took place in Maine's mental health system, a lot of social workers and their clients were attracted to CBD, which served as a meeting place for them. CBD employees began to notice some of their customers were struggling with mental illnesses. You can usually sense that a person is in distress. They are more easily agitated than usual, Lindemann said.
Because persons with mental illnesses frequented the coffee shops, the CBD team requested employee training about mental illnesses. A representative of the State's Department of Behavioral Health Services came in on more than one occasion to train employees on how to work with customers who have mental illnesses. These trainings empowered the employees by providing them with information and insights on how to treat customers with sensitivity and respect.
Promoting Mental Health
CBD took advantage of its relationship with the Department of Behavioral Health Services to showcase its mental health resources and brochures during Maine's Mental Health Month. They handed out a large volume of materials, and afterwards, Lindemann was inundated with messages from community members who expressed great support for the accessibility of these resources.
Benefits
The State of Maine requires that mental health insurance be part of overall health insurance policies. On principle, CBD has always worked to acquire a generous benefits package, complete with maternity and mental health coverage. Recently, short-term disability was added.
Results
In 1994, Mary Allen Lindemann and Alan Spear established CBD as a coffee roaster. They now operate three coffee houses in Portland and a wholesale coffee roasting business that has achieved 40 percent annual earnings growth.
In 2002, CBD won an award from the Disability Rights Center for work on behalf of people with mental illnesses based on a word-of-mouth nomination.
In 2003, Aetna, Inc. named Coffee By Design its northeast region winner of the Small Business of the Year award. Factors in the award included:
•Exemplary community involvement;
•A unique start-up story;
•Overcoming significant business obstacles; and
•Outstanding earnings growth and profitability.
In announcing this award, James Reid, Aetna spokesperson, said, Coffee By Design is a great example of how small business owners can achieve profitable growth and become leaders in local communities like Portland.
A Mental Health-Friendly Workplace is inseparable from our bottom line, said Lindemann. CBD is thriving, even in the face of fierce competition from mega corporations like Starbucks and Dunkin' Donuts.
Highsmith, Inc.
Fort Atkinson, Wisconsin
Highsmith, Inc., based in rural Fort Atkinson, WI, is a distributor of supplies, furniture, and equipment to public, academic, and special libraries, including schools and school libraries throughout the United States and abroad. Founded in 1956, Highsmith employs more than 200 people and markets 25,000 products through more than a dozen specialty catalogs and direct sales. A staggering increase in health care premiums caused the corporation to reexamine its culture and to institute programs now credited with holding premiums at a steady level, increasing productivity, and maintaining very low turnover. Highsmith has a reputation as an innovator in organizational design, employee development, health risk management, and wellness programming. It is a two-time recipient of the Wellness Council of America's Gold Well Workplace Award and the inaugural recipient of its Platinum Well Workplace Award. Highsmith also has been featured on the NBC Nightly News With Tom Brokaw, and in The New York Times, Business & Health magazine, and MSN.com.
Inspiration
In 1989, Highsmith experienced a 53 percent increase in overall health care costs. Executives began developing initiatives to manage their health care costs rather than let health care manage them. Highsmith made three key decisions: (1) to transition its workforce to a managed care environment; (2) to use money as a motivator to encourage healthier practices; and (3) to develop a wellness program that addressed both physical and mental well-being.
Striving for more than a typical corporate wellness program, Highsmith focused on the development of human potential, on support of healthy lifestyle choices, and on wellness. For example, monetary incentives are tied to health insurance premiums. Under the incentive plan, employees who meet eligibility requirements (not using any tobacco products, participating in the annual health screening, and completing annual physical exams) pay only 25 percent of the health insurance premium. Those who do not meet the eligibility requirements are covered under the base plan, in which Highsmith pays 60 percent of the premium and the employee pays 40 percent.
As time passed, Highsmith stayed current with best practices in health care, adjusted for changing employee demographics, stayed abreast with research, and continued to develop its model. Highsmith was influenced strongly by a 1998 breakthrough study performed by the Health Enhancement Research Organization (HERO, www.the-hero.org), that showed quantitatively and convincingly, that depression and stress were the leading causes of health care cost increases in the United States surpassing even tobacco use and heart disease.
As a result, mental health is integral in Highsmith's overall view of health and well-being. Mental health-friendly practices are both implicit and explicit in the corporate culture.
Highsmith's Essentials for the "Accountable Organization"
Learning and Development: T.A.G.
Total commitment to developing human potential.
Access to learning opportunties.
Growth as an individual and as a company.
Enactment
Highsmith also revamped its organizational structure by adopting a team-based environment that promotes problemsolving, leadership, and group interaction skills. Curricula were developed and offered to all employees to develop these skills and to expand other personal interests as well. The intention is to move decisionmaking closer to the task and make employees accountable for both.
The cornerstone of Highsmith's accountable organization is T.A.G., Highsmith's learning and development initiative. The course catalog is the most visible tool, with class offerings spanning:
•Job/Career Development (e.g., Basic Principles for a Collaborative Workplace; Identifying Work Priorities and Setting Verifiable Goals; Now, Discover Your Strengths)
•Personal Well-Being (e.g., First Aid Kit for the Mind; The Power of Positive Self-Talk; Assisting Aging Parents; Chair Massage)
•Self-Care (e.g., Breast Health; Headaches and Migraines; Protect Yourself From Identity Theft)
•Physical Well-Being (e.g., Discovering Dr. Phil's Ultimate Weight Solution; Managing Cholesterol; Supplements and Herbal Remedies)
•Work/Life Enrichment (e.g., Boating Safety; Mechanics of Mutual Funds; Balancing Work and Family)
The personal well-being component targets emotional health. Stress, depression, and anxiety are frequently visited topics of discussion and selfassessment. Highsmith has recognized that to bring mental health awareness information and education to an organization successfully, a conscious effort must be made to sensitize members of that organization to the stigma that surrounds mental illnesses.
Within T.A.G., Highsmith offers a comprehensive menu of health promotion and disease prevention activities and programs, such as mental and emotional health programming and screenings, domestic abuse outreach and education, and stress reduction and time management programs, to name just a few.
Employee Assistance Program (EAP)
In describing this important tool to balance work and life, Bill Herman, Highsmith's vice president of human resources, said Our relationship with our EAP is critical to our success in dealing with work-life balance and personal well-being. We made a conscious decision to heighten awarenesss of mental health issues. We have partnered with our EAP, National Employee Assistance Services (NEAS), to assist us in making our vision a reality. We have learned from each other and work very closely together to provide employees with tools to balance work and life.
During their orientation, new employees are introduced to the T.A.G. model. Emphasis on personal well-being starts immediately. All new employees attend a session called T.A.G. Essentials: First Aid Kit for the Mind, which is presented by a counselor from National Employee Assistance Services. Participants learn about signs of mental illness; information about stress, relationships, depression, and substance abuse; tips for maintaining mental fitness, and where to go for help. Each employee participates in confidential selfassessments on stress management, relationships, and depression. Laura Hanson, manager of learning and development, said, This training session helps to establish the foundation regarding the importance of personal well-being and encourages employees to build awareness about mental health topics.
Annual Health Screening
Each year, employees and their spouses can participate in a free, comprehensive health screening held during work hours. The screening includes: height and weight assessment, cholesterol lipid panel and glucose test, blood pressure check, and treadmill fitness walking test. After the tests are completed, participants meet with a health educator to go over their results and set lifestyle goals. Next, the participant meets with an NEAS counselor to talk about personal well-being and learn more about the tools and resources NEAS provides to balance work and life. Last, participants meet with Laura Hanson to learn about the health resources and services Highsmith provides for employees and their families.
For the last 2 years, the NEAS station at the health fair has featured a resiliency survey. The survey asks questions such as, Given the current economic environment and what is happening to our business, where are you on the resiliency scale? There are 10-12 categories to indicate where the individual is on this scale, from hopeless to hopeful.
Communication With Employees
Highsmith's Intranet
Highsmith's Intranet has become an effective tool to educate employees and provide resources on health and wellness. The E-Health section links employees to quality health information on a variety of topics from blood pressure, weight management, and fitness to depression and anxiety, relationships, and domestic abuse. Leader's Edge is an area of Highsmith's Intranet that features resources for line managers, including Your Role and the EAP.
Quarterly State of the Business Meeting
The CEO and CFO meet with employees quarterly to go over the state of the business and openly discuss finances, even though Highsmith is a private company. The CEO talks about what is going on in the business and its future challenges, and solicits questions and feedback.
Support in Times of Distress: Employee Stories
Finding Support and Comfort
An employee experienced depression after her husband of 20 years decided he wanted a divorce. She became a single mother of a teenage son and felt her life slipping out of control. She did not know where to turn for help but found support and comfort at Highsmith. Highsmith assisted her with educational opportunities in personal well-being and referred her to a counselor from NEAS. With the consent of the employee, Bill Herman also worked with NEAS to provide her team with information on depression and discuss ways they could support her during this difficult time. In addition, the employee's line manager provided her with time off from work to attend therapy sessions. The employee discovered the positive impact of physical activity on her emotional well-being and overall health. As a result, she started to use the one-mile path that surrounds the building to walk during her breaks, joined the onsite exercise classes, and saw dramatic changes in her overall health. She said, If it wasn't for the people at Highsmith, I would not be here today.
Overcoming Anxiety
When the order processing team was cross-trained to take customer orders, several team members were extremely reluctant to get on the phones with customers. More than just nervous, they felt they simply could not do the jobs. Highsmith contacted NEAS for recommendations on how to work through this problem. NEAS met with managers to explore the complexities of dealing with anxiety. Employees were referred to NEAS, where they worked with a counselor, and were supported by Highsmith through the transition. Management education and awareness, coupled with guidance from NEAS, created a framework for employees to overcome their issues with anxiety.
Improving Health
NBC Nightly News With Tom Brokaw did a segment on Highsmith and the success of its wellness initiatives. During their visit to Highsmith, NBC producers interviewed an employee with problems maintaining self-esteem and her struggles to manage diabetes, weight, and high blood pressure. Laura Hanson had worked closely with the employee to help her manage her health and personal well-being. On national television, the employee was quoted as saying, Highsmith saved my life.
Results
Making the choice to integrate mental health into a comprehensive approach to encourage healthy lifestyle choices has paid off for Highsmith. At a time when health insurance premiums are increasing at double-digit rates, Highsmith's premiums have held steady. The rate increase for 2002 was 2.9 percent, and 3.1 percent for 2003.
Employee loyalty was tested in April 2002 when a workforce reduction affected 31 employees. A month later, the EAP conducted a resiliency survey that found that faith and trust in the management remained solid. Average length of service is 13 years, with minimal turnover. From 1999 to 2002, turnover in the Madison/Milwaukee business corridor overall averaged 22 percent, but Highsmith's turnover was around eight percent.
Final Words
At Highsmith, wellness is not viewed just as a program, but rather as a strategic initiative to nurture the valued workforce to meet corporate goals and objectives.
Highsmith's overall environment engaged employees, emphasis on learning and development, tools to balance work and life responsibilities, and health and wellness programming positively impacts health insurance premiums, turnover, and productivity. This all contributes to the unique culture that is Highsmith.
Duncan Highsmith, chairman and owner, said, If a wellness initiative is to succeed as a long-term business strategy, it must change lives, not just the bottom line.
Quad/Graphics
Pewaukee, Wisconsin
Quad/Graphics was founded in 1971 with 11 employees in an abandoned millwork factory in Pewaukee, WI. Since then, the firm has grown rapidly, adding several other facilities in Wisconsin as well as in States across the country. Today, Quad/Graphics is the largest privately held printing company in the world, employing 12,000 employees spanning more than 20 print-production facilities on three continents. Among its more than 1,000 clients are magazines such as Architectural Digest, National Geographic, Shape, BusinessWeek, Time, U.S. News & World Report, and Newsweek; and catalogs such as Lands End, Victoria's Secret, Cabela's, and Coldwater Creek.
Early in the company's development, a strong emphasis was placed on employee welfare, which led to the creation of QuadMed, an internal medical division that provides employees with complete wellness coverage. QuadMed's employee assistance program (EAP), well into its second decade, is a model for other companies around the State and accross the country. It is administered through QuadMed.
Inspiration
Quad/Graphics started out as a small, family-run printing company. Because of its commitment to the whole individual, employee welfare has been a priority since day one. Creating a division to handle its growing employee ranks and their physical and emotional needs seemed a natural fit early on in the company's development. This has since blossomed into a full-service medical division with a well-rounded EAP that can handle virtually any aspect related to work wellness. QuadMed offers a wide range of medical services, from internal medicine to pediatric care, drug and alcohol abuse counseling, and other EAP services.
